Type 2 diabetes (T2D) and its complications cause a significant public health and economic challenge. To enable the optimal resource allocation across different prevention and treatment policies for the management of T2D-related complications, detailed cost estimates related to the complications of T2D are needed. Therefore, the objective of the study was to provide reliable and sufficiently detailed real-world estimates of costs associated with different T2D complications in a Finnish university hospital setting.A cohort of T2D patients living in the catchment area of a university hospital during 2012 and 2016 was identified from the comprehensive national FinDM diabetes database for longitudinal assessment of T2D associated complication treatment costs. Data on patient-level events were extracted from the FinDM data and complemented with all accountable services and related detailed costing data gathered from the university hospital’s electronic patient information systems by using unique personal identity codes. Patients were screened for their first diagnoses of complications using the same national quality registry definitions as in the FinDM database. Multivariable gamma regression model with a log link function was applied to study the association between baseline factors and complication costs. In addition, an interactive online tool was developed to create predicted costs for complication costs with selected baseline factors.A total of 27 255 prevalent and incident patients with T2D were identified from the national FinDM register. Finally, a total of 16 148 complication episodes for 7 895 patients were included in the cost analyses. The mean estimated one-year hospital treatment costs of T2D-related complication varied from 6 184 to 24 507 euros per complication. Regression analyses showed that coexisting conditions are significantly associated with initial and recurrent complication costs.The study shows updated Finnish cost estimates and their main cost drivers for T2D-related complications treated in the university hospital setting. The results of our study highlight the significance of guideline implementation, effective preventive treatments for T2D, as well as the importance of treatment adherence to avoid these costly complications.The online version contains supplementary material available at 10.1186/s12913-022-07895-6. The increasing epidemic of type 2 diabetes (T2D) and its complications cause a significant public health and economic challenge. Currently, the global prevalence of T2D is around 8,4% . T2D is It is not only the disease itself but mainly complications, that adversely affects to quality of life, life expectancy and being behind the overall costs around to T2D . ComplicIn Finland, patients with T2D are typically treated and monitored in primary health care, where over 300 municipalities  are responsible for the provision of these services to their residents. Health centres commonly have General Practitioner (GP)-run inpatient units, largely for chronic and long-term care patients. In addition, these Finnish municipalities form 20 hospital districts to provide hospital care as secondary and tertiary settings. Secondary care  is mainly provided by hospitals and tertiary care is delivered in five university hospitals. Patients need a referral to access specialist care, except for emergency cases. The management and follow-up of T2D patient population with micro- and macrovascular complications takes place in hospital setting in Finland.N = 5.5 million).The present study was conducted in Kuopio University Hospital (KUH), which provides the secondary health care services for around 250 000 citizens in its catchment area. In addition, it provides highly specialised tertiary health care services for around 810 000 inhabitants in Eastern and Central Finland, which is around 15% of all Finnish citizens  as well as other accountable services related the treatment and monitoring of patients with T2D complications.To evaluate costs at the complication level from the payer’s perspective, the costs taking place at more general resource related aggregate-level  must be assigned to actual outputs, i.e. to the treatment of patients at the hospital. The standard way is to assign the costs to the observed components of the given treatment using suitable weights determined using e.g. diagnosis related group (DRG) or per diem costs. In the current study, the unit and total costs were obtained from the detailed patient-specific municipality billing data linked to the study dataset from KUH’s financial administration system. The KUH’s financial administration data provides an exceptionally detailed classification of the components of the treatment that allows comprehensive “reconstruction” of the actual treatment costs. Those costs are linked to the primary admission (inpatient period or outpatient visit) and the calculated cost is the price that is accounted from the payer of the treatment .As part of the treatment during the follow-up period have been given in the other  hospitals within the hospital district, costs for other hospital care than given in KUH were calculated using the CRHC data containing reported costs for part of the service providers, and for the rest of the costs of in- and outpatient admissions observed in the CRHC data were approximated by weighting the available treatment data  using the published unit prices of health care .Finally, we had component specific cost data for each admission (costs time stamped to accounting/discharge date). All costs were deflated to the price level of 2019 using a price index for health care. We used those to derive the cost outcomes of which the one-year costs after the complication event was the primary one. One-year costs are widely used in health economics and capture the burden of costs associated with diabetic complications in a way that also allows comparisons to any other cost-estimates of one-year hospital costs. As the KUH is a public non-profit university hospital with accurate costing system operating in the Finnish welfare state providing universal access to care, it is likely that the costs mapped to the components reflect the “real” costs of the treatment in a generalizable way – at least in the sense that costs within the hospital are on the same scale so that the relative differences are reliably reflecting the real differences of costs within hospital.The statistical analysis unit was a complication event and there were six main classes of complications. For each complication event, three observation time periods were used: 1) the first year since the onset of complication, 2) the year preceding the complication, and 3) the second year since the onset of complication. The later time period was expected to reflect the ongoing long-term costs of complications, such as rehabilitation and monitoring, but also subsequent events of the same type , 9. The In addition, multivariable gamma regression models with log link functions taking an account to the positive skewness of cost data were applied to study the effects of patient characteristics on one-year costs and to generate covariate-adjusted mean estimates of one-year costs. For the incident complications, studied variables included sex, age, duration of T2D, and several comorbidities. In addition, death during the period of one year after the complication was included as a variable as that is known to modify the costs of treatment . For thehttps://uef-phoru.shinyapps.io/T2DCost/). The developed website application fits, in real time, customised regression models based on user-selected subset of predictors to predict the hospital treatment costs of different T2D-related complications.To dynamically estimate cost distributions for the patients with varying background characteristics, a Cholesky decomposition approach based on regression coefficients and covariance matrices of the models was used to simulate a large amount of possible predictions of the model for the populations with wanted background characteristics. In addition, freely accessible website application was developed for the further analysis of complication costs and their modifiers  at the beginning of 2012 to 21 600 (8.8%) at the beginning of 2018. About half of the prevalent T2D patients had admissions at KUH each year . A diagnosis code “diabetes with chronic complications”, which was recorded for 13.3%—67.6% of patients (depending on the type of a recurrent event), had also significant increasing effect on one-year costs (except for eye complications). Furthermore, moderate or severe renal disease as a coexisting condition increased one-year costs significantly in patients with recurrent events (except for neurologic complications). The average marginal effects for the regression coefficients, i.e. the average costs in euros in regard to unit increase of a variable, of incident and recurrent models are presented in Supplement tables SThe present study showed the substantial hospital treatment costs of T2D-related complications as average per-patient first-year treatment costs varied from 6 184 to 24 507 euros with total raw mean costs of 11 708 euros. On average, the treatment costs of incident complications were higher than the treatment costs of recurrent events (except for recurrent nephropathy complications). In case of all considered complications, a resource category with highest category-specific costs was the number of treatment days in hospital wards. Whereas, in a case of nephropathy complications, “other procedures” category  had the highest category-specific costs in patients with the recurrent complications. In addition, it is notable that the patients with recurrent nephropathy complications were also younger than patients with other complications, on average. This finding is a line with a recent real-world data study indicating patients with nephropathy complications as a patient subgroup with highest treatment costs . AlthougThe results of our study also showed that the mean complication costs were higher (with some exceptions) during subsequent second-year after the year of event than during a year before an index year of event indicating potential increased long-term service need due to occurred T2D-related complications. Furthermore, our multivariable analyses showed that many of coexisting conditions at the time of a complication event account significantly for one-year cost variability. As showed above, over 30% (60%) of patients with an incident (recurrent) complications had at least one coexisting condition at the time of a complication event indicating the importance of these associations in the accumulation of treatment costs. This finding is in a line with previous studies showing the type and combination of comorbidities may impact on access, intensity, and health care utilization patterns of care –19. Our https://uef-phoru.shinyapps.io/T2DCost/) allow to “predict” the detailed costs by a selection the patient characteristics, which hopefully provides some useful insights for end-users, when they consider trade-offs between accuracy and usability of these estimates e.g., when parametrising a health economic model under development, or just to increase awareness and understanding of the applicability as well as the possibilities (and limits) of health economic modelling of real-world data. In any case, it must be recognized that the model (and the online tool) only describes the systematic patterns that can be observed from the real-world data – those are not suggestions how things should go, and all the predictions must be carefully assessed before making any strong conclusions.In addition, in the era of the “precision medicine”, subgroup-specific cost estimates are increasingly needed (and required by HTA bodies) e.g., in health economic modelling studies evaluating the cost-effectiveness of new therapies for T2D in more and more specific patient subgroups. Our results and the accompanied web-application  determinants of T2D-related complications with a developed website application tool providing an opportunity to study the effect of selected baseline sociodemographic variables and co-existing comorbidities on the predicted complication costs in patients with and without the history of T2D-related complications at baseline. As far as we know, there is no similar type of real-world data studies that provide a such detailed description of costs in patients with T2D-related incident or recurrent complications. However, there are naturally also limitations that need to be considered when interpreting the results of the present study. First, we applied a real-world dataset collected mainly from the electronic patient information systems of one university hospital. This potentially limits the generalisation of study results since there might be differences in treatment practices and the unit costs of resources across hospitals. Second, we were not able to consider all cost components, such as travel costs, relevant for decision-making and resource allocation in health care. In some cases, such as in a case of nephropathy complications, this may underestimate the total costs of care. For example, it has been previously estimated that travel costs account for around 15% of total treatment costs for haemodialysis . More reAs a summary, this study shows updated Finnish one-year cost estimates for T2D-related complications treated in the university hospital setting. In a case of all complications (except for recurrent nephropathic complications), the number of treatment days in hospital wards is the most significant cost driver. The results of our study highlight the role of guideline implementation, effective preventive treatments for T2D, as well as the importance of treatment adherence to avoid these costly complications.Additional file 1.


