A prospective study of a dromedary camel herd during the 2013–14 calving season showed Middle East respiratory syndrome coronavirus infection of calves and adults. Virus was isolated from the nose and feces but more frequently from the nose. Preexisting neutralizing antibody did not appear to protect against infection. Ongoing transmission of Middle East respiratory syndrome coronavirus (MERS-CoV) to humans underscores the need to understand the animal sources of zoonotic infection (>2 years of age). The herd did not go to pasture in the desert . The animals were sampled on 5 occasions during November 2013–February 2014. Farm B (“semi–zero-grazing”) had 17 adults and 3 calves; its herd was sampled in February 2014. Nasal, oral, or rectal swab samples and blood samples were collected  targeting MERS-CoV upstream of E (UpE) and open reading frame (ORF) 1a genes and a broad-range RT-PCR reacting across the CoV family to detect other CoVs were used as described , it is likely, though not certain, that the MERS-CoV infections in the 2 adults  sampled on December 30 were reinfections, as has been reported for other CoVs (8 to 1.78 × 108/mL specimen), and a 2-week-old calf, no. 22, with (presumably passively acquired) titers of 1,280 became infected but had a much lower viral load. Overall, these data suggest that prior infection or passively acquired maternal antibody might not provide complete protection from infection  had a high viral load and was seronegative at the first MERS-CoV–positive result (indicating that it had been recently infected) but was MERS-CoV RNA negative 6 weeks later, suggesting that virus shedding is not prolonged. We did not detect virus RNA by RT-PCR in the 3 acute-phase serum samples from infected dromedaries , suggesting that acute infection is not associated with prolonged viremia. Dromedaries from farm B were sampled once on February 11; all results were negative.Four MERS-CoV–positive calves had mild respiratory signs , abnormally elevated body temperature, and loss of appetite at the December 30 sampling, which resolved over a few days. Three calves from which paired serum samples were available  and 1 fecal swab (no. 19Dam) specimens collected on December 30; these were the specimens with high numbers of MERS-CoV copies (9.27 × 107 to 1.78 × 108 copies/mL). The full-genome sequence of 1 virus culture isolate was obtained in parallel with that of the original virus in the original clinical specimen. We observed 3 nucleotide changes in ORF1b, spike, and membrane protein genes in the isolates after 2 passages in Vero E6 cells, of which 2 were nonsynonymous, leading to changes in spike (S1251F) and membrane proteins (T8I). This finding highlights the importance of sequencing the viral genome directly from clinical specimens.Virus isolation in Vero E6 cells was attempted from 7 positive nasal swab and fecal specimens that had >10−6). The estimated mutation rate for epidemiologically unlinked human MERS-CoV was 3.1 × 10−6 (95% CI 2.4 × 10−6 to 3.8 × 10−6)  were nonsynonymous. These amino acid changes are located outside the binding interface between MERS-CoV spike protein and human DPP4 receptor, suggesting these amino acid differences are unlikely to affect receptor binding. Thus, these dromedary viruses may retain capacity to infect humans, as Chu et al. suggested for dromedary MERS-CoV in Egypt (MERS-CoV may be isolated from nasal swab specimens and feces, indicating that both could be possible sources of virus transmission to humans and other animals, but virus detection rates were higher in nasal swab specimens. Our preliminary data suggest that preexisting MERS-CoV antibody might not completely protect against re-infection; however, this question needs more investigation.Testing of dromedary camels by reverse transcription PCR and serologic testing for Middle East respiratory syndrome coronavirus, Al-Hasa, Saudi Arabia; and detailed methods used in this study


Flaviviridae, genus Flavivirus that causes a mild, acute febrile illness similar to dengue. In 1947, scientists researching yellow fever placed a rhesus macaque in a cage in the Zika Forest (zika meaning “overgrown” in the Luganda language), near the East African Virus Research Institute in Entebbe, Uganda. A fever developed in the monkey, and researchers isolated from its serum a transmissible agent that was first described as Zika virus in 1952. It was subsequently isolated from a human in Nigeria in 1954. From its discovery until 2007, confirmed cases of Zika virus infection from Africa and Southeast Asia were rare. In 2007, however, a major epidemic occurred in Yap Island, Micronesia. More recently, epidemics have occurred in Polynesia, Easter Island, the Cook Islands and New Caledonia.Zika virus is a mosquito-borne positive-sense, single-stranded RNA virus in the family


A within-participants experiment was conducted in two countries (the UK and Colombia) in order to investigate the matching of shapes to taste words. Comparing the two countries allowed us to explore some of the cultural differences that have been reported thus far solely in terms of people's visual preferences. In particular, we addressed the question of whether properties other than angularity influence shape-valence and shape-taste matching . The participants in the present study repeatedly matched eight shapes, varying in terms of their angularity, symmetry, and number of elements to one of two words—pleasant or unpleasant and sweet or sour. Participants' choices, as well as the latency of their responses, and their hand movements, were evaluated. The participants were more likely to judge those shapes that were rounder, symmetrical, and those shapes that had fewer elements as both pleasant and sweet. Those shapes that were more angular, asymmetrical, and that had a greater number of elements, were more likely to be judged as both unpleasant and sour instead. The evidence presented here therefore suggests that aside from angularity and roundness, both symmetry/asymmetry and the number of elements present in a shape also influence valence and taste categorizations. Research on the crossmodal correspondences  also influence such crossmodal correspondences. The idea here is that the valence of a shape is determined by its various features, and taste/shape correspondences are influenced by the emotional valence of the component stimuli. That said, it is possible to hypothesize that the manipulation of such features may influence the correspondence between taste and shape.What is more, cross-cultural differences have also been reported between Western and non-Western populations . Our response to salty tastes, on the other hand, seems to depend on our physiological needs . We were also interested in determining whether shape-valence and shape-taste matching are similar in two different countries, namely the United Kingdom and Colombia. Here, it is important to note that different studies have reported cultural differences in the valence attributed to different visual features  and the word sweet. By contrast, those shapes that are angular, asymmetrical, and those shapes possessing a greater number of elements would be matched to a negative valence  and to the word sour instead. We anticipated that our participants' performance , would be influenced by the different shape properties. In particular, those shapes that are matched with a negative valence and to the word sour were expected to yield faster RTs than those shapes matched with a positive valence and to the word sweet. We also expected that shapes that presented properties that conveyed conflicting valences or tastes would generate slower RTs and more hand movements  on the part of the participant. Our hope in conducting the present research was partly that the findings could potentially be applied to the development of brands, product packaging, and advertising that can more consistently/effectively communicate a specific the taste using visual cues , recruited via the database of the Crossmodal Research Laboratory at the University of Oxford took, part in the study. The experiment was reviewed and approved by the Central University Research Ethics Committee at the University of Oxford (MS-IDREC-C1-2014-056). All of the participants had normal or corrected-to-normal vision. The participants signed a standard consent form at the start of their session and were compensated with £5 for taking part in the study.Twenty-six participants  were invited to take part in the study via the database of the International School of Economics and Administrative Science at Universidad de La Sabana in Colombia. The experiment was reviewed and approved by the Research Committee of the International School of Economics and Administrative Science at Universidad de La Sabana. The participants were compensated with academic credit for taking part.Thirty-seven participants , were conducted. The participants were informed that they would be presented with different shapes  instead. The order of presentation of the two tasks was counterbalanced across participants. In both tasks, the shapes were presented on the lower center of the screen and afterwards the participants had to move the mouse and click on one of two possible words  method was used to analyze the data . Note that we only present in Figures, and in the main text, those effects that displayed significant differences .An overview of the results revealed the same main effects in both countries  in both tasks . It would appear that symmetry/asymmetry and the number of elements seemed to exert the greatest influence as to how the participants matched each shape to a valence word  to shapes that were asymmetrical  as compared to those shapes that were symmetrical  by the participants when compared to shapes with fewer elements  to asymmetrical shapes that had a greater number of elements (CI: 1980–2295 ms) as compared to those shapes that had a greater number of elements but which were symmetrical  when presented with shapes that had more elements and were asymmetrical (CI: 1638–1838 ms) as compared to those shapes that were made-up of more elements and were symmetrical  and from left to right (x-flips) and creating an index to standardize these movements across participants. The motor complexity index is calculated by counting the number of hand reversals on each axis (x and y), before each participant clicked the mouse on each trial  were, on average, categorized 119 ms faster than rounder shapes (CI: 2000–2411 ms). The participants responded 164 ms more rapidly to the asymmetrical shapes (CI: 1848–2281 ms) than to the symmetrical shapes  faster than rounder shapes (CI: 1743–2010 ms). Shapes with fewer elements (1602–1857 ms), yielded faster responses  than those shapes with more elements (CI: 1692–1934). Significant interactions were found between the number of elements possessed by a shape and both roundness/angularity Wald p < 0.001 ; showing that those participants who matched a shape with the word pleasant also associated the same shape with the word sweet. The correlation also revealed that the participants tended to match those shapes with sourness that were also associated with the word unpleasant. Furthermore, the choices made by the participants were classified in terms of their consistency; that is, whether the participants matched a shape to the same word across the four trials. After this process had been completed for both tasks, standardized residuals were calculated to determine if the participants categorized shapes as pleasant-sweet and as unpleasant-sour. The standardized residuals . Since each participant categorized each shape four times on each task, the categorizations were transformed into ranked values depending on how many times a shape was consistently classified as sweet/pleasant or sour/unpleasant . On the other hand, shapes that were more asymmetrical were more consistently matched by the participants with the words unpleasant and sour (SR = 2). The number of elements that make-up each shape also had an influence on how likely it was that shapes were categorized as both pleasant and sweet (SR = 2.9) and unpleasant and sour (SR = 1.4).The results also revealed that symmetry/asymmetry influenced how easy it was for participants to match a shape to both the word pleasant and the word sweet , the results revealed that all three shape attributes  exerted varying degrees of an influence over the way in which shapes are matched to the words sweet and sour. It would seem that symmetry/asymmetry is an important property when it comes to conveying sweetness/sourness. What is more, since, by itself, roundness did not present a significant main effect in terms of valence, if affective matching actually mediates shape-taste correspondences, shape attributes such as symmetry/asymmetry may have a significant contribution when matching shapes to sweet and sour tastes.The fact that we did not find an effect for roundness may be explained by the type of task used. Previous studies primarily used scales to measure preferences for roundness . Analysis of the RT data also revealed that shapes that presented properties that had a congruent valence  produced faster responses than those shapes that had an incongruent underlying valence . This effect was further enhanced for those shapes that not only presented congruent shape properties but that were also matched to a negative valence. This is consistent with evidence showing that unpleasant stimuli tend to elicit faster RTs  may provide an interesting candidate with which to evaluate association strength between a stimulus and the target response. Moreover, hand movements could also indicate when a stimulus is harder to process or interpret. For example, those shapes that are made-up of properties that communicate contradictory opposite valences or different tastes  may produce more hand movements. This suggestion is supported by the results of the present study showing that increased motor complexity indexes for those shapes presenting mismatched shape properties  and also those shapes that presented more elements tended to yield faster RTs . There are two potential, and not necessarily exclusive, explanations for such results. On the one hand, there is evidence to suggest that complex shapes can actually be processed more rapidly than simple shapes, because they have more redundant information  on shape valence-matches in the Colombian sample. In the taste task, the relevance of taking into account different shape properties in the study of shape-taste correspondences becomes even clearer. In the UK sample symmetry/asymmetry and the number of elements displayed a similar effect size (with roundness/angularity following close) over how shapes are matched to a specific taste. On the other hand, roundness/angularity had a dominating influence in the Colombian sample, with symmetry/asymmetry and the number of elements having a much smaller effect. This study provides preliminary evidence showing that the valence hypothesis to explain shape-taste correspondences maybe incomplete. Furthermore, we found that symmetry/asymmetry presented the greatest effect size in the valence task. On the other hand, symmetry/asymmetry, and the number of elements, both played key roles in shape-taste matches in the UK sample, while roundness/angularity presented the highest effect in the Colombian sample. Nevertheless, shape-taste matches were similar in both countries, thus suggesting that there may be other mechanisms that were not included in our study. Further research is therefore needed in order to determine what specific properties facilitate the matching of shapes and tastes to a specific valence (and to each other). Our results suggest that somewhat different shape properties facilitate shape-taste matches in each country.Tinio and Leder's  study reFinally, the findings of the present study may potentially have implications for the fields of packaging and label/logo design since they offer guidelines when it comes to matching visual information to specific tastes. It would be interesting to conduct further research with a greater variety of stimuli, given that we used just one shape for each condition. Nevertheless, the clear effect reported for symmetry on both samples is consistent with previous findings on aesthetics and evolutionary biology showing that symmetry is preferred over asymmetry. Our results are also consistent with findings demonstrating that roundness is more easily matched with sweetness and angularity to sourness.The effects reported in the present study could be explained via different mechanisms. On the one hand it is possible that semantic associations in both Spanish and English regarding the word sweet and sour with both a taste and a valence could influence the matches made by the participants. On the other hand, there is a growing body of research showing the pervasive and structural influence of visual properties without any sort of context and even when presented for a few seconds. For example, angular shapes seem to active neural circuitry for threat detection  can have a positive influence on the emotional judgments made by consumers (Salgado-Montejo et al., In future studies, it will be interesting to include novelty and familiarity as covariates in order to determine their influence on shape-taste matches. Furthermore, it would be interesting to determine if the effects reported here can be extrapolated to more complex stimuli (e.g., products, brands, and websites, see Crilly et al., 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.


Most of hepatitis cases were reported in the central sector of the Portsudan city. The diagnosis of hepatitis E virus and dengue virus in an endemic area is a great challenge for health care staff working in these areas. Both Dengue virus and Hepatitis E virus infection should be considered in pregnant women especially in similar settings.Dengue fever and hepatitis E virus infection are both a public health problem in developing countries due to poor sanitation. Infection with viral hepatitis and dengue fever can present with similar clinical such and fever, headache and abortion. This study was conducted in Port-Sudan city in the eastern part of the country. ELISA and Real Time PCR tests were used to detect the infection. A total number of 39 pregnant women with a mean age 26 ±7.8 were included in the study. All of them had fever, 32 (92.3%) admitted with headache, 11 (28.2%) of them had vomiting, and abortion was reported in two cases (5.1%). The study showed that 4 (10.3%) of pregnant women were positive for the Hepatitis E virus, 5 (12.8%) positive for Dengue virus IgG, and only one sample (2.6%) was positive for IgM capture ELISA and real time PCR. Death due to hepatitis E infection was reported in one case with 7 Dengue fever and hepatitis E virus infection are both a public health problem in developing countries due to poor sanitation. Infection with viral hepatitis and dengue fever can present with similar clinical such and fever, headache and abortion. Dengue haemorrhagic fever and dengue fever are an arboviral disease caused by dengue virus, belong to the genus Flavivirus, family Flaviviridae. Dengue virus is a vector borne disease transmitted mainly by Aedes aegypti . Dengue The total number of 39 women admitted the Port Sudan Maternity hospital with fever symptoms were included in this study. The study duration was between January and April 2012. A.Data was analysed by using SPSS. Informed consent was taken from each participant. For laboratory diagnosis; Enzyme linked immune assay capture, ELISA, was used to detect the Dengue virus IgM and IgG from patient's serum. Commercial kit (Dengue IgM and IgG capture ELISA) was used to detect both IgM and IgG antibodies. Reaction result was read by the ELISA reader at 450 nm with reference filter of 600-650nm absorption . ELISA kA total number of 39 pregnant women with a mean age 26 ±7.8 were included in the study. All of them had fever, 32 (92.3%) admitted with headache, 11 (28.2%) of them had vomiting, and abortion was reported in two cases (5.1%). The study showed that 4 (10.3%) of pregnant women were positive for the Hepatitis E virus, 5 (12.8%) positive for Dengue virus IgG, and only one (2.6%) were positive for Dengue IgM capture ELISA . Real TiDengue virus infection and hepatitis R virus infection symptoms and clinical signs are similar and it is difficult to distinguish especially during the acute phase of infection. These medical signs and symptoms include Fever, headache, and Jaundice. A study conducted in India among pregnant woman, dengue virus infection was presented mainly with myalgia plus a few cases with fever and abdominal pain . FurtherThe diagnosis of hepatitis E virus and dengue virus in an endemic area is a great challenge for health care staff working in these areas. Both Dengue virus and Hepatitis E virus infection should be considered in pregnant women especially in areas where these diseases are circulated.