Arteriviridae, expanding the known diversity and host range of this group of complex RNA viruses. Although the pathological relevance of these new viruses is not always clear, several well-studied members of the family Arteriviridae are known to be important animal pathogens. Here, we report the complete genome sequences of four new arterivirus variants, belonging to two putative novel species. These new arteriviruses were discovered in African rodents and were given the names Lopma virus and Praja virus. Their genomes follow the characteristic genome organization of all known arteriviruses, even though they are only distantly related to currently known rodent-borne arteriviruses. Phylogenetic analysis shows that Lopma virus clusters in the subfamily Variarterivirinae, while Praja virus clusters near members of the subfamily Heroarterivirinae: the yet undescribed forest pouched giant rat arterivirus and hedgehog arterivirus 1. A co-divergence analysis of rodent-borne arteriviruses confirms that they share similar phylogenetic patterns with their hosts, with only very few cases of host shifting events throughout their evolutionary history. Overall, the genomes described here and their unique clustering with other arteriviruses further illustrate the existence of multiple rodent-borne arterivirus lineages, expanding our knowledge of the evolutionary origin of these viruses. Recent years have witnessed the discovery of several new viruses belonging to the family  Over the past decade, the number of pathogens known to infect animals or humans has expanded considerably . Major aArteriviridae have emerged as important animal pathogens, although there are currently no known arterivirus species capable of infecting humans [In the past few decades, several members of the family g humans . Of partg humans ,7. Many g humans ,9,10. Fug humans . Arteriviridae have a positive-sense, single-stranded RNA genome, varying from 12–18 kb in length [All members of the family n length . The poln length ,15. In an length .Arteriviridae, there are currently 23 recognized arterivirus species spread across 13 genera in 6 subfamilies [Variarterivirinae, some others were found in reptiles and likely represent novel subfamilies within the family Arteriviridae, or even separate families [Following the latest reorganization of the family families . Furtherfamilies ,19,20. Arteriviridae, characterize virus–host phylogenetic relationships and propose their taxonomic clustering into two separate, novel genera in the Variarterivirinae and Heroarterivirinae subfamilies, respectively. In the present study, we describe the discovery and genome organization of two novel arteriviruses, Lopma virus and Praja virus, which were detected in rodents from Mozambique and Tanzania, respectively. We explore their evolutionary relationships with other members of the family Rodents were captured in four different countries between 2010 and 2013, with the aim to study the taxonomy and molecular ecology of rodent populations in sub-Saharan Africa ,27,28,29We revisited this sample collection, as part of a larger initiative to investigate the evolutionary relationships of hepaciviruses in small African rodents . To uncoIllumina reads were adapter and quality trimmed and subsequently de novo assembled using the CLC Genomics Workbench (v10.0.1). Arteriviral contigs were identified by performing a tBLASTx search of all contigs against a local database containing all available arterivirus RefSeq genomes . In totan = 4), thus resulting in a final collection of 38 sequences (Amino acid sequences of the ORF1ab were retrieved from each (putative) arterivirus species for which a coding complete genome sequence was available in GenBank. In addition to their amino acid sequences, metadata such as their accession number, information on the host species, sampling location and collection date were also obtained. In this dataset, we added the ORF1ab amino acid sequences of our novel genomes , followed by manual curation using Aliview (v1.18.1) ,33. FromHeroarterivirinae subfamily. We constructed the host phylogeny based on a credible distribution of 1000 trees obtained from VertLife.org for all identified rodents and one hedgehog host species that harbor arteriviruses [To investigate virus–host co-divergence patterns, we plotted the topology of the host phylogeny opposite the virus tree and examined their degree of association. For this analysis, we revisited the rodent-wide dataset and enriched it with one additional ORF1ab amino acid sequence obtained from a hedgehog , as thisiviruses . The co-iviruses . Praomys jacksoni or Jackson’s soft-furred mice from Tanzania and three Lophuromys machangui or Machangu’s brush-furred rats from Mozambique. For two of the Lophuromys samples, a near-complete genome sequence was obtained in a single contig from the Illumina data, while the three other samples yielded only fragmented assemblies. The two complete genomes obtained from the Lophuromys individuals share ~93% nucleotide identity and appear to be variants of the same virus species. Based on the genetic identity (>90% over >80% of the genome), the virus identified in the third Lophuromys rat most likely belongs to that same virus species, although a complete sequence could not be obtained due to the limited resources available. The Praomys arteriviruses are likely genomic variants of the same virus species, with ~89% identity on the nucleotide level. For these samples, the fragmented Illumina assemblies were further completed by PCR and subsequent Sanger sequencing. RACE was used to complete the obtained genome sequences. The resulting genomes are 13,739/13,738 (Lophuromys 1/2) and 14,146 nucleotides (Praomys 1 and 2) long and are highly divergent from each other, sharing only 33–35% nucleotide similarity, as determined by PASC [Lophuromys machangui) and Praja virus (Praomys jacksoni), respectively. Both the Lopma virus and Praja virus are significantly different from all known arteriviruses, sharing respectively 47.3–47.7% (Lactate dehydrogenase-elevating virus 1) and 41.2–41.4% (forest pouched giant rat arterivirus) nucleotide similarity with their closest classified relatives. A set of 42 hepacivirus-positive mixed tissue RNA extracts was selected for Illumina sequencing . These s by PASC . Based oArteriviridae, with the exception of the subfamily Simarterivirinae. The genomes encode both the 1a and 1b parts of the viral polyprotein, as well as at least eight smaller ORFs found in all arterivirus genomes   . These shttp://www.cbs.dtu.dk/services/TMHMM/, last accessed on 22 December 2020). Both viruses share a similar genome organization, having the 1a and 1b genes that together encode the viral polyprotein, as well as the 2a, 2b, 3, 4, 5, 5a, 6 and 7 ORFs encoding structural proteins. Both viruses also encode a transframe (TF) that is presumably expressed through the joining of this ORF with the 1a ORF via -2 ribosomal frameshifting. This TF is predicted to have a transmembrane organization, as shown in the corresponding probability plots. Plots were made using the TMHMM web server v2.0  region of the 1a ORF, truncating the 1a polyprotein (-1) or joining it with a transmembrane region encoded on a different reading frame (-2) ,41. Nsp2Arteriviridae, we inferred the phylogeny of all arterivirus species based on the deduced ORF1ab amino acid sequences. None of the known arteriviruses have been found in more than one host species. By indicating the corresponding mammalian host species for each virus species, it becomes apparent that arteriviruses appear to form host-specific groups with a limited number of cross-species transmission events  can be distinguished. All simian arteriviruses group together in a monophyletic clade (clade B), which is synonymous with the subfamily Simarterivirinae. Contrary to the well-confined nature of arteriviruses in primate hosts, rodent-borne arteriviruses are interspersed throughout the phylogenetic tree and form multiple divergent lineages in clades A and C. Three distinct groups can be distinguished, two in clade A and one in clade C. All viruses in the first group in clade A were identified in rodents from the Muridae family, while for the other group, the origin was more heterogeneous, involving two rodent families (Cricetidae and Chinchillidae) and one pig family (Suidae). Together, these two groups form the subfamily Variarterivirinae. Lopma virus clusters within this subfamily as a sister lineage to the other Muridae-borne viruses. The rodent-borne arteriviruses in clade C have been discovered in Muridae and Nesomyidae rodents. In addition to the two strains of Praja virus, this last group consists of the non-rodent hedgehog arterivirus 1 (HhAV-1), which was discovered in an Erinaceus europaeus from the UK (MT415062), and the distantly related forest pouched giant rat arterivirus (KP026921), the only previously known rodent-borne arterivirus sampled in Africa. The clustering of Lopma virus and Praja virus as distinct lineages within their respective subfamilies was also validated by comparing a conserved part of the ORF1ab polyprotein for all known and putative arterivirus species . Additionally, arteriviruses found in Cricetidae rodents all group together, while an arterivirus hosted by a chinchilla (Chinchilla lanigera) falls outside of this clade as an outgroup. Finally, a single arterivirus obtained from a Cricetomys emini rat (family Nesomyidae) forms a sister lineage to the Praja virus variants, highlighting the relatively close phylogenetic relationship between the arteriviruses from these rodent hosts, even though their most recent common ancestor indicates a much deeper evolutionary branching