Image-guided surgery potentially enhances intraoperative safety and outcomes in a variety of craniomaxillofacial procedures. We explore the efficiency of one intraoperative navigation system in a single complex craniofacial case, review the initial and recurring costs, and estimate the added cost . We discuss the potential challenges and benefits of utilizing image-guided surgery in our specific case and its benefits in terms of educational and teaching purposes and compare this with traditional osteotomies that rely on a surgeon’s thorough understanding of anatomy coupled with tactile feedback to blindly guide the osteotome during surgery. A 13-year-old presented with untreated syndromic multi-suture synostosis, brachycephaly, severe exorbitism, and midface hypoplasia. For now, initial costs are high, recurring costs are relatively low, and there are perceived benefits of imaged-guided surgery as an excellent teaching tool for visualizing difficult and often unseen anatomy through computerized software and multi-planar real-time images. Craniofacial surgery can be complex, frequently requiring multiple surgeries over a patient’s lifetime. Thorough knowledge of craniofacial skeletal and soft tissue anatomy is necessary when planning and executing such complicated surgery, especially in cases involving syndromic craniosynostosis where severe aesthetic and functional deformities of the skull, orbits, and face exist. Image-guided surgery (IGS) uses preoperative imaging studies that are then viewed in multi-planar three-dimensional images intraoperatively allowing the surgeon to correlate physical landmarks with this radiographic map. IGS has known initial and recurring costs including increased setup time, registration, and calibration of instrumentation, which increases overall time under anesthesia.We utilized a stereolithographic model but did not do a virtual surgical plan (VSP) in a large part because the goal was to advance the orbits and mid face Leforte III to the point that the lagophthalmos and exorbitism was improved Fig. . The SteA custom orthodontic palatal splint was cemented and wired to the maxillary molars. A wavy-line bicoronal incision was marked and injected with local anesthetic. The scalp flaps were raised subgaleally; then separate pericranial and temporalis flaps were raised. A fiducial star with infrared spheres was screwed into the right parietal region Fig. . DissectWe present a 13-year-old boy with Crouzons and multi-suture synostosis with resultant brachycephaly, severe exorbitism, proptosis, malocclusion, midface, and maxillary hypoplasia Fig. –d. The fEwers et al. reviewed 158 operations with successful use of IGS concluding that in the majority of cases, the medical benefit outweighed the technical expenditure . Jeelani® Spheres, which come 12 in a pack for $20 per sphere and any additional anesthesia costs ($482/h) during the setup and calibration of the IGS. The total recurring costs were $481.We describe our experience relative to 1) perceptions and 2) expenditures of IGS for this one patient. It is our perception that IGS, while not necessary for most routine craniomaxillofacial surgery is useful 1) as a teaching tool in the OR to highlight anatomy and 2) as an adjunct in cases of unusual anatomy, revision surgery, or complicated reconstructions. There is little or no data in the craniofacial literature in terms of improved safety, outcomes, patient aesthetics, or decreased need for further surgery. Our perceptions in terms of potential downsides of IGS include increased time in the OR for setup and small risks of mounting fiducial marker in the case of infrared IGS systems. There are additional costs including those needed for preparation and performance of surgical procedures supported by IGS. The FUSION™ ENT on Medtronic StealthStation S7 Surgical Navigation System costs $359,000 and this as well as the $18,900 for the supplemental instrument set, and $1,076 for the new surgeon wireless mouse are fixed costs though in our case these were on trial by the hospital. The recurring costs include the StealthStationRecurring costs that are not part of the IGS system include the cost of the rigid external distraction (RED) system  and the stereolithographic model (SLM), which totaled $14,500. The hospital stay accrued to $33,144 in the pediatric intensive care unit and $8,384 on the pediatric floor. The sum of these expenditures  far exceeds the recurring costs of the IGS. The financial benefit of improved clinical outcomes or decreased complications is unknown at this point—ideally randomized case controlled studies would help in answering such questions although it would be impossible to blind such studies.We demonstrate that IGS can be easily integrated into clinical use with only 30 min of added time to the case, although further studies are certainly warranted to discover if IGS leads to decreased lengths of stay, reduced return trips to the operating room, and/or reduced complications. While the costs of IGS are not inconsequential, most of these costs are up-front and the recurring costs are relatively minimal when compared with the total costs of caring for children with complex craniofacial deformities including the need for multiple surgeries, at times lengthy hospital admissions, as well as the need for expensive hardware, devices, and diagnostic imaging tests. IGS allows junior craniofacial and plastic surgeons, oral surgery or otolaryngology residents, fellows, or medical students with an interest in craniofacial surgery the opportunity to visualize otherwise unseen anatomy using multi-planar radiographic data points . SyndromWritten informed consent was obtained from the patient for the publication of this report and accompanying images.


MS-2 bacteriophage in each home. After 8 h, the hands of each family member (10 fingers) and 20 frequently touched fomites were sampled to determine baseline contamination without intervention. Within 8 h, MS-2 was detected on all of the family member’s hands and most of the fomites. The intervention consisted of providing the families in all selected homes with bottles of an ABHS, which were placed in the kitchen, bathrooms, and nurseries. Smaller individual bottles were provided for each family member greater than 12 years old to place in purses, pockets, backpacks, etc. The families were instructed to use the ABHS one time or three times during the day. For one and three uses, a statistically significant reduction of virus on un-inoculated and inoculated hands of ~99 % occurred within 8 h. Similar reductions occurred on fomites throughout the households (97–99 %). These results demonstrate that the use of an ABHS can significantly reduce transfer of a virus to the hands, and to the commonly touched surfaces within the household.The objectives of this study were to determine the movement of a virus throughout a household and the impact of an alcohol-based hand sanitizer (ABHS) on reducing the movement and exposure of the virus to household members. Bacterial virus MS-2 was used as the surrogate for human enteric and respiratory viruses. Seven households with families having at least two children in the age range of 2–18 living in the home were used in this study. The hands of one adult family member were contaminated with 1 × 10 Good hand hygiene involving hand washing and/or the use of alcohol-based hand sanitizers (ABHS) has been shown to reduce the risk of infection from both respiratory and enteric viruses  to rhinovirus (common cold), norovirus (most common cause of adult gastroenteritis), and many other enteric viruses. For these reasons, it was selected as a surrogate.The objectives of this study were to study the movement of a virus throughout a household and the impact of an intervention with ABHS on reducing the movement and exposure of the virus to household members and fomites. Bacteriophage MS-2 has similar shape and size to many human disease-causing enteric and respiratory viruses likely to be spread in a home setting. Bacteriophage MS-2 infects the bacteria E. coli ATCC 15597 as the host. The E. coli was grown overnight and transferred to Tryptic Soy Broth (TSB)  in a shaking water bath, and one ml of it was transferred to a new sterile broth for 3 h at 37 °C in a shaking water bath to reach the log growth phase. The virus was produced by collecting it from an infected lawn of E. coli by addition of 6 ml of TSB and then removing it with a pipette after 2 h. The suspension was then centrifuged at low speed to remove bacterial debris filtered through a 0.45-µm pore size membrane filter and finally stored at 4 °C until needed for further use.Bacteriophage MS-2 (ATCC 15597-B1) was assayed by the double-layer agar technique with 8 MS-2 bacteriophage. After 8 h, the hands of each family member (10 fingers) and selected high-touch fomites shown in Table To assess the spread of the MS-2 before the interventions, seven households with families having at least two children in the age range of 2–18 living in the home were selected randomly from a pool of available houses that were recruited. Basic demographic data for all households such as number of people living in the home, ages, sex, number and types of pets were obtained for all houses. The hands of one adult family member in each home were contaminated with 1 × 10In all phases, virus was added to the hands of one adult in the household. All individuals received one mL of a physiological saline suspension onto the palm of their hand; however, the virus was only applied to the hands of one adult member of the household. This was done so the household members did not know whose hand was inoculated. Each individual was then asked to gently rub the palm of one hand together with the other hand and move the hands in an upward motion so that the fingertips of one hand slide onto the palm of the opposite hand to disperse the virus onto the fingertips. The contamination of the adult hand occurred at approximately 8:30 AM in the morning. The family was asked to stay at home during the day and go about normal daily activities in between the sampling times. All studies were done on weekend days when families spent most of the day at home. During the study, family members were not allowed to use any other antimicrobial hand products including wipes, sanitizers, and disinfecting cleansers . All families were asked to practice their normal hand washing routine using soap and water during the course of this study. The study consisted of a baseline phase, and then two intervention phases.Families in all the selected houses were given 354 ml bottles of alcohol-based hand sanitizer  to place in the kitchen, bathrooms, and nurseries (3–5 bottles depending on the household size). This product has an active ingredient of 70 % ethanol. Individual bottles (56 ml) for each family member more than 12 years old were provided to place in purses, pockets, backpacks, etc. Instructions on when and how to use sanitizers were given to the families. They were instructed to use the hand sanitizer three times during the day (8 h) in the first intervention phase, and once per day in the second intervention phase  of each family member and fomites were sampled. The fomites sampled in each household are shown in Table 2 of each fomite was sampled.The hands of the same adult family member in each home were contaminated with 1 × 10Permission for conduct of the study was obtained from the University of Arizona’s Office for Human Subjects Research prior to the study.t statistic  was constructed for the log base 10 reductions with upper and lower limits using student Kabacoff .p < 0.0005) for Phase 1  group. The only sites that were not contaminated in the control (baseline) period were toilet handles in two houses and bedroom light switches in three houses. The highest average virus concentrations for fomites were found in the kitchen and living room areas, as well as on cell phones. Reduction in virus on hands (inoculated and non-inoculated) and fomites with use of the ABHS was statistically significant  and reductions may have been greater if a higher virus concentration had been used to contaminate the hand. This may also explain why the reduction in virus for one use per day was similar to three uses per day; if one use per day lowers the virus concentration to or just above the limit of detection, then the study is unable to detect a greater difference. Also the study was based on a single contamination event which is more representative of a person that contaminated their hands outside the home, and is not sick. It is not representative of the contamination that would occur if there was a sick person in the household, as they would be recontaminating the household continuously. Therefore, there would be a higher overall viral concentration in the household, and it is likely that a difference between one use and three uses per day could be detected. Future studies should evaluate the impact of ABHS in reducing viral concentration on hands and fomites where multiple contamination events occur.8 MS-2 was added to the hands to ensure enough viruses to trace its movement through the household. Although this may be high, this level of virus on the hands may not be unexpected. Norovirus, adenovirus, and rotavirus occur in concentrations up to 1011 to 1012 per g; thus, as little as 0.001–0.0001 g of feces could contain 108 of these viruses (Haas et al. A concentration of 10The results of this study demonstrate that the use of an ABHS can greatly reduce the exposure of family members to viruses in the household. The information generated in this study will be useful to validate models for the spread of viruses within households.


In Juvenile Idiopathic Arthritis (JIA) the temporomandibular joint (TMJ) can be involved leading to pain, dysfunction and growth disturbances of the mandible and associated structures. There may be value to a three minute screening protocol allowing the rheumatologist to detect TMJ involvement systematically. Reliability and validity of the TMJ protocol for detecting TMJ co-morbidity were determined in 74 consecutive JIA patients.The assessments of the rheumatologist and of a reference examiner (RE) were compared and validity of the TMJ protocol was established using the disease activity (JADAS-27) as an external reference.The internal consistency of the protocol was 0.73 . The inter-examiner agreement between the rheumatologist and the RE varied between 0.25 and 0.87 (Cohen’s Kappa). Sensitivity and specificity, with the JADAS “3.8” indicating minimal disease activity, were 0.57 and 0.77 respectively. The area under the curve (AUC) was 0.70. A cut-off value of two positive items was found to be an optimal threshold to select the patients with likely TMJ involvement.The use of the protocol is feasible in everyday clinical practice. Reliability and validity aspects were satisfactory. The screening protocol for TMJ involvement provides the rheumatologist with systematic and focused TMJ information which relates to the JIA disease activity (JADAS-27). Arthritis of the temporomandibular joint (TMJ) can be a manifestation of Juvenile Idiopathic Arthritis (JIA), with impact on the masticatory system ,2. It isThe severity of TMJ involvement in JIA has been reported to be directly related to inflammatory variables: symptoms of TMJ dysfunction coincide with flares of disease activity . MoreoveOur aim was to test the TMJ examination protocol for internal consistency, reliability and concurrent validity against the JADAS-27 in a consecutive series of patients diagnosed with JIA.Research was in compliance with the Helsinki Declaration. The Medical-Ethics Committee of the UMC Utrecht approved all study procedures (12-604/C).Seventy eight consecutive patients with JIA, classified by the International League Against Rheumatism (ILAR) criteria , betweenThe pediatric rheumatologists were trained for the TMJ examination before the start of the project by a dentist (MHS) who is an orofacial pain and temporomandibular joint dysfunction specialist experienced with the clinical examination of the masticatory system and the examination of children with JIA. For this reason the examiner was considered as the Reference Examiner (RE). A two hour training session was sufficient to explain the aim of the study, the protocol and the clinical examination to the rheumatologists, who were then tested by the RE on four patients in the clinical setting. Written instructions regarding the protocol were handed out. Four weeks after the last training session the study started.On the day of consultation, the patient was first examined by the rheumatologist. Within 15–30 minutes, the patient was then examined by the dentist, blinded to the findings of the rheumatologist. The TMJ protocol consisted of five history related questions and six clinical examination items Figure a. PatienTo test the concurrent validity of the protocol, the juvenile arthritis disease activity score (JADAS-27)  was usedThe JADAS consists of the following variables: 1) physician global rating of overall disease activity measured on a 10-cm horizontal visual analog scale (VAS) or a 21-numbered circle VAS ; 2) parent/child ratings of well-being and pain, assessed on a 10-cm horizontal VAS or a 21-numbered circle VAS ; 3) number of active joints, assessed in 71, 27, or 10 joints ; and 4) Westergren erythrocyte sedimentation rate (ESR), normalized to a 0–10 scale. The final result is the sum of the scores of its four components, with a global score of 0–101, 0–57, and 0–40 for the JADAS-71, JADAS-27, and JADAS-10, respectively. We used the JADAS-27, because it is more feasible than the JADAS-71, and not as limited as the JADAS-10. Moreover the TMJ’s are not included in the JADAS-27, which makes this score more appropriate for validation of the TMJ protocol than the JADAS-71. Different cut-off values have been validated for the JADAS-27. Minimal disease activity has been defined with a score below “2” for oligoarticular JIA, and below “3.8” for polyarthritis . In our The internal consistency of the protocol was determined using Cronbach’s alpha. Inter-examiner reliability of the individual items, composite scores Fh and Fe, and the total score, as assessed by the RE and the rheumatologist, was determined using Cohen’s Kappa .Correlation between the outcome variables and JADAS was tested using Pearson’s correlation. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were established using the test result of the rheumatologist. ROC analysis was performed to calculate the cut-off point of the TMJ examination protocol. All statistical tests were 2-sided. P-values less than 0.05 were considered significant. All analyses were carried out with the statistical package SPSS version 20 for Windows .A group of 76 patients, female to male ratio 2.4:1  vs 5.0 (TMJ involvement)  0.70.A screening instrument to assist rheumatologists in determining TMJ involvement was tested. The internal consistency was adequate. Cohen’s kappa values expressing reliability of the history and function related items varied between 0.42 (fair) and 0.87 . Concurrent validity was found to be fair to good. The rheumatologists noted that the TMJ screening could easily be included in the regular consultation time, making it applicable in standard clinical care such as follow-up.The internal consistency of the protocol could be raised to 0.85 by deleting “asymmetry” and “retrognathia” with low internal correlations. However, because these variables need to be evaluated in order to assess growth disturbances and for referral to an orthodontist and/or an oro-maxillofacial surgeon, we propose that these two items should be retained in the protocol despite the lower reliability of the assessments.A striking finding was the absence of major mandibular underdevelopment in this patient group. This finding supports a decreased future demand for surgical correction at an adult age. Using the suggested criterion of “at least 2 positive scores,” 34 percent of the patients were identified as having potential TMJ involvement (Table In this study one rheumatologist examined the majority of the patients (n = 44). The other patients were examined by three other rheumatologists. Their participation is not expected to disqualify our results regarding agreement. Agreement studies indicate lower inter-examiner agreement than intra-examiner agreement. However in clinical settings the same rheumatologist will perform repeated measurements in follow-up visits and in such a scenario agreement is likely to be higher than our results.Limitation of MMO is traditionally perceived as a key sign of TMJ involvement. Restricted mouth opening capacity is found more often in patients with JIA with radiographic signs of mandibular condyle lesions than in those without any detectable lesions . In our Since all patients were examined first by the rheumatologist, an order effect might have occurred. Considering the non-significant differences in MMO measurements between the rheumatologist and the RE, this effect is considered nonexistent Table .Since the JADAS-27 is a relatively new protocol, the scores for defining minimal disease activity in JIA categories were established only recently ,20. A cuWe used the JADAS-27 values at the time of the examination in 66 patients. The other eight patients were in complete remission. In these eight patients a blood test wasn’t indicated on the day of examination and the JADAS-27 was calculated using ESR values originating from a period no longer than 3 months before the examination. This approach allowed for the use of the JADAS-27 in 74 patients.Because the screening protocol for TMJ involvement is applicable in standard clinical care it provides the rheumatologist with systematic and focused TMJ information which relates to the JIA disease activity (JADAS-27). It is a tool to detect signs and symptoms of dysfunction of the masticatory system. Diagnosing TMJ arthritis is not possible with clinical assessment only, as indeed it can exist in the absence of signs and symptoms. In order to diagnose arthritis as early as possible, we investigated the correlation between the protocol score and inflammatory activity. Ideally TMJ arthritis should be detected with 100 percent certainty and this goal is approached by MRI . MeasuriIt is probable that MRI with contrast detects more TMJ inflammation than the screening protocol detects TMJ dysfunction. Nevertheless the clinical significance of MRI contrast enhancement is not completely known, as suggested by a recent study in which indeed TMJ MRI enhancement is compatible with a normal range of mouth opening, normal TMJ function, absence of arthritis in other joints and may be present in the context of immunosuppressive therapy . The corRegarding disease activity, the JADAS-27 was used for correlation with the TMJ protocol, because the TMJ examination is not included in this score. If the TMJ examination would have been included in the disease activity score like in the JADAS-71, the calculated correlation with the TMJ protocol would be biased. The aim of the investigation was to test the validity of the protocol against a reference score. We chose the disease activity JADAS-27 to avoid circular reasoning. The JADAS-71 might be more suitable as disease activity score from a clinical standpoint, but methodological considerations predominated our choice for the JADAS-27.The cut-off value for reduced MMO has been suggested throughout the literature as < 40 mm. However, there are good reasons to consider values that are age-related when examining the mandibular range of motion in children. For that reason we used two cut-off scores for children ≤ 10 years of age and > 10 years of age. Measuring MMO, like we did, indicated a wide range of MMO per age category in a population of 20709 schoolchildren . The autThe use of the screening TMJ protocol for the rheumatologist is feasible in the everyday clinical practice. The internal consistency of the protocol was good. Several function related items regarding actual signs and symptoms of TMJ involvement in patients with JIA could be scored with moderate to almost perfect reliability. Validity using the JADAS-27 as an external reference indicates good clinical utility. Replication using the TMJ protocol in a larger patient group and the use of other external references can provide additional validity of the TMJ protocol in detecting TMJ involvement.Written consent was obtained from the patient and the parents for publication of Figure