event. As a next step in our analysis, we reconstructed the phylogeny of all full-length rodent-borne arteriviruses . VirusesRattus and Bandicota genera, but also from the Myodes, Caryomys, Microtus, Mus and Lophuromys genera. However, some host shifting events are also evident in the tanglegram of Cricetulus longicaudatus, Praomys jacksoni, Cricetomys emini, Chinchilla lanigera rodent species as well as with the Erinaceus europaeus hedgehog. To assess the co-divergence between arteriviruses and a subset of their hosts, we mapped the viral phylogeny to the evolutionary lineages of rodents and a single hedgehog host species . In geneIn the last few years, arteriviruses have been discovered in a diverse group of mammals, the majority being in rodent and primate species. Despite the absence of human arterivirus reports, these pathogens pose a considerable threat to livestock health and wildlife . In the A series of analyses were performed to characterize the genome organization of the Lopma and Praja viruses. Comparable to most arteriviruses, the genomes of both Lopma virus and Praja virus contain the necessary motifs required for ribosomal frameshifting. In addition to the expression of the 1ab polyprotein, ribosomal frameshifting is used by arteriviruses to join a transmembrane domain to the nsp2 region in the 1a ORF . Nsp2 isLophuromys machangui rodents from the same location in Mozambique. Brush-furred mice are found throughout sub-Saharan Africa, and little is known about their role as virus reservoirs [Lophuromys machangui individual, as well as several hepaciviruses in different Lophuromys rats [Praomys jacksoni mice captured in Tanzania. Akin to brush-furred mice, Jackson’s soft-furred mice are found throughout East Africa, and besides our recent discovery of hepaciviruses in these mice [On a host species level, our data show that Lopma virus was detected in three servoirs . Howevermys rats ,48. Prajese mice , their rVariarterivirinae as sister lineages to several other yet unclassified rodent-borne arteriviruses. Most of these unclassified arteriviruses have been detected in rodents from the Muridae and Cricetidae families and show strong evidence of confinement to these hosts. Whether the propensity of such rodents to harbor arteriviruses indicates a possible evolutionary origin in these rodent families or if this is due to the sheer number of rodent species that these families contain needs to be interpreted with caution. Praja virus, conversely, does not fall within the subfamily Variarterivirinae but clusters distantly within the Heroarterivirinae subfamily. As described above, the closest relatives of Praja virus are HhAV-1 of the European hedgehog and forest pouched giant rat arterivirus, the latter being the only known rodent-borne arterivirus that lies outside of the subfamily Variarterivirinae [The relatively high diversity of arteriviruses in rodents and prominence of rodent hosts throughout the arterivirus tree seems to indicate a deep evolutionary history of arterivirus infections in rodent hosts. Although rodents are not currently believed to be active reservoirs for known livestock pathogenic arteriviruses, the results presented here do argue for rodents as ancient arterivirus reservoir hosts from where the virus has passed to other mammalian species . This isivirinae ,37. ThisArteriviridae has been reorganized twice in recent years and there are currently no clear guidelines for the classification of novel arteriviruses. In 2016, it was decided to use the NCBI Pairwise Sequence Comparison (PASC) tool for taxon demarcation within the family Arteriviridae, using 39–41% and 71–77% as genus and species cut-offs, respectively [Arteriviridae. This is further supported by the low amino acid similarity between Lopma virus and Praja virus and their corresponding most closely related sequence when comparing the regions of the ORF1ab polyprotein that contain the five abovementioned conserved domains. In accordance with the current ICTV nomenclature, these genera could be named Xiarterivirus and Omicronarterivirus, respectively.The taxonomy of the family ectively . Accordiectively . This noVariarterivirinae. Given the considerable impact arteriviruses have on agriculture and livestock health, further research is needed to identify the role that rodent hosts play in the spread of arteriviruses and to characterize the possible routes of transmission between and/or among those hosts.In conclusion, we present here the complete genome sequences of four novel arterivirus strains that represent two new virus species. Both Lopma virus and Praja virus were discovered in African rodents and have the archetypical arterivirus genome organization. These sequences considerably increase the diversity of known arteriviruses from Africa, since only a single rodent arterivirus genome was previously available from the continent. Additionally, their unique positions in the arterivirus phylogenetic tree provide new insights into the evolution of rodent-borne arteriviruses, with Praja virus further illustrating the existence of rodent-borne arterivirus lineages outside the subfamily


Cydia pomonella: two Cydia pomonella granulovirus genotypes, CpGV-M and CpGV-R5, and Cryptophlebia peltastica nucleopolyhedrovirus (CrpeNPV). The influence of the order of ingestion of the virus genotypes, the existence of an ingestion delay between the genotypes and the specificity of each genotype involved in the success of multiple infection were studied in the case of Cydia pomonella resistance. To obtain a multiple infection in resistant insects, the order of ingestion is a key factor, but the delay for ingestion of the second virus is not. CrpeNPV cannot substitute CpGV-R5 to allow replication of CpGV-M.The genetic diversity of baculoviruses provides a sustainable agronomic solution when resistance to biopesticides seems to be on the rise. This genetic diversity promotes insect infection by several genotypes  that are more likely to kill the host. However, the mechanism and regulation of these virus interactions are still poorly understood. In this article, we focused on baculoviruses infecting the codling moth,  The use of pathogens is a well-known approach for biological control of insect pests. Among them, members of the baculovirus family are widely used as crop protection products ,2.Alphabaculovirus, Gammabaculovirus and Deltabaculovirus, previously classified as nucleopolyhedroviruses (NPVs), while granules are found only in the Betabaculovirus that are also called granuloviruses (GVs). Polyhedra contain tens of virions while granules usually contain one (or sometimes more) virion [The most common way of infection for baculovirus-based biocontrol products is the oral ingestion of the virus by host larvae. Baculoviruses produce occlusion bodies (OBs) that facilitate the survival and transmission of the virus from one host to another. Two types of OB can be found in baculovirus, polyhedra and granules. Polyhedra are found in the genera ) virion ,4. When ) virion . Each nuBaculoviruses show a high level of genetic diversity. In a given virus population, diverse genotypes can be found. In addition, geographically distant virus populations can differ not only in the genotypes present, but also in their respective frequencies ,7.Spodoptera frugiperda MNPV (SfMNPV), or Autographa californica MNPV (AcMNPV), it has been demonstrated that various genotypes can be occluded in a single OB [In various MNPV, like ingle OB . This obingle OB . In suchingle OB .The various genotypes of a virus population differ in their biological characteristics, particularly the ability to overcome host defense mechanisms ,11. GenePhthorimaea operculella (Zeller) (Lepidoptera: Gelechiidae) it has been shown that some granulovirus isolates, which are mixtures of genotypes, have a higher pathogenicity than isolates composed of pure genotypes. It has also been shown that such association of different Phthorimaea operculella granulovirus (PhopGV) genotypes does not result in a “hybrid” genotype but that genotypes are maintained in stable frequencies over time [In SfMNPV, the genetic diversity of isolates is maintained and finely regulated during the different generations to guarantee the best efficiency. In multiple SfMNPV infections, each genotype appears to contribute to preserve the survival of the whole population ,17,18. Iver time ,20.Betabaculovirus) used as a bioinsecticide worldwide in the biological control of the codling moth, Cydia pomonella (Linnaeus) (Lepidoptera: Tortricidae), a pest of apples and pears. The first isolate of CpGV was found in Mexico. It is composed of a single genotype called CpGV-M. This isolate was used to develop commercial bioinsecticides extensively used in Europe since their approval in the nineties. However, after years of using CpGV-M, codling moth populations have developed resistance [CpGV is a granulovirus  were allowed to feed on mixtures of CpGV-M and CpGV-R5, successful replication of CpGV-M was detected. Surprisingly, these mixed virus populations appear to be more effective in controlling RGV resistant individuals than CpGV-R5 alone [Five types of resistance in escribed . They diescribed . In laboR5 alone . SimilarR5 alone . In our Cryptophlebia peltastica nucleopolyhedrovirus (CrpeNPV) [Once the order and the delay of ingestion was characterized, it was necessary to determine (i) if the help needed for CpGV-M replication in a non-permissive insect is generic, for example by weakening the host, making it permissive to a second infection, regardless of the first pathogen, or (ii) the help provided to CpGV-M is specific to CpGV-R5. To that end, we tested the ability of another