In order to stimulate appropriate antimicrobial use and thereby lower the chances of resistance development, an Antibiotic Stewardship Team (A-Team) has been implemented at the University Medical Center Groningen, the Netherlands. Focus of the A-Team was a pro-active day 2 case-audit, which was financially evaluated here to calculate the return on investment from a hospital perspective.Effects were evaluated by comparing audited patients with a historic cohort with the same diagnosis-related groups. Based upon this evaluation a cost-minimization model was created that can be used to predict the financial effects of a day 2 case-audit. Sensitivity analyses were performed to deal with uncertainties. Finally, the model was used to financially evaluate the A-Team.One whole year including 114 patients was evaluated. Implementation costs were calculated to be €17,732, which represent total costs spent to implement this A-Team. For this specific patient group admitted to a urology ward and consulted on day 2 by the A-Team, the model estimated total savings of €60,306 after one year for this single department, leading to a return on investment of 5.9.The implemented multi-disciplinary A-Team performing a day 2 case-audit in the hospital had a positive return on investment caused by a reduced length of stay due to a more appropriate antibiotic therapy. Based on the extensive data analysis, a model of this intervention could be constructed. This model could be used by other institutions, using their own data to estimate the effects of a day 2 case-audit in their hospital. Inappropriate and inefficient use of antimicrobial therapy and consequent resistance development can lead to unwanted clinical effects, such as toxicity, hospital acquired infections, longer length of stay  and to hOne way to improve patients’ antimicrobial therapy and stimulate prudent use is through Antimicrobial Stewardship Programs (ASPs) –12. ThisPart of an ASP is an Antibiotic Stewardship-Team (A-Team). At the University Medical Center Groningen (UMCG) in the Netherlands, an A-Team has been implemented at a urology ward to perform a case audit after 48 hours (day 2) of initiation of antibiotic therapy to improve the quality of care. The aim of this study was to construct a cost-minimization model reflecting direct costs and benefits on a hospital-wide level. This has been achieved by means of a historic cohort study for this case-audit performed by an A-Team, with the focus on direct return of investment from a hospital perspective. This study provides a framework, which can be used for other hospitals when implementing an A-Team, giving an indication what the direct return on investment of this specific ASP would be.The day-2 case audits by the A-Team were implemented within a 1339-bed academic medical center. It is a multidisciplinary team consisting of clinical microbiologists, infectious disease specialists and hospital pharmacists. One of the team members performed ward visits and discussed patients’ antibiotic therapy with the attending physician (fellow/resident). These ward visits could include a bed-side consultation and examination depending on the patient’s condition. During weekends, the consultations were either done by phone or on site during the subsequent working day. Eligible patients were selected on the basis of an automatic e-mail alert from the hospital’s pharmacy. An alert, generated from a clinical rule program  was sent when a patient used an antibiotic, considered to be of specific relevance , beyond 48 hours after initiation. Together with the attending physician, interventions were decided upon to improve the therapy. The case-audits were implemented on a urology ward after a successful test on a trauma surgery ward .http://www.dbconderhoud.nl) and the same antibiotics for 48 hours consecutively. Treatment policies based on national and local guidelines did not change within this period.Patients who stayed at the urology ward and received consultations by an A-Team member, between June 2013 and June 2014 were evaluated. Patients of whom antibiotics were started within three days of admission were included in this financial evaluation, resulting in data for 114 included patients. Financial effects related to length of stay, antibiotic consumption and nursing time needed for intravenous treatment were compared to a frequency-based historic cohort. The control cohort included patients who stayed at the same ward within a period of 30 months before the intervention started. This cohort was filtered based on the frequency of the Dutch equivalent of Diagnosis Related Group (DRG) codes of the intervention patients  consisted of patients with codes for infections and infections-related indications. The second group (DRG Group 2) consisted of patients with codes for more severe underlying diseases (e.g. cancer), but who developed a subsequent clinical infection and received antibiotics.All prices are given in Euros, 2013 level. Older prices were adjusted to 2013 using the Dutch consumer price index (statline.cbs.nl). Costs for the implementation and running of the A-Team were subdivided into personnel costs of the A-Team, costs made at the ward, medical costs, research/evaluation costs, overhead and implementation costs. Personnel costs are based upon Dutch gross salaries. Costs per hour for medical specialists in the A-Team, the hospital pharmacist, attending physicians, nurses and investigators were based on gross salaries and set at 120, 120, 35, 30 and 25 Euros respectively . The A-TPrices for the antibiotic medication were provided by the hospital pharmacy and reflect the actual prices charged by pharmaceutical companies. For all data, 2013 prices were used to account for possible changes over time.Costs of one patient day in the hospital were based on the internal costing system applied to the urology ward, based on the actual budgets of 2012, resulting in a total of €716 per patient per day. Notably, overhead costs  are included in these estimations; procedures are not included in this figure because we believe that a reduction in LOS does not influence the number of procedures substantially.Subsequently, total costs and benefits of this specific A-Team case-audit on day 2 were compared via a model. Costs for the consultations were subtracted from the costs of the chosen outcome measures, if they statistically significantly differed from the historic control cohort. For the model, values were calculated using the historic cohort. The respective variables are shown in brackets.PDRG).It was assumed that outcome measures of patients having a DRG for an infection related problem could be influenced, but that patients with (severe) underlying causes will not see any differences in the outcome measures. This ratio was therefore included in the model as the percentage of patients with infection-related DRG codes (LOS) was calculated and multiplied by the abovementioned price (Cbed).A change in hospital days (ΔTnurse) was calculated for this study, based on a survey on the ward. PIV denotes the percentages of patients that received IV treatment. This number was multiplied by the nursing time and the gross salary of the nurse.A switch form IV to oral administration is one of the interventions that was promoted by the A-Team. Therefore, nursing time spent on the administration of IV treatment per patient (Caudit) were calculated based on time spent by the A-Team doctor for the case-audit. For each consultation he/she scored the total time spent, including travel time and administration. Costs were multiplied by the average number of audits per patient (naudit) and the gross salary. The total figure also included costs for the attending physician on the ward, the hospital pharmacist, an investigator of the department and miscellaneous costs (e.g. meetings of the A-Team members).Case-audit costs (Cab) were evaluated between the group that received consultations and the historic cohort group.Lastly, the average costs of the antimicrobials per patient (This resulted ultimately in the following formula for the costs and benefits of the A-Team:http://www.ccmo.nl).The described stewardship case-audit was normal every day care implemented within the hospital and approved by the antimicrobials committee following national guidelines. ASPs are mandatory by Dutch law for every hospital. Data was collected retrospectively from the hospital's data warehouse. It was anonymous and did not contain any (in)directly identifiable personal details. Following Dutch legislation and guidelines of the local ethics commission, approval was therefore not required .Firstly the implementation costs were calculated. To then examine the costs or benefits of the ASP, all parameters for the model that were unknown were determined, based on the comparison between the patients with interventions and the patients without intervention in the historic cohort. To account for uncertainties that the model might possess, multivariate sensitivity analyses and a probabilistic sensitivity analysis were performed. Ultimately the final number was calculated with the model.Before starting the A-Team there was time invested to develop the procedures and protocols that were used, as well as the developing and testing of the clinical rule of the e-mail alerts. Time was scored retrospectively based upon A-Team members’ personal time schedules. Total costs came to €17,732. This includes implementation for other wards as well. These costs are not used in the model, because they are independent of this specific ward.PDRG). All measured effects were thus multiplied with this percentage. Within DRG Group 1, LOS (ΔLOS) dropped from 7.57 (95% CI: ±0.65) to 6.20 (95% CI: ±0.61) (p = 0.012). Nursing time needed for the administration of IV antibiotics (Tnurse) was based upon a survey at the specific urology ward. IV-treatment was assessed to cost on average 64.83 minutes a day. Respective times were 10.5 minutes for preparation per dosage; one time 7.5 minutes for catheter insertion; 10 minutes every 4 days for changing the catheter; 10 minutes for control per day; one time 2.5 minutes for removal. On average, IV antibiotics were given 2.27 times a day for 4.04 days. For DRG Group 1 the nursing time dropped from 251.66 minutes (95% CI: ± 32.94) to 178.19 (95% CI: ±40.91) (p = 0.016). 74% of the audited patients received IV treatment (PIV). Within DRG Group 2 there were no significant changes . 1 audit took on average 12.1 minutes (95% CI: ± 0.77 min.), costing €24.03 (95% CI: ± €1.53). During the audit, the A-Team member spoke with the attending physician, costing €7.01 (95% CI: ± €0.45). The A-Team’s hospital pharmacist was responsible for the e-mail alerts and the clinical rules, including daily maintenance. His costs were estimated at €35.95 per audit. An investigator of the department evaluated the A-Team interventions for quality assurance, costing €2.08 per audit. This amounts to a total of €69.07 of direct personnel costs of the A-Team. Furthermore there are miscellaneous costs that need to be taken into account (e.g. meetings of A-Team members); total costs of this are €11.19 per audit. On average, patients received 1.09 case-audits (naudit) per admission.Cost for 1 case-audit was on average €80.26 (Cab) showed a trend towards decreasing costs compared to the historic control groups, however it was not significant. In DRG Group 1 mean costs decreased from €17.42 (95% CI: ± 3.33) to €13.34 (95% CI: ± 4.55) (p = 0.030), for DRG Group 2 costs went from €21.47 (95% CI: ± 6.56) to €15.76 (95% CI: ± 8.30) (p = 0.637). However, because p-values were higher than 0.025 effects on cost price were not taken into account in the model  had the highest impact on the financial profitability.For the parameters with the largest/highest effect on the end result, multivariate sensitivity analyses were performed to visualize the effect they have on the return of investment. On the surfaces plots  the rangIn the model for DRG Group 1, where significant results were found, a PSA was performed for LOS, nursing time and antibiotic costs. Other parameters within the model had the baseline value . For perCosts and benefits for the hospital based on the implementation on the urology ward were calculated with the model. Using all the baseline values as mentioned above, for one year of interventions and 114 patients the total profits amounted to €60,306 (€529.05 per consultation), which led to a direct return on investment (ROI) of 5.9.Here we show a model, which can be used to calculate the financial effects of an A-Team. Using the data from the intervention study, the case-audit on day 2 performed by an A-Team was cost-effective and saved more than 60,000 Euros with consulting just 114 patients in one year on one ward. Revenues can therefore be expected to be much higher when a program like the one presented here were implemented in the whole hospital while implementation costs would remain relatively stable and acceptable.Antimicrobial stewardship programs (ASP) are introduced in more and more hospitals to improve quality of antimicrobial therapy and thereby controlling the growing resistance to antibiotics. Consequently more studies are published about the effects of stewardship programs, both with regard to clinical and financial aspects . In our This study looked at two outcome measures (LOS and antibiotic use). The effects on those parameters will be greater for patients who were admitted primarily for an infection (DRG group 1), which is clearly visible in the surface plots . A reducThe monetary costs and benefits in this study are for the most part indirect costs and savings because these are fixed costs in the hospital budget. Fixed costs are defined as costs that do not vary with the quantity of output in the short run, and include e.g. capital, equipment and staff . PersonnUnfortunately not all costs were known and could be incorporated into the model. For example adverse reactions and complications are missing because they are not stored in an objective, usable manner. Also missing are the indirect costs from a societal perspective. Preferably a study should include all costs associated with the implementation of an ASP, direct and indirect . HoweverOne of the main expected results of correct antibiotic usage is the lowering resistance rate in the hospital. These lowered rates will most likely reduce the risk of acquiring nosocomial infections in the hospital. This in turn will most likely contribute to reducing the risk of an outbreak of such an infection, which will be accompanied by substantial costs . As show


Schistosoma (S.) haematobium is a neglected tropical disease which may affect any part of the genital tract in women. Female genital schistosomiasis (FGS) may cause abnormal vaginal discharge, contact bleeding, genital tumours, ectopic pregnancies and increased susceptibility to HIV. Symptoms may mimic those typical of sexually transmitted infections (STIs) and women with genital schistosomiasis may be incorrectly diagnosed. An expert consensus meeting suggested that the following findings by visual inspection should serve as proxy indicators for the diagnosis of schistosomiasis of the lower genital tract in women from S. haematobium endemic areas: sandy patches appearing as (1) single or clustered grains or (2) sandy patches appearing as homogenous, yellow areas, or (3) rubbery papules. In this atlas we aim to provide an overview of the genital mucosal manifestations of schistosomiasis in women.S. haematobium in Malawi, Zimbabwe, South Africa and Madagascar. Images and specimens were sampled from sexually active women between 15 and 49 years of age. Colposcopic images of other diseases are included for differential diagnostic purposes.Photocolposcopic images were captured from women, between 1994 and 2012 in four different study sites endemic for This is the first atlas to present the clinical manifestations of schistosomiasis in the lower female genital tract. It will be freely available for online use, downloadable as a presentation and for print. It could be used for training purposes, further research, and in clinical practice. Sandy patches and rubbery papules identified by visual inspection may serve as indicators for the diagnosis of genital schistosomiasis. However, text books do not contain this information and it is not taught in medical school or to nurses serving these patients in endemic areas. The aim of this Atlas is to present the photocolposcopic manifestations of schistosomiasis in the lower female genital tract. Photocolposcopic images were captured from women between 15 and 49 years of age, between 1994 and 2012 in four different sites endemic for S. haematobium in Malawi, Zimbabwe, South Africa and Madagascar. This is the first atlas to present the clinical manifestations of schistosomiasis. Two types of sandy patches, abnormal blood vessels and rubbery papules are shown, as well as differential diagnoses. PloS NTDs makes it possible for all to access this information.Female genital schistosomiasis commonly remains undiagnosed due to its unacknowledged clinical manifestations. Millions of women in endemic areas are infected, and many suffer from abnormal vaginal discharge, contact bleeding, genital tumours, ectopic pregnancies, and an increased susceptibility to HIV.  S. haematobium in the lower female genital tract for clinicians, researchers and health professionals in training. The material is based on investigations by the group in the last 20 years in, Malawi, Zimbabwe, Madagascar and South Africa.The objective of this paper is to provide an overview of gynaecological lesions due to S. haematobium; however, cases of urogenital infections with other schistosome species have been reported. S. haematobium is particularly common in Africa, but may also occur in the Middle East. Previously, S. haematobium infection has been referred to as urinary schistosomiasis Urogenital schistosomiasis is most commonly caused by Female genital schistosomiasis affects at least 16 million women in endemic areas, and may cause abnormal vaginal discharge, contact bleeding, ectopic pregnancy, and possibly an increased susceptibility to HIV S. haematobium in the lower genital tract may be identified by the colposcopic examination of the cervix, vagina and vulva  smears have been shown to have a low sensitivity for the diagnosis of schistosomiasis in the female genital tract Serology, Circulating anodic antigen (CAA), Eosinophil Cationic Protein (ECP) and Eosinophil Protein-X  do not provide information of the location of the clinical problem. Serological tests range from 70% in sensitivity and will very often remain positive after treatment. CAA may indicate the presence of a live worm, but will be negative if the parasites are dead and the ova calcified. The eosinophil products rely on the host's eosinophil reaction to the ova. In chronic disease, this is often not present. Furthermore, eosinophil tests may become positive in other diseases, such as asthma In Zimbabwe, the Provincial and District Medical Directors, the village headman and village meetings gave their permission to conduct the study. Ethical approval was given by the Medical Research Council of Zimbabwe and by the ethical committee of the Special Programme for Research and Training in Tropical Diseases Research, UNDP/WB/WHO. While in Malawi, ethical approval was given by the Medical Ethical Committee of Malawi, Ministry of Health and Environmental Affairs 1993 and by UNDP/WB/WHO TDR. In South Africa, four ethics' committees granted permission to perform the study; Biomedical Research Ethics Administration, University of KwaZulu-Natal (KZN), Department of Health, Pietermaritzburg, KZN, Regional Ethics Committee (REK) Eastern Norway, and the European Group on Ethics in Science and New Technologies 2011. The Departments of Health and Education in KwaZulu-Natal gave local permission. In Madagascar, ethical permission was obtained from the Committee of Ethics at the Ministry of Health in Madagascar.Study information was provided to the study populations in the local languages. Informed oral or written consent was obtained. Oral informed consent was obtained in Malawi some hours prior to the investigations. It was done in accordance with the ethics approval from the Ethical committee of the Special Program for Research and Training in Tropical Diseases Research/World Bank/World Health Organization in1993 and documented on the interview forms as was general practice at the time and location. In the three other study sites, written informed consent procedures were performed. Furthermore in each of the study sites the woman was asked before each step if she was willing to participate. Following consent, all women who fulfilled the inclusion criteria were offered gynaecological examination . ConsentS. haematobium in Malawi, Zimbabwe, South Africa and Madagascar between 1994 and 2012. All areas were low-endemic for S. mansoni. In all sites, except for Madagascar, some women had access to safe water sources; however, rivers were commonly used or had been used for laundry, playing and bathing  single or clustered grains or (2) sandy patches appearing as homogenous, yellow areas . The graRubbery papules were only found and documented in Madagascar , 17. TheMicroscopic examination of the cervicovaginal schistosome lesions frequently reveals viable and/or dead schistosome eggs in the stroma , 19. No In contrast to cervicovaginal schistosomiasis, CIN causes an aceto-white positive reaction. CIN is located within the transformation zone whereas schistosomiasis may be located anywhere in the genital mucosa. CIN and schistosomiasis have variable margins, surface contours and vascular patterns. The low-grade CIN lesions are characterised by feathery margins (“geographic”) and smooth surfaces . This maThe finding of abnormal blood vessels should always raise the suspicion of malignancy . The mucS. haematobium ova have been found inside condylomas that have not been explored for HPV aetiology.Aceto-white reaction positive lesions with sharply demarcated, elevated and cauliflower-like surfaces, mostly multiple and located outside the TZ. To date schistosomiasis has not been found to be associated with human papillomavirus (HPV) infection; however, The normal finding of Nabothian cysts may represent a differential diagnosis to the homogenous sandy patches and rubbery papules , 23. SucS. haematobium eggs may be found in such cases but are not necessarily the cause  single or clustered grains or (2) sandy patches appearing as homogenous, yellow areas or (3) rubbery papules.To diagnose cervicovaginal schistosomiasis all mucosal surfaces must be inspected with an good (non-LED) light sourceThe genital damages have been found to be independent of current water body contact, is acquired in childhood and may increase the risk for other infections, such as HIV Several rounds of anti-schistosomal treatment may be needed to alleviate symptoms. However, clinical findings may persist, and there may be need for invasive, non-pharmaceutical treatment Have you ever, in your lifetime visited a rural/peri-urban area ? When and where? In these areas do you recall having had contact with fresh water? Did you cross streams to get somewhere? Did you ever fetch water in a river or a lake? Did you go on a boat or fish? Is there any possibility that your tank water was taken from an unsafe water source? Are you sure they used chemicals to clean it?Have you ever had red urine, genital ulcers, swellings/protuberances or genital discharge? Has anyone in your family had this?Have you ever been treated for schistosomiasis/Bilharzia? When and where?Checklist S1STROBE checklist.(DOC)Click here for additional data file.Text S1Glossary and definitions in this atlas.(DOCX)Click here for additional data file.