baculovirus to act as helper for CpGV-M. The CrpeNPV)  is able CrpeNPV) , therefo®. CpNPP is a colony susceptible to CpGV-M and CpGV-R5 [CpNPP is the reference insect colony susceptible to CpGV-M and was provided by Natural Plant Protection . It originates from Northern France, and is used for the industrial production of Carpovirusine CpGV-R5 . The susGV insect colony is resistant to CpGV-M. This colony originates from a natural insect population collected in the field at Saint-Andiol (St-A) in the Bouches-du-Rhône region of France. Its resistance is characterized as dominant and carried by the Z sex chromosome (type I resistance). This colony remains susceptible to other isolates, such as CpGV-R5 [The R CpGV-R5 .50s are 13.10 (6.55–23.20), and 6.76 (2.6–13.37) OB·µL, respectively, while in RGV, CpGV-M and CpGV-R5 LD50s are 2.22 × 106 (1.19 × 106–5.67 × 106), and 22.43 (13.73–34.36) OB·µL, respectively [CpGV-M is the first recorded CpGV isolate, discovered in Mexico and described by Tanada in 1964 . Its genectively .C. peltastica (litchi moth). It has a genome of 115,728 bp (GenBank accession numbers: MH394321) [CrpeNPV is an SNPV isolated in 2018 in South Africa from H394321) . The CrpOB concentrations were estimated by counting on dark field light microscopy as previously described .GV larvae. Three independent assays were carried out. CpGV-M and CpGV-R5 viruses were deposited on different dishes of Stonefly Heliothis medium (20 cm²) at a concentration of 104 OB·cm−2. Neonate larvae were placed onto the surface of the 1st and then the 2nd virus treated medium (CpGV-M or CpGV-R5), for various durations . The larvae were then transferred to non-treated medium for 3 days. The larvae were then crushed individually and the virus resuspended into 200 µL of distilled water and analyzed by quantitative polymerase chain reaction (qPCR) coupled to high-resolution melting (qPCR/HRM)  see  below.GV neonate larvae were first allowed to feed on CpGV-R5 treated medium for 30 min (time necessary for ingestion of sufficient virus to result in double infection [Rnfection ). LarvaeGV was first verified (data not shown).It has been demonstrated that CrpeNPV is able to infect various codling moth colonies . The abi4 OB·cm−2. At 3 days, the larvae were collected and crushed into 200 µL. Each sample was split into two separate qPCR reactions and each amplicon was identified by HRM analysis.To check if double infections can occur using two virus species, neonate CpNPP larvae were exposed to medium (Stonefly Heliothis medium) inoculated with a virus mixture , with final concentration of 10GV neonate larvae were fed with a mixture of 50% CrpeNPV and 50% CpGV-M, and processed under similar conditions. Similarly, RGV third instars were fed with a mixture of 50% CrpeNPV and 50% CpGV-M with 2.22 × 104 OB·cm−2, collected at 4 days and processed under similar conditions.Lastly, to check if CrpeNPV can substitute CpGV-R5 for helping CpGV-M replication in resistant larvae, Rpe38 gene region using the primers CpGV-18734F (5′-GCCACCATTAGTGAATCATC-3′) and the reverse primer CpGV-18855R (5′-TAAGTCAGGACACCCAAACC-3′). The pe38 gene is involved in type I resistance of C. pomonella [qPCR was carried out in the conditions previously described . CpGV-M CrpeNPV was identified using the primers polh_CrpeNPV_F (5′-CGAGCATGAAATCGAGGAAC-3′) and polh_CrpeNPV_R (5′-ACTTCGTGAGGCACATAGTC-3′) targeting the polyhedrin region (GenBank accession no.MH394321) . CrpeNPVEach amplicon produced by the different viruses was submitted to HRM analysis. A melting curve step was added: 5 s at 95 °C then 10 s at 50 °C and increasing the temperature from 70 to 90 °C by steps of 0.2 °C, maintained for 10 s each. The software Biorad CFX maestro™ and Precision Melt Analysis™ were used for interpretation. To avoid possible interferences, amplifications of CpGV and CrpeNPV were carried out separately.GV larvae are resistant to the CpGV-M isolate and none were found infected with CpGV-M alone; they are susceptible to the CpGV-R5 isolate. In our experimental conditions, the proportion of larvae infected with CpGV-R5 varied from 50% to 80%, regardless of the order of ingestion.CpNPP larvae are susceptible to all viruses tested. RGV, when CpGV-M was ingested first, followed by CpGV-R5, no CpGV-M infection was observed. Conversely, if CpGV-R5 was ingested first, 5% to 20% of individuals were infected with both viruses  larvae were allowed to feed on mixtures of CrpeNPV and CpGV-M. The replication of each virus was detected using qPCR followed by HRM. The mean Tm (melting temperature) of CpGV-M and CrpeNPV amplicons were 81.8 °C and 84.4 °C, respectively, and their size was verified by electrophoresis (data not shown). The two peaks are clearly distinct, allowing non ambiguous identification of each infection. Each larva was analyzed separately. Replication of GV and NPV was detected in more than 70% of the CpNPP infected larvae, for both CpGV genotypes . As shown for CpNPP, it was found that RGV larvae are permissive to multiple infections.When RGV larvae were inoculated with CpGV-M and CrpeNPV-SA isolates. No RGV larva was found infected with CpGV-M in the presence of CrpeNPV, even when doubling the quantity of CpGV-M. Given the sensitivity of qPCR approaches, if CpGV-M replication had occurred, it certainly would have been detected. To check if the development stage was a factor influencing the multiple infection, a similar experiment was carried out with third instar RGV larvae. No double infection was detected.Finally, neonate RPseudaletia unipuncta, while the NPV alone could not replicate [trans complementation manner [Spodoptera littoralis NPV (SpliNPV). pif-1 deficient genomes can infect orally only if the virions contain active PIF-1 protein, that is, a cis complementation. Co-infection allowed pif-1 deficient genomes to be enveloped with PIF-1 containing membranes due to the presence in the same cell of complete genomes [Helper activities have been previously described in other baculovirus/host systems. Tanada (1959) described how the presence of a GV allowed replication of PsunNPV in the armyworm eplicate . Later in manner ,41,42. Sn manner . A diffe genomes .The point of blockage of CpGV-M replication on type I resistant codling moth larvae has been studied by Asser-Kaiser et al. (2011). Replication is blocked independently of the mode of entry, by ingestion or by injection. CpGV-M is able to enter into the cells, but its replication is stopped at an early stage prior to DNA replication. These authors concluded that the resistance is not restricted to the primary infection in the midgut, but all cells in the larvae appear to be restrictive for the replication of CpGV-M .GV host [Previous work on multiple infections has shown that the CpGV-R5 isolate allows replication of the CpGV-M isolate in the non-permissive RGV host . Our preGV host . It can 4 OB·µL) that do not reach 100% mortality to avoid such a massive midgut infection.If a midgut cell needs to be infected by CpGV-R5 prior to CpGV-M co-infection to allow replication of the latter, the total number of midgut cells infected should be very important to result in 10% to 20% double infections , even ifIn the systems that have been studied, midgut infection appears to be transient, that is, infected cells are lost by sloughing and no infection from cell to cell was observed in the midgut ,46,47. TCydia pomonella/CpGV model and with the tools currently available, it is only possible to determine the duration of the ingestion delay allowing a double infection and not the existence of a superinfection time-lapse, which is only accessible at the cell scale. For these hypotheses to be tested, it will be necessary to follow the infection of each individual virion in the midgut. Such an observation will be possible once the ANCHORTM system we have previously adapted to AcMNPV [In cell culture, it has already been shown for SfMNPV that the probability of a successful infection with a second virus is related to the time-lapse between the first and second infection, referred to as the window of superinfection . The timo AcMNPV  is transC. pomonella larvae, carrying diverse resistance genes to CpGV, CpS, CpRR1, CpR5M, and CpRGO colonies [GV, this virus also replicates efficiently. We have used this second virus species (CrpeNPV) to test if the helper effect of CpGV-R5 could be substituted by another virus that replicates in the larvae. We first determined that double infections can occur using CrpeNPV and CpGV-M in fully permissive CpNPP larvae and CrpeNPV and CpGV-R5 in RGV larvae. Subsequently, the occurrence of double infection was analyzed when a mixture of CrpeNPV and CpGV-M was given to RGV larvae. No double infections were found, suggesting that CrpeNPV cannot help CpGV-M to replicate. Probably other CpGV genotypes could act as helpers, but this has not yet been tested.It has been demonstrated that CrpeNPV is able to replicate in four different groups of colonies . We haveGV cells susceptible to CpGV-M. This theory would explain the results observed in the present experiments. If such a factor exists, the absence of helper activity of CrpeNPV would suggest that it is specific.We have previously proposed  that a dCodling moth resistance to CpGV genotypes is a major threat for apple and pear producers. The presence of multiple CpGV genotypes in the virus inoculum results in it not behaving as single genotypes do. The interactions between CpGV genotypes appear to be specific and cannot be substituted by the presence of more distant viruses infecting the same host. The analysis of these interactions opens the way to a more detailed understanding of the early steps of the infection process.


To estimate the individual cost and population‐level economic burden of Bipolar Disorder (BD), and explore the impact of clinical and sociodemographic factors on costs in the United Kingdom.Annual UK health care, social care and societal cost data were collected from a prospective cohort of 91 BD patients using digital monitoring of symptoms. Costs (in £) were calculated for the year of resource use collection (2010–2011) and main results inflated to year 2018–2019. A Generalized Estimating Equation framework was used to investigate individual factors influencing costs. An economic burden estimate was derived by multiplying the mean annual cost per patient with literature‐based population prevalence.The average annual cost of BD per patient was £12,617 (SE = ±£1085) or £14,938 (SE = ±£1281) at 2018–2019 prices with 68% of the total costs attributed to lost productivity and informal care, 31% to health care costs, 1% to private out‐of‐pocket expenses, and 0.5% to social care costs. A unit increase in average levels of depressive or manic symptoms were associated with 7% and 11% higher societal costs, respectively. The estimated annual prevalence of BD in the United Kingdom was 0.8% resulting in a population‐level economic burden estimate of £5.1 billion for 2010–2011 or £6.43 billion for 2018–2019.BD is a disease of substantial costs in the United Kingdom with the majority of the economic burden falling outside the health care system in the form of productivity losses and informal care. These costs highly correlate with patient outcomes highlighting further needs for improved treatment efforts into functionality. We assess the individual cost and population‐level economic burden of Bipolar Disorder (BD), and explore the impact of clinical and sociodemographic factors on costs in the United Kingdom. Based on a prospective cohort of 91 BD patients, we estimate an annual prevalence of BD in the United Kingdom of 0.8% and average annual costs of BD £12,617 per patient in 2010–2011, resulting in a population‐level economic burden estimate of £5.1 billion for 2010–2011 or £6.43 billion adjusted to 2018–2019 prices. We further provide a breakdown of the annual costs per major cost categories.  The prevalence estimates of BD vary widely between studies; reviews have suggested estimates ranging from 0.5% to as high as 6.0% , modalities of care  and service delivery options   assess the cost of BD over a 1‐year period through prospectively following‐up a well‐defined cohort of community BD patients in the United Kingdom, (b) explore the main clinical and sociodemographic factors that drive variations in the costs associated with BD, and (c) estimate the population‐level economic burden for the United Kingdom.22.1The study used data obtained from the OXTEXT‐2 substudy which was part of the OXTEXT research programme (RP‐PG‐0108‐10087) and followed a cohort of 91 BD patients over a 12‐month period in 2010–2011. Patients were invited to take part between May 2010 and June 2011 from the larger OXTEXT‐1 cohort study which was a pragmatic longitudinal cohort of patients with a confirmed diagnosis of BD who attended psychiatric clinics in Oxford Health NHS Foundation Trust (OHFT) and were monitored with a user friendly SMS or web‐based system called “True Colours” (TC) .Clinical status of patients was measured using the five‐item Altman Self‐Rating Mania (ASRM) scale and 16‐item Quick Inventory of Depressive Symptoms–Self Report (QIDS‐SR) scale. The ASRM scale (scores range from 0 to 20) consists of five questions marked between 0 and 4 with increasing severity. In the literature, cut‐off point of less than or equal to 5 is indicative of “being not in a manic state,” whereas a score of greater than 5 indicates a “state of mania” ; and productivity losses. Data on distance travelled to psychiatric health care providers and the time informal carers  spent providing unpaid care and support was also collected for each study participant.2.3We used both health and social care, and societal perspectives in our analyses. Resource use categories were multiplied by their relevant national‐level unit costs using British pounds sterling (£). Unit costs were obtained from various sources including the National Schedule of Reference Costs . Informal care costs were estimated by multiplying the average hourly salary derived from the average annual gross UK wage rate with the number of hours of unpaid work . Days off work were multiplied by the average daily cost of sickness absence in the United Kingdom CMH, . These c Bovill, .Average annual per patient costs and population‐level economic burden were updated for year 2018–2019. For health care‐related costs, we used the Hospital & Community Health Services (HCHS) index for the period 2011–2012 to 2014–2015 and the NHS Cost Inflation Index (NHSCII) from 2015–2016 onward .A Multiple imputation (MI) by chained equations was used with age, gender, type of BD, duration‐of‐illness, concurrent clinical measures, and the value of the missing variable at baseline as covariates  was implemented on the fully imputed dataset. A multivariate regression model with gamma distribution and log‐link function was used to address skewed cost data and an exchangeable covariance matrix was found appropriate to account for the correlation between repeated covariates and their influence on the primary outcomes which were measured on multiple occasions . To check the impact of joint uncertainty in the input data and assumptions, a multivariate probabilistic sensitivity analysis (PSA) using Monte Carlo simulation was undertaken using Microsoft Excel 2010 , 78% (71/91), 76% (69/91), and 75% (68/91) of the cohort at 3‐, 6‐, 9‐, and 12‐month follow‐ups, respectively.n = 91) alongside the characteristics of the complete cases (n = 48) are provided in Table Baseline characteristics of the full OXTEXT‐2 study sample n = 9 alongsid3.2The mean annual societal cost of BD per patient was estimated at £12,617 . Costs by resource use category and their relative contributions to the economic burden are presented in Table 3.3Primary care costs included visits to/by general practitioners (GP) and general practice nurses. GP costs accounted for 88% of the total primary care costs. The mean primary care cost per patient was £253 , 2% of the estimated mean annual societal BD cost per patient. The mean annual community mental health care (CMH) cost per patient was £221 . These costs were divided among community psychiatric nurse (29%), community psychologists (17%), community psychiatrists (25%), community drop‐in centers (5%) and support group visits (25%). Visits to A&E and use of ambulance services were categorized under emergency care. The mean annual cost of emergency care per patient was £40 , with 59%  of the costs being associated with the use of ambulance services.Mental health outpatient care comprises hospital‐based outpatient visits to psychiatrists and psychologists. The mean annual cost of using mental health outpatient services per patient was £401 . Psychiatrist visits accounted for 91% of the total outpatient costs. The mean annual cost of nonmental health outpatient visits per patient was £122 .Hospitalization costs were analyzed separately for mental health‐related inpatient costs (63%), mental health‐related day‐patient costs (11%), and other, nonmental health inpatient and day‐patient costs (26%). Mean annual mental health‐related inpatient hospitalization costs per patient were estimated at £1225 , mental‐health day‐patient costs at £223 , and nonmental health hospitalization costs at £514 . Overall, hospitalization costs accounted for 16% of the total annual economic burden per patient and formed the largest health care cost subcategory.3.4Mean annual psychiatric medication costs were estimated at £859  per patient, the second largest health care cost subcategory contributing to 7% of the total annual economic burden per patient.3.5Social care costs included services offered by social workers, community support workers, home care workers, housing workers, and voluntary workers. In total, mean annual social care costs per BD patient were estimated to be £60 .3.6Patient costs were out‐of‐pocket expenditures spent on services offered by private health service providers  and travel costs to mental health facilities. The average annual out‐of‐pocket costs per BD patient were £111 .3.7Major indirect costs of £8588  occurred due to lost productivity and informal care provided by family members and friends. Informal care costs amounted to £7033 (2018–2019 prices: £8340) and lost productivity due to sickness absence to £1555 (2018–2019 prices: £1844). These costs accounted for 68% of the total annual economic burden of BD per patient in the United Kingdom representing the largest cost component.3.8p = .012) increase in the mean annual societal cost and for a single unit increase in the ASRM score, the increase in mean annual societal costs was 11.6% (p = .022). When health care costs were considered, only the association with the severity of mania remained significant at the 5% level; a unit difference in the mean ASRM score was associated with an increase in the mean annual health care costs of 11.5% (p = .03). Costs due to lost productivity and informal care were more closely associated with the severity of depression; a single unit of QIDS score increase was associated with an increase in annual indirect costs of 9.2% (p = .036).Results of the GEE analyses are presented in Table 3.9A total of 913 citations were retrieved following the initial search, out of which, 26 studies were included for abstract review. Eventually, seven studies were deemed as eligible and were included in a random‐effects meta‐analysis to derive a pooled estimated for the 12‐month period prevalence of BD relevant to the United Kingdom for the study period . When applying the prevalence rate of 0.8% to the mid‐2010 and mid‐2018 UK population over 16 years of age , the total number of adults living with BD in the United Kingdom was estimated at 407,567 and 430,491 in 2010 and in 2018, respectively . Of these costs, £3.5 billion (£4.4 billion adjusted to 2018–2019) were due to productivity losses and informal care costs, £1.6 billion (£2.0 billion adjusted to 2018–2019) due to health care‐related costs, £24.3 million due to social care costs (£29.3 million adjusted to 2018–2019), and £45.3 million (£56.5 million adjusted to 2018–2019) incurred as patients’ out‐of‐pocket expenses  were attributed to lost productivity and informal care costs, 31% to health care costs, 1% to patients’ out‐of‐pocket expenses, and 0.5% to social care costs. The average estimated health care costs of £3859 in 2010–2011 were considerably higher than the Treasury reported average health care expenditure of £1926 per person in the United Kingdom for the same year  incurred by individuals with BD. It also enabled the exploration of factors influencing costs using GEE modeling.Due to the lack of epidemiological studies of BD in the United Kingdom for the year of resource use collection, prevalence estimates were derived from a random‐effects meta‐analysis of population based epidemiological studies of BD in Europe. This yielded a mean prevalence of 0.8% (95% CI = 0.43%–1.3%), which is consistent with a more recently published study that reported the prevalence of BD in the United Kingdom using Bayesian meta‐regression modeling to be 0.8% (95% CI = 0.7%–0.9%) in females and 0.6% (95% CI = 0.5%–0.7%) in males  and the overall sample (n = 91) and the complete case sensitivity analysis showed no significant impact of data gaps on the overall results, the lower mean costs estimated for the complete cases suggests that patients retained in the follow‐up likely had better functioning outcomes. Third, due to the lack of data, productivity losses for unemployed individuals whose ongoing unemployment was attributed to BD and premature mortality due to BD were not included likely leading to some underestimation of the overall economic burden.We want to caution that our study results need to be interpreted in light of some important limitations. First, the relatively small sample of 91 individuals used in this study was recruited from psychiatric clinics across the Oxfordshire and Buckinghamshire counties in England. While such patients are likely to be more representative than RCT participants, they may not be fully representative of the entire UK BD population. Second, we addressed the presence of missing data with multiple imputation of missing variables assuming a missing at random (MAR) mechanism to limit the loss of too many observations or variables for the analysis. Although there were no statistically significant differences between the baseline characteristics of the complete case patients , resulting in £1.6 billion (2018–2019: £2.0 billion) costs directly related to the health care sector in the United Kingdom. This corresponds to approximately 1.2% of the total government‐financed health care expenditure of £131.0 billion in 2010–2011 ONS, . DespiteThe magnitude of health care and social care‐related costs and the costs of informal care and due to lost productivity were significantly associated with self‐reported levels of mood symptoms. From a public mental health perspective, these results generate the hypothesis that significant cost savings could result from improved monitoring and control of self‐reported symptoms between episodes using a low‐cost and relatively simple method of mood monitoring.This study provides robust evidence that BD is a disease of substantial economic burden in the United Kingdom. Policy makers need to pay attention to this distribution of expenditure in BD as health care and medications represent a lesser proportion of the total economic burden, implying that the focus of any future interventions should be related to improving the functionality and productivity of individuals with BD.