Nylanderia fulva virus 1 (NfV-1), the first virus identified and characterized from the ant, Nylanderia fulva. The NfV-1 genome (GenBank accession KX024775) is 10,881 nucleotides in length, encoding one large open reading frame (ORF). Helicase, protease, RNA-dependent RNA polymerase, and jelly-roll capsid protein domains were recognized within the polyprotein. Phylogenetic analysis placed NfV-1 in an unclassified clade of viruses. Electron microscopic examination of negatively stained samples revealed particles with icosahedral symmetry with a diameter of 28.7±1.1 nm. The virus was detected by RT-PCR in larval, pupal, worker and queen developmental stages. However, the replicative strand of NfV-1 was only detected in larvae. Vertical transmission did not appear to occur, but horizontal transmission was facile. The inter-colonial field prevalence of NfV-1 was 52±35% with some local infections reaching 100%. NfV-1 was not detected in limited samples of other Nylanderia species or closely related ant species.We report the discovery of   •Nylanderia fulva.A new positive-strand RNA virus was discovered in the ant, •The Nylanderia fulva virus 1 genome was comprised of 10,881 nucleotides.•NfV-1 was detected in larval, pupal, queen and worker ants, but not eggs.•Replication of NfV-1 appeared to be limited to the larval stage. We describe the genome organization and phylogeny of NfV-1 among related RNA viruses and characterize the virus infection in its host, tawny crazy ant, N. fulva.In 2012, we employed a metatranscriptomics—next generation sequencing approach to facilitate discovery of potential viral natural enemies of tawny crazy ant . From th22.1Nylanderia fulva virus 1 (NfV-1) was constructed by compiling sequences acquired from a series of three successive 5′ RACE reactions, a 3′ RACE reaction, and contiguous sequence 3776.C1 identified previously from the transcriptome of the ant (Genbank accession KX024775). The NfV-1 genome sequence contained 58% adenine/uracil, and 42% guanine/cytosine. The genome contains a single large open reading frame (ORF) (The genome of  the ant . Two othme (ORF)  of the pme (ORF)  identifime (ORF) , indicatme (ORF) . Given tme (ORF) . In SINVApplication of HHpred to the NfV-1 polyprotein sequence also revealed an Ovarian Tumor (OTU) domain upstream of Hel, and a dsRNA-binding protein , VP1-FSD  and VP2 (encoded downstream of FSD) can be expressed from the genomic RNA (gRNA); however, a subgenomic RNA (sgRNA) is also produced during virus infection from which only the dsRBP and capsid proteins can be expressed . VP1 has2.2Sequences similar to NfV-1, SINV-3 and APV were identified in the NCBI non-redundant nucleotide (nr/nt) and Transcriptome Shotgun Assembly (TSA) databases using tblastn. A total of 17 sequences with full or substantial genome coverage were selected for further analysis ; Fig. 2.Solinviviridae [type species Solenopsis invicta virus 3] and Acypiviridae [type species Acyrthosiphon pisum virus]. NfV-1 clusters within the SINV-3 clade.To establish an RdRp-based phylogeny, we extracted the picornavirus-like superorder RdRp alignment provided in supplementary file 2 of Sitobion avenae [Arthropoda: Insecta: Hemiptera] TSA) have similar genome structure, including conservation of two predicted overlapping genes that might be translated via leaky scanning on the inferred sgRNA (Drosophila species (Arthropoda: Insecta: Diptera)  TSA, derived from 454 sequencing, apparently had a number of frame-shift sequencing errors, but no change in reading frame corresponding to the APV frameshift site. Thus the sequence from Clavigralla tomentosicollis is likely to be monocistronic, similar to the Thika and Kilifi virus sequences to which it is most closely related. More distantly related were the TSAs from Eucyclops serrulatus (Arthropoda: Maxillopoda: Cyclopoida) and Anurida maritima (Arthropoda: Collembola: Poduromorpha). For the Eucyclops serrulatus TSA, the characteristic dsRBP domain downstream of RdRp was not found but instead was replaced with a predicted zinc-finger domain.Within the APV-clade, three closely related aphid-derived sequences  , lack thDiptera)  but instMonomorium pharaonis (Arthropoda: Insecta: Hymenoptera) had a very similar genome organization to SINV-3 but also encoded a potential overlapping gene that might be translated from the inferred sgRNA (Diabrotica virgifera (Arthropoda: Insecta: Coleoptera) TSA, derived from 454 sequencing, had two frame-shift sequencing errors which could be accurately corrected by amino acid alignment to the Meligethes aeneus (Arthropoda: Insecta: Coleoptera) TSA sequence, following which both the Diabrotica virgifera and partial Meligethes aeneus sequences appeared to be monocistronic, but otherwise consistent with the SINV-3 genome architecture. More divergent TSA sequences from Liposcelis bostrychophila (Arthropoda: Insecta: Psocoptera) and Leptinotarsa decemlineata (Arthropoda: Insecta: Coleoptera) also appeared to be monocistronic but, while the Leptinotarsa decemlineata TSA displayed the characteristic gene order Hel-Pro-RdRp-dsRBP-JR, the dsRBP and JR domains could not be identified with HHpred in the Liposcelis bostrychophila sequence. It is possible that this sequence represents a “chimeric” virus that has acquired a different C-terminal gene block (perhaps containing novel capsid proteins) or, alternatively, the TSA sequence may be misassembled at the 3′ end. Finally, a TSA sequence from Menopon gallinae (Arthropoda: Insecta: Phthiraptera) appeared to be dicistronic. While we could not rule out sequencing/assembly errors being responsible for the “broken” ORF, the dicistronic architecture with Hel-Pro-RdRp encoded in the 5′ ORF and the capsid proteins encoded in the 3′ ORF would be compatible with the production of a sgRNA in viruses of this clade. KFV has a rearranged genome structure and may be misassembled , ORF3 encodes a minor capsid protein, and ORF1 encodes a viral suppressor of RNAi  Ekström. Althoug2.3Particles purified from NfV-1-infected tawny crazy ants migrated to a density of 1.287±0.012 g/ml CsCl. Electron microscopic examination of negatively stained samples revealed particles with icosahedral symmetry, vaguely visible surface projections (spikes), and a diameter of 28.7±1.1 nm . RT-PCR 2.4p<0.05) lower compared with larvae, pupae, and queens (n=4) or collected directly by known NfV-1-infected queens (n=5) suggesting that virus is not vertically transmitted.NfV-1 was detected in all stages of the ant examined except eggs. NfV-1 was regularly detected in workers, larvae, pupae, and queens . Intra-cd queens . NfV-1 tN. fulva, the mean inter-colonial prevalence of NfV-1 was 52.4%  strand of NfV-1 was detected in RNA samples collected from larvae, but not workers, indicating replication of the virus, confirming previous experiments (n=3) and uninfected colonies . Five infected queens produced a mean (±SE) of 38.4 (±19.9) eggs/24 h, while the uninfected queens (n=13) exhibited a mean oviposition rate of 67.5 (±12.4) eggs/24 h.NfV-1 was transmitted to uninfected colonies by feeding. NfV-1 was detected in eriments . No signies n=5, . Colonie3Myrmecamorba nylanderiae, a microsporidium (Nylanderia fulva virus 1 (NfV-1). The 10,881 nucleotide RNA genome was monopartite, monocistronic, single-stranded, and possessed a poly(A) tail at the 3′ end of the genome. Sequencing also revealed that the three fragments identified in the earlier study  were all part of the same virus genome.Recent emergence and limited scientific inquiry have hampered efforts to control tawny crazy ant. Control methods are limited currently to chemical insecticides, so discovery of natural enemies is sorely needed to develop sustainable control methods. To date, efforts to identify biologically-based control organisms of tawny crazy ant have led to the discovery of poridium  and putaporidium . The putporidium . Blast aporidium  of nucleporidium . Using sCaliciviridae. A single picorna/calici-like jelly-roll capsid domain was predicted downstream of the RdRp domain, making the genome structure more calici-like than picorna-like. The related virus SINV-3 has been shown to produce a sgRNA for capsid protein expression, which is another calici-like feature of these viruses. Phylogenetic analysis of the RdRp amino acid sequence placed NfV-1 in a clade with SINV-3, KFV and several arthropod-derived TSA sequences. APV, rosy apple aphid virus, Thika virus, Kilifi virus and several other arthropod-derived TSA sequences formed a separate sister clade  and Acypiviridae .Analysis of the NfV-1 genome revealed superfamily III helicase, 3C-like protease, and superfamily I RdRp domains in the order Hel-Pro-RdRp, characteristic of members of the order Picornavirales and family er clade . In bother clade . These tDicistroviridae)  . In the n “Z” in . While mn “Z” in ; thus thn “Z” in .n=2) becoming infected (D.H.O unpublished data). This same problem was encountered with SINV-3 and its host, the red imported fire ant, Solenopsis invicta  and pupae. The purpose of these experiments was to determine which developmental stages were