Total costs were obtained across the continuum of care including outpatient clinics, emergency department, and inpatient or observation units. Cost variability was described comparing different health systems, races, and diagnoses. Thirteen thousand two hundred and fourteen patients were identified accounting for 17,287 encounters. Total costs were available for 38.7% of the encounters. There was considerable variability in costs within and, especially, across health systems. Costs also varied across race, urban vs. rural site of care, and AP-FGID diagnoses. In conclusion, there was considerable variability in the costs for care of AP-FGIDs which is sufficient to support multi-site studies to understand the value of specific tests and treatments. Significant differences in costs by race merit further investigation to understand key drivers.The purpose of this study was to assess cost variability in the care of abdominal pain-associated functional gastrointestinal disorders (AP-FGIDS) in youth across health systems, races, and specific AP-FGID diagnoses. Patients, aged 8–17 years, with a priority 1 diagnosis corresponding to a Rome IV defined AP-FGID were identified within the Health Facts Pediatric chronic abdominal pain is a common problem with a worldwide prevalence rate of 13.5% .The costs of care of pediatric AP-FGIDs are significant and continue to rise ,4,5. The® database  is one of the largest single vendor electronic health record (EHR) databases. It provides multi-site longitudinal data regarding outpatient/clinic, ED, and inpatient/observation encounters, making it an ideal source to assess total costs across the continuum of care for youth with AP-FGIDs.Most previous studies regarding costs have been performed within single sites or utilizing large databases with only emergency department (ED) and/or inpatient data without outpatient clinic cost data. A recent study utilizing a nationally managed healthcare plan database reported total yearly costs (whether directly related to IBS or not) in 1215 pediatric IBS patients across outpatient and inpatient encounters . Data inThe primary objectives of the current study were to assess variability in direct costs accrued in the care of AP-FGIDs in youth across healthcare systems, races, ages, gender, and AP-FGID diagnoses.® . Cerner Corporation is a leading EHR vendor and maintains a publicly available database including data from facilities geographically distributed across the United States. The database contains data from over 68 million patients from 664 facilities within 100 non-affiliated healthcare systems. Health Facts contains data extracted from electronic health records (EHRs) under a data use agreement between Cerner Corporation and individual systems utilizing the Cerner EHR. The database contains data across the continuum of care including outpatient, clinic, emergency department, observation, and inpatient encounters. The data are collected in a longitudinal fashion. Consent and assent were waived by the Institutional Review Board of Children’s Mercy.This study was conducted utilizing a single vendor database, Cerner Health FactsWe included all patients meeting an ICD-9 or ICD-10 code corresponding to an AP-FGID, who were between 8 and 17 years of age and who received care from 2010 to 2017. Only encounters with priority 1 AP-FGID diagnoses were utilized. A priority 1 designation indicates that the AP-FGID was the primary reason for the encounter as designated by the care provider. Diagnoses, diagnostic codes, and the % of the total sample for each diagnosis are shown in In addition to demographic data , we assessed the geographic region and urban/rural status to ensure broad representation in the sample. The study variables included the total charges per encounter across: (1) healthcare systems, (2) races, (3) age groups, (4) urban/rural site of care, and (5) diagnoses. Within Health Facts, the race category also includes the ethnic group “Hispanic”.Descriptive statistics were assessed for all study variables. Costs were assessed by encounter so that they were not affected by differences in total encounters for different patients. Costs are shown as boxplots reflecting median charges, from the 25th to 75th percentile ranges, and outliers.The total final sample was 13,214 patients  with 17,287 encounters. The age and sex distributions are shown in Total costs were reported by 46 of the 77 health systems with total charge information available for 38.7% of the encounters overall. There was considerable variation in total costs within and across systems. The distribution of total encounter costs across health systems are shown on a logarithmic scale in The median costs and cost distributions by race/ethnicity for children (8–12 years of age) and adolescents (13–17 years of age) are shown in The median costs and cost distributions by race/ethnicity for care delivered in rural locations compared to urban locations is shown in The total charges also varied across diagnoses as depicted in The economics of abdominal pain-associated FGIDs need to be considered in the context of overall health care economics. Globally, healthcare expenditures continue to rise, outpacing gross domestic product (GDP) growth in Europe, North America, and the world’s emerging economies such as the BRICS nations  ,10. GrowThe economic impact of IBS has been well studied within Europe and North America with some data from Asia and the Middle East, demonstrating high direct and indirect costs including loss of productivity ,14,15. IIn the current study, there was considerable variability between health systems (and to a lesser degree within single systems) with regards to direct costs in the care of AP-FGIDs in youth. Perhaps this is not unexpected, as there are no evidence-based guidelines to direct evaluation and treatment. Variability could be explained, to some degree, by differences in regional algorithms for diagnosis and treatment. Previous studies have reported high variability in costs even within single systems. Dhroove and colleagues evaluated the cost of the diagnostic evaluation in children with chronic abdominal pain and demonstrated a cost range from just over USD 1000 to nearly USD 21,000 within a single institution . Costs wCosts could also be affected by the patient’s age and/or race/ethnicity. Our data would indicate that age does not appear to drive up costs at an encounter level. We found no differences in encounter costs comparing children and adolescents. We evaluated these as two separate groups, as a previous study found that most children diagnosed with recurrent abdominal pain before the age of 12 years did not have persistent symptoms, while recurrent abdominal pain at the age of 12 years was associated with an increased risk of an AP-FGID at age 16 years . CertainCosts could also be driven up by co-morbid conditions. A previous study of pediatric IBS patients demonstrated higher yearly healthcare costs (not limited to costs directly attributable to IBS) compared to a control group with increased outpatient visits, emergency department visits, and hospitalizations . These pThere also appeared to be cost variability across AP-FGID diagnoses. However, interpretation of these costs appeared to be affected by the conversion from ICD-9 to ICD-10. We analyzed ICD-9 and ICD-10 separately, because the transition to ICD-10 occurred shortly before the release of Rome IV, which significantly altered the pediatric criteria for FD and, to a lesser but still substantial degree, for IBS . More imThe main weakness is that the database would not capture care delivered at facilities utilizing a different EHR system. A challenge inherent in this and all pediatric studies of chronic abdominal pain is the inconsistencies in diagnosing specific AP-FGIDs. The strength of the current study is that the database allowed for the description of costs across a large population drawn from multiple sites and across the continuum of care with wide geographic distribution ,23. UtilThere is sufficient variability in costs related to the evaluation and management of pediatric AP-FGIDs to support multi-site studies to understand the value of specific tests and treatments. An existing pediatric model exists in other diseases such as the ImproveCareNow (ImproveCareNow.org) collaborative study in pediatric inflammatory bowel disease . Such st


Fraxinus rhynchophylla, common name ash, belongs to the family Oleaceae and is found in China, Korea, North America, the Indian subcontinent, and eastern Russia. It has been used as a traditional herbal medicine in Korea and various parts of the world due to its chemical constituents. During a field survey in March 2019, mild vein thickening  was observed in a few ash trees. High-throughput sequencing of libraries of total DNA from ash trees, rolling-circle amplification (RCA), and polymerase chain reaction (PCR) allowed the identification of a Fraxinus symptomless virus. This virus has five confirmed open reading frames along with a possible sixth open reading frame that encodes the movement protein and is almost 2.7 kb in size, with a nonanucleotide and stem loop structure identical to begomoviruses. In terms of its size and structure, this virus strongly resembles begomoviruses, but does not show any significant sequence identity with them. To confirm movement of the virus within the trees, different parts of infected trees were examined, and viral movement was successfully observed. No satellite molecules or DNA B were identified. Two-step PCR confirmed the virion and complementary strands during replication in both freshly collected infected samples of ash tree and Nicotiana benthamiana samples agro-inoculated with infectious clones. This taxon is so distantly grouped from other known geminiviruses that it likely represents a new geminivirus genus. Fraxinus, commonly known as ash tree, is an important member of the Oleaceae family found in North America, northeast Asia, east and western France, China, Korea, eastern Russia, Pakistan, India, and Afghanistan [Fraxinus plants contain various secoiridoids, phenylethanoids, flavonoids, coumarins, and lignans, so they are considered to have diverse biological and pharmacological activities [hanistan ,2,3,4. Ctivities ,6. Theirtivities ,2,5,7.Fraxinus species, Fraxinus rhynchophylla, our target study, also known as East Asian ash, grows mainly in moist, fertile soils on hillsides and in river valleys in Korea, China, and Japan . F. rhynchophylla regenerates and dominates naturally after thinning in Korea, promoting the restoration of native hardwood forests [Among  forests . It serv forests ,9.Fraxinus species. To date, only RNA viruses, namely, Arabis mosaic virus, cherry leaf roll virus, tomato ringspot virus and tobacco ringspot virus ; tobacco necrosis virus ; tobacco mosaic virus ; and white ash mosaic virus (unclassified) [Fraxinus species.Few viruses have been reported as infectious agents in ssified) ,17,18,19Geminiviridae [Becurtovirus, Begomovirus, Capulavirus, Citlodavirus, Curtovirus, Eragrovirus, Grablovirus, Maldovirus, Mastrevirus, Mulcrilevirus, Opunvirus, Topilevirus, Topocuvirus, and Turncurtovirus [High-throughput sequencing (HTS) technologies have revolutionized systems for detecting viruses ,21. Thisiviridae . Approxirtovirus ,24,25,26rtovirus ,32,33,34Geminiviridae, i.e., replication enhancer protein gene (ren), a C4 gene (which encodes a symptom determinant and/or a silencing suppressor), and a transactivation protein gene (trap), are possibly conserved in genera: Begomovirus, Curtovirus, Eragrovirus, Topocuvirus, and Turncurtovirus [Geminiviruses are circular single-stranded DNA genomes encapsidated in twinned icosahedral particles and encode up to seven genes that are bi-directionally transcribed ,35. Amonrtovirus ,36,37,38rtovirus .Geminiviruses mainly cause severe economic losses in a variety of crops  ,40,41,42Fraxinus species, namely, F. rhynchophylla, in Korea. The virus was shown to exhibit a separate grouping during phylogenetic analysis and was thus named: Fraxinus symptomless virus (FSMV). Infectivity assays involving Nicotiana benthamiana confirmed the asymptomatically infection of FSMV.Here, we describe the characterization of a novel geminivirus found to infect F. rhynchophylla plant samples from various regions of Korea were collected in different time periods , Busan , Pocheon (n = 6 in September 2019), Jeonnam (n = 2 in September 2019), Yeongdong (n = 3 in September 2019), and Daegu (n = 2 in September 2019)  . No inseAliquots of the RCA product of two samples collected from the Jinju sample (J1 & J2) in March 2019 were sequenced on an Illumina HiSeq 4000 platform (paired end 2 × 100 bp) at Macrogen Inc. . Raw reads were de novo assembled using SPAdes v.3.12.0  and the KpnI, PstI, and BamHI, and PCR with universal betasatellite [We selected a total of 41 DNA extracts representing different geographic areas and provinces across South Korea . First, atellite , alphasaatellite , and DNAatellite  (SupplemLeaf tissue samples were collected from three different sites of ash trees (B1 *–B6 *) and processed by PCR using Ash_Gemini_2F/R primers to confirm virus movement and infectivity in all parts of the trees.https://www.ncbi.nlm.nih.gov/orffinder/, accessed on 29 September 2020), and conserved domains were characterized using BLASTx and PLACE [Geminiviridae.PCR products obtained through conventional Sanger sequencing were assembled using multiple sequence alignment by Florence Corpet (MultAlin) . Open rend PLACE ,60. Idennd PLACE . Alignmend PLACE . Phylogend PLACE . MaximumSouthern hybridization analysis was conducted to confirm the viral replication of FSMV in the samples using the modified method from Southern et al. ,65. TotaStrand-specific amplification method introduced by Rodríguez-Negrete using virion-sense- and complementary-sense-specific primer sets was conducted with slight modifications to detect the virus in the samples, i.e., J1, B6, P4, and JM2 ,67. In tEscherichia coli strain DH5α using the heat shock method and then transformed into GV3101 Agrobacterium strains and confirmed by both enzyme digestion and colony PCR with the detection primer sets.Infectious clone (1.1 mer) of FSMV was constructed to check its infectivity in the host plants. Two partial genomes containing restriction sites at the edge were amplified using primer sets designed based on the sequence of FSMV and ligated into the pGEM-T Easy vector  using the TA cloning technique, in accordance with the manufacturer’s instructions followed by the sequencing  and restriction digestion with specific enzymes. These two partial genomes were introduced into the pCAMBIA1303 vector and first transformed into competent Nicotiana benthamiana plants were planted in a growth chamber at Sungkyunkwan University, Suwon, Korea. Approximately 4-week-old N. benthamiana plants of similar sizes were selected to check the infectivity. Agrobacterium GV3101 strains (both transformed and untransformed) were cultured in LB broth in the presence of pCAMBIA1303 selection antibiotic, namely, kanamycin (50 mg/L), and strain-specific selection antibiotics, namely, gentamycin and rifampicin (50 mg/L), at 28℃ with agitation for 30 h . Agro-inoculation was performed by the pin-pricking method [g method . Leaf tiGeminiviridae members. Pairwise alignment of putative DNA-A-like contigs revealed that DNA-A does not exhibit a greater identity with the reference viruses cited in the literature. A more accurate analysis of the sequence of the contig disclosed five ORFs in a circular pattern very similar to the findings in the genus Begomovirus of the family Geminiviridae.HTS of the two DNA libraries yielded 74,391,351 raw paired reads. A total of 54,465 contigs were obtained from the libraries. BLASTx search of these contigs indicated the presence of virus-derived DNAs with an identity with Olea europaea geminivirus (MW316657) and 8% to Tomato Chino La Paz virus (MH678590). The full-length sequences (2.7 kb) were detected from samples from all locations but at first only from Jinju and Pocheon samples and sequenced followed by GenBank submission; Accession numbers: MZ054403 and MZ054404 . All other ORFs showed the same pattern as in begomoviruses with respect to their location . An inteGeminiviridae were initially examined by comparison of the whole-genome sequences by nucleotide pairwise alignments and identity matrices. Phylogenetic analysis was run at the nucleotide level sampling representative virus sequences , but in the hybridization assay, none of them showed any specific band for the virus either as DNA or as plant genome-integrated viral sequences.Strand-specific amplification using virion-sense- and complementary-sense-specific primer sets A showed We also checked the presence of the virus in three different locations by PCR to investigate viral replication ability and systemic movement. According to PCR, the virus was detected in four out of six samples  whereas the virus was successfully detected in all three sites of positive samples, which confirmed its presence A,B.N. benthamiana plants showed no symptoms in both mock and FSMV-inoculated groups. We could not observe any differences among all N. benthamiana groups inoculated. Leaf tissues were harvested and analyzed by PCR to investigate viral replication ability. According to PCR, the virus was detected, which confirmed its presence , olive tree, grey fig (Ficus virens), and Jatropha multifidi have been identified, expanding the host range to woody trees [The advent of new molecular techniques  has significantly broadened our knowledge of plant viruses, especially the geminiviruses. Recently, many divergent geminivirids infecting grapevine, citrus, apple, pear, dy trees ,47,69,70dy trees  and MCOIdy trees  but all Geminiviridae family and the overall nucleotide identity levels suggest that this virus could belong to a novel unclassified genus within the family, although information on vectors and viral particles is currently lacking (F. rhynchophylla is one of the most abundant trees found in almost all parts of Korea [Furthermore, phylogenetic analysis showed that FSMV does not group with begomoviruses or with other approved geminiviral genera. These findings together with a neighbor-joining tree of representative full-length genomes of all genera within the  lacking . F. rhynof Korea ,8 and fiN. benthamiana confirms the monopartite infectious nature of FSMV (Detection of the virus from different sites within the tree confirms the virus infection in it and its movement either from cell to cell or over long distances. Infectivity assay in  of FSMV . There hF. rhynchophylla-infecting DNA virus, is the latest discovered member of the family Geminiviridae. Despite its high divergence from other known geminiviruses, we believe that it is still a geminivirid based on its resemblance in terms of genomic structure and length. FSMV has only been found in woody trees. Two FSMV isolates, i.e., MZ054403 and MZ054404, were detected in our experiment, which share very high nucleotide sequence identities with each other. We were also able to show that cloned FSMV sequences are capable of initiating asymptomatic systemic infections in N. benthamiana. Although we can only confirm that FSMV is present in Korea, it remains plausible that it occurs in the Americas or other parts of the world where Fraxinus species are found in high numbers.FSMV, the first reported


We report detecting infectious Toscana virus in the seminal fluid of a 25-year-old man from Italy returning from Elba Island. The presence of infectious virus in human semen adds Toscana virus to the long list of viruses detected in this genital fluid and indicates a potential for sexual transmission. Phlebovirus, that was first isolated in Monte Argentario in 1971 from the sand flies Phlebotomus perniciosus and P. perfiliewi (Toscana virus (TOSV) is an arthropodborne virus, belonging to the genus On October 5, 2019, a 25-year-old man in otherwise healthy condition was admitted to the emergency department of Aurelia Hospital , for a history of acute headache, mental confusion, dysarthria, and high-grade fever since October 1. He had been living in Italy since January 27, 2019, after a 4-year period of residence in London, UK, where he abused alcohol and cocaine. During April 23–October 1, 2019, he worked as a waiter in a hotel on Elba Island, Tuscany, where he lived with his girlfriend. Their most recent sexual intercourse occurred on September 25. He reported several mosquito bites related to use of a shower located outside the hotel.Physical examination revealed signs of meningeal irritation in the absence of focal neurologic deficits. Results of chest radiograph were negative; blood tests showed unremarkable liver and renal function results but indicated lymphocitopenia , and thrombocytopenia .Neisseria meningitides, Streptococcus pneumoniae, Escherichia coli K1, Haemophilus influenza, Listeria monocytogenes, S. agalactiae, herpes simplex virus types 1 and 2, varicella zoster virus, cytomegalovirus, enterovirus, human parechovirus, human herpesvirus 6, and Cryptococcus neoformans/gattii).Brain computed tomography excluded brain swelling with evidence of elevated intracranial pressure. Examination of cerebrospinal fluid (CSF) revealed pleocytosis (88 cells/μL) consisting primarily of polymorphonuclear cells, normal glucose levels, and increased total protein levels (129 mg/dL). PCR results were negative for neurotropic pathogens  in Rome in a state of psychomotor agitation. Orotracheal intubation was performed with mechanical ventilation because of worsening Glasgow Coma scale score (10). Empiric treatment with acyclovir, ceftriaxone, ampicillin, and steroids was started. Epidemiologic evaluation of the case  suggested the possibility of an arboviral disease.https://www.euroimmun.com) on serum collected 17 days after symptom onset.Real-time reverse transcription PCR (rRT-PCR) for TOSV  was positive on CSF collected 5 days after symptom onset (cycle threshold 30.82); molecular assays for Naples, Sicilian, and Cyprus virus and flaviviruses and culture of CSF for bacteria and fungi were negative. Sequencing analysis of the medium gene revealed that the TOSV RNA detected in CSF belonged to lineage A , the patient was enrolled in a study on the tropism of arboviruses. To this purpose, every 7 or 14 days, and according to the patient’s willingness and ability to reach the INMI, we collected whole blood, serum, saliva, urine, and seminal fluid for viral RNA and specific antibody detection .Serologic tests demonstrated the presence of both TOSV IgM and IgG from day 17 to the end of the follow-up period at day 107 after symptom onset . Afterwahttps://www.nidacon.com)  .To determine the potential for viral transmission from semen, we inoculated Vero cells (ATCC CCL-81) grown in cell vials with blood, seminal fluid, and seminal plasma collected at day 26 after symptom onset. We were able to isolate TOSV from seminal plasma when the culture showed a cytopathic effect at passage 3. We confirmed TOSV positivity by immunofluorescence on infected cells using anti-nucleocapsid protein serum (data not shown). We extracted total RNA from supernatant of infected cells and amplified the viral genome . To date, there have been few reports on genital involvement in men infected by TOSV; reported manifestations have included testicular pain, orchitis, and epididymitis (