infected, not necessarily to examine viral pathogenesis, so the NfV-1 titer may actually be higher in different stages depending on the infection time course. The NfV-1 replicative strand was only detected in the larval stage. However, failure to detect the replicative strand in the adult stage does not necessarily suggest that it is not involved in NfV-1 pathogenesis. Indeed, low NfV-1 titer and the absence of the replicative genome strand in worker ants may be attributed to RNA degradation. Worker ants were shown previously to contain a potent RNA degrading substance . LocalizN. fulva according to the phylogeny-based system proposed by Nylanderia genus  and reported to exhibit unexplained extensive reductions and corresponding disappearance from established areas , near Winter Garden (Lake Co.), Lakewood Ranch (Manatee Co.), and Callahan (Nassau Co.) Florida. Colonies were generally obtained from dead branches or in man-made debris such as beverage cans and nested plant pots. For the field prevalence experiments, workers and larvae were often collected under leaf litter and at the bases of trees or shrubs. Multiple collections within a site were a minimum 30 m apart. Ants were anaesthetized on an ice pack and preserved in 95% ethanol in the field. Ants were identified by morphological examination of workers and male alates using available keys and descriptions  also using contig 3776.C1 as template. cDNA was synthesized from total RNA (1 µg) using an oligo dT primer. The cDNA was amplified by PCR with a GSP  and the Once a draft of the genome was acquired, overlapping gene specific oligonucleotide primers were designed and used to amplify the entire genome with a minimum of 5-fold coverage.4.3Domains within virus and TSA inferred amino acid sequences were identified using National Center for Biotechnology Information (NCBI) blastp  and HHpr4.4Nylanderia fulva ants, which targeted a portion of the virus genome. N. fulva colonies were collected from various locations in Florida, returned to the laboratory, and RNA was extracted from 10 to 20 ants from a colony using Trizol reagent according to the manufacturer׳s directions. cDNA was synthesized with oligonucleotide primer, p1168 (Reverse transcription polymerase chain reaction (RT-PCR) was used to identify NfV-1-infected r, p1168 , and PCRg and the supernatant collected by pipette. The supernatant was layered onto a discontinuous CsCl gradient (1.2 g/ml and 1.5 g/ml), which was centrifuged at 190,000g for 2 h in a Ti50.1 rotor. A whitish band visible near the interface was removed and brought to a density of 1.3 g/ml CsCl. This sample was then centrifuged at 330,000g for 18 h in a Ti70.1 rotor. A faint opaque band at 1.287±0.012 g/ml was collected. Approximately 10 μl of the gradient purified viral suspension was placed onto a formvar coated grid for 5 min and the excess removed. A 2% (w/v) aqueous phosphotungstic acid (PTA) adjusted to pH 7.5 with 1 N NaOH was applied (10 μl) to the grid for 2 min, the excess was removed and allowed to air dry. The negatively stained specimens were viewed and viral particles photographed with a Hitachi H-600 transmission electron microscope  at an accelerating voltage of 100 kV.NfV-1 was purified by discontinuous and isopycnic centrifugation. A mixture of worker and larval stages (12 g) were homogenized in 120 ml of NT buffer  in a Waring blender on high speed for 2 min. The mixture was filtered through 8 layers of cheesecloth and then extracted with an equal volume of chloroform for 10 min with constant shaking. The mixture was centrifuged for 5 min at 50004.5n=87 larvae, 25 pupae, 24 queens, 46 workers). Presence of NfV-1 was also evaluated in egg clusters. RNA was isolated and RT-PCR conducted.The NfV-1 intra-colonial infection rate was determined in individual larvae, workers, queens, and pupae of known virus-infected colonies. Total RNA was isolated from individual ants and RT-PCR was conducted as described above using oligonucleotide primers p1167 and p1168. Individuals from 14 different colonies were examined  from colonies directly in the field. RT-PCR was subsequently conducted to detect the virus as described.The NfV-1 inter-colonial infection rate was also determined by examining 2, 5 μl of the cDNA synthesis reaction, and 10.7 μl of DEPC-water. QPCR conditions consisted of one cycle at 50 °C for 2 min and 95 °C for 10 min, followed by 35 cycles at 95 °C for 15 sec, 60 °C for 1 min. The non-template control for QPCR included a complete cDNA synthesis reaction devoid of RNA template. A standard curve was constructed from a plasmid clone of the corresponding NfV-1 genome region (nucleotides 1011–1187) using a copy number range of 103–108 copies. Reaction efficiencies were determined by regressing CT values against the template copy number (log) and calculated according to the formula [E=(10−1/slope)−1]  in a 25 μl reaction volume. The reaction contained 12.5 μl of SYBR Green SuperMix , 0.4 μl each of 10 μM NfV-1-specific primers , 3 mM MgCllope)−1] . Reaction=10) from known NfV-1-infected colonies and used as template for RT-PCR detection of the replicative genome strand by the modified method of 2, 200 μM dNTP mix, 0.5 units of Platinum Taq DNA polymerase (Invitrogen), 0.2 μM of each oligonucleotide primer (p1362) [genome region 6469–6492] and TAG [5′GGCCGTCATGGTGGCGAATAA], and 5 μl of the cDNA preparation. The temperature cycling program was 1 cycle at 94° C for 2 min, 35 cycles of 94 °C for 15 s, 59 °C for 15 s, 68 °C for 30 s, and 1 cycle of 68 °C for 5 min. PCR products were separated on an agarose gel (1%) and visualized by SYBR-safe (Invitrogen) staining.Active virus replication was evaluated by detection of the replicative genome strand of NfV-1. Total RNA was extracted from a pooled group of workers or larvae (Nylanderia (following Prenolepis (Host specificity of NfV-1 was examined by testing 9 species of ants within the genus enolepis  for the enolepis . These a4.6N. fulva colonies a sucrose solution containing a homogenate of NfV-1-infected ants (workers and brood). Eight N. fulva laboratory colonies were established from field colonies collected near Winter Garden (Lake Co.) and Callahan (Nassau Co.) Florida. All colonies were determined to be free of NfV-1 infection by RT-PCR. Colonies consisted of an average (±SD) of 1600 (±346) adult worker ants, 1.0 (±1.0) ml of brood , and an average of 7 queens  and were confined to trays with harborage and nesting tubes. Four colonies were starved for 1 day then exposed to virus by feeding them a homogenate of NfV-1-infected ants in 25% (w/v) sucrose solution. A small glass test tube filled with 7–8 ml of the solution and plugged with cotton was placed within each tray. In addition a droplet (1 ml) of the solution was provided on a small weigh boat to provided unfettered access to the virus solution. The ant colonies were allowed to feed on the virus preparation for 3 days and then it was removed and replaced with unadulterated 25% sucrose, water, live house fly (Musca domestica) larvae and frozen crickets (Acheta domesticus), ad libitum. Four corresponding colonies were used as negative controls and fed 25% sucrose solution without NfV-1-infected ants. Colonies were maintained at ambient room temperature and relative humidity that averaged (±SD) 24.4 (±2.1) °C and 39 (±12.5)%, respectively.Horizontal transmission of NfV-1 was evaluated by feeding n=5 pooled) from each colony were examined for the presence of NfV-1 by extracting total RNA and conducting RT-PCR 6 days after exposure to the virus preparation. Colonies were re-inoculated 16 days after the initial inoculation. Larvae and adult workers (n=5 per colony for each stage) were subsequently sampled at 27, 76, 139 days after the initial inoculation and tested for NfV-1. The number of ants, brood volume, and the presence of queens were recorded for each colony to determine potential colony level effects of virus infection at 2, 10 and 19 weeks after initial inoculation. The percent change in brood volume and worker counts after 19 weeks were compared between persistently infected (NfV-1 detected on more than one sampling) and uninfected colonies by t-test .Larval ants (n=19 queens) at 24.9 (±0.9 SD) °C and 23.5 (±0.1 SD)% RH. Eggs were counted within each tube under a dissecting microscope. Queens were obtained from seven colonies used in the transmission test of which NfV-1 was detected in two colonies. A total of 9 queens were sampled from the infected colonies and 2 queens each were collected from the five uninfected colonies. The queens were removed from the vials and placed into a different clean 1.5 ml tubes. The egg clusters were washed with 1 ml of RNAse-free water two times and collected at the bottom of each tube by centrifugation. Total RNA was extracted from the paired queen and water-rinsed eggs and RT-PCR was conducted to detect the presence of NfV-1 as described.Vertical transmission of NfV-1 was evaluated by confining individual queens in 1.7 ml microcentrifuge tubes for 24 h  data were subjected to analysis of variance using the general linear models procedure . When si