Many viruses involved in interference are pathogenic to humans or to economically important animals. Thus the phenomenon may be relevant to medicine and to animal production due to the possibility to use it as alternative to chemical therapies against virus infections to reduce the severity of disease/mortality caused by a superinfecting virus. Virus interference is defined as the host resistance to a superinfection caused by a pathogenic virus causing obvious signs of disease and/or mortality due to the action of an interfering virus abrogating the replication of the former virus. Different degrees of inhibition of the superinfecting virus can occur. Due to the emergence of novel pathogenic viruses in recent years, virus interference has recently been revisited using different pathogens and hosts, including commercially important farmed aquatic species. Here, some highly pathogenic viruses affecting farmed crustaceans can be affected by interference with other viruses. This review presents data on the history of virus interference in hosts including bacteria and animals, with emphasis on the known cases of virus interference in crustacean hosts.Virus interference is a phenomenon in which two viruses interact within a host, affecting the outcome of infection of at least one of such viruses. The effect of this event was first observed in the XVIII century and it was first recorded even before virology was recognized as a distinct science from microbiology. Studies on virus interference were mostly done in the decades between 1930 and 1960 in viruses infecting bacteria and different vertebrates. The systems included Life Science Identifiers (LSIDs)Escherichia coli [(Migula 1895) Castellani & Chalmers 1919]Aedes albopictus (Skuse 1894)Liocarcinus depurator (Linnaeus 1758): urn:lsid:marinespecies.org:taxname:107387Penaeus duorarum (Burkenroad 1939): urn:lsid:marinespecies.org:taxname:158334Carcinus maenas (Linnaeus 1758): urn:lsid:marinespecies.org:taxname:107381Macrobrachium rosenbergii (De Man 1879): urn:lsid:marinespecies.org:taxname:220137Penaeus vannamei (Boone 1931): urn:lsid:zoobank.org:pub:C30A0A50-E309-4E24-851D-01CF94D97F23Penaeus monodon (Fabricius 1798): urn:lsid:zoobank.org:act:3DD50D8B-01C2-48A7-B80D-9D9DD2E6F7ADPenaeus stylirostris (Stimpson 1874): urn:lsid:marinespecies.org:taxname:584982 Virus interference is a phenomenon observed before the dawn of virology itself and even before proper experimental methods were available in the decade of 1950 . The earEscherichia coli [(Migula 1895) Castellani & Chalmers 1919], was used as host upon which two distinct bacteriophage strains , were able to replicate. The interference experiments showed that using equal amounts of these two viruses (α and γ), virus γ inhibited replication of virus α by 67%. Also, the interference did not occur by differences in virus adsorption by the cells, and the time at which virus γ was inoculated after virus α influenced the interference, with longer times (4 - 6 min) showing less interference  and other cytokines, cellular immune responses or immunostimulation  C6/36 cell cultures  simultaneously infected with two different types of T bacteriophages showed interference, as one single interfering virus particle was able to inhibit replication of a super-infective virus in any bacterial cell . Bacteria  the interference was not due to differences in virus adsorption to cells, penetration into the host cell or competition for a key enzyme , 18, 23;Examples of superinfection exclusion in animal hosts include various homologous interfering viruses such as influenza virus , 23, visThe interference of homologous viruses is far more difficult to distinguish from the immunological effects and genetic interactions than for heterologous interference, since both the interfering and superinfecting viruses are antigenically equivalent . Nonethein vivo or in vitro. Another criterion for heterologous virus interference is the lack of immunogenicity against the virus pairs by the host, or the independence of interference to any relationship to antigenic reactions and antibody production. This type of interference has been reported among viruses that are antigenically and taxonomically distinct  and hemagglutinating (HA) antigens produces broadly cross-reacting neutralizing antibodies . NonetheThis interaction is another example of the category of direct interactions of viral genes or gene products. This occurs in any virus that may lack replication ability at some degree and hence requires the gene products of another virus to produce infection. This interaction does not produce virus interference, but it allows a defective virus to successfully replicate and exit the cell. An example of this interaction occurs in the bacteriophage P4, which is able to replicate its own genome in the presence of a coinfecting phage (P2), thus providing capsid components and cell lysis .In vertebrates, an adeno-associated virus (AAV) is a replication-defective parvovirus that usually requires a host cell that is coinfected with an adenovirus or herpesvirus in order to produce virions to be released from the host cell. Later, it was discovered that AAV is not completely replication defective, since genotoxic stress and other factors may also make a host cell permissive for AAV progeny production .Macrobrachium rosenbergii (De Man 1879) causing muscle whitening in the abdomen and sometimes cephalothorax, resulting in massive mortalities to postlarvae (Macrobrachium rosenbergii Nodavirus (MrNV) is icosaedrical with 27 nm diameter and its genome composed by two equimolar linear single-stranded (ss) RNA molecules of ≈ 3200 and 1250 nucleotides, respectively  (Penaeus duorarum (Burkenroad 1939), the virus Baculovirus penaei  . Later, s penaei  was firss penaei , 47. Sins penaei . At press penaei . Crustacs penaei . Severals penaei , 37, 50 Carcinus maenas (Linnaeus 1758) was first mentioned in 1971 and later found to display autointeference in the same host (-2 and 10-3) did. This effect is similar to the phenomenon of autointerference observed in vertebrates. Autointerference was tested with undiluted and diluted hemolymph samples and it was observed when the more diluted samples caused disease faster than the undiluted ones. All six samples of whole hemolymph taken late in the course of disease did not show the normal dilution effect or even showed a reversal. Further, none of the fresh sera samples taken showed the expected normal dilution effect, and five out of six (83%) showed autointerference. This phenomenon could not be determined to be caused by the virus, from an associated virus or by the innate defense system  and the black tiger shrimp Penaeus monodon (Fabricius 1798) among others (Marine shrimp is an important commodity and is produced in aquaculture facilities in many countries worldwide. The main farmed species are the Pacific white shrimp g others . Many vig others . Due to Taura syndrome virus (TSV) has a single stranded, positive-sense linear RNA genome and replicates in cytoplasm (Yellow-head virus (YHV) has a single-stranded positive sense RNA genome and also replicates in cytoplasm  of YHV. Results showed that virus interference occurred between TSV and YHV and survival of shrimp treated with TSV was significantly higher than YHV positive controls at the different times evaluated. The highest survival occurred when YHV was inoculated at 27 d after TSV inoculation  (Penstylhamaparvovirus 1 (white spot syndrome virus 1 (WSSV) (Penaeus stylirostris (Stimpson 1874) and disease to P. vannamei and P. monodon (Probably the most studied virus interference event in shrimp is between  (IHHNV) , also knovirus 1 , and whi1 (WSSV) . The IHH1 (WSSV) . This vi1 (WSSV) . It caus monodon . The WSS monodon . WSSV isP. stylirostris , whereas moribund and dead shrimp had higher WSSV load than IHHNV (107 vs 104), respectively. The protective effect of IHHNV infection lasted at least 6 weeks.The first evidence of interference was found in experiments done in juvenile Pacific blue shrimp irostris . Shrimp P. vannamei postlarvae. Shrimp treated with IHHNV at nauplius V or zoea I stages or treated with formalin-inactivated WSSV showed a delay in shrimp mortality from day 4 until the end of the experiment, indicating an interfering effect of such treatments. Nonetheless, shrimp treated with IHHNV or inactivated WSSV had 4 and 4.7% survival at 10 d post WSSV challenge, respectively. Surviving shrimp had similar virus loads between IHHNV and WSSV , whereas moribund shrimp had higher WSSV load   .per os in juvenile P. vannamei was evaluated at different times after IHHNV inoculation (0 to 50 d). Shrimp challenged only with WSSV died at 3 dpi, whereas shrimp treated with IHHNV between 30 and 50 d before WSSV challenge died at 5 dpi. The virus load in shrimp treated with IHHNV showed an increase during the 50 d peaking at 40 d with an average IHHNV virus load of 2.6 × 109 copies μg–1 DNA. Shrimp challenged with WSSV showed a reduction in IHHNV load (2.7 × 107 and 9.7 × 107 copies μg–1 DNA) compared to shrimp inoculated only with IHHNV (2.5 × 108 - 2.6 × 109 copies μg–1 DNA) at 30 and 40 d, respectively. A delay in mortality due to WSSV infection was a function of IHHNV virus load and duration of infection. A significant delay in mortality occurred when IHHNV load was higher than 108 copies μg–1 DNA at the time of WSSV challenge . This method requires the analysis of DNA/RNA obtained from the environment or organisms, including soil, water, host tissues, feces and other samples. Two common eDNA methods are amplicon-based (metabarcoding) or whole shotgun metagenomics/metatranscriptomics. The former amplifies and sequences variable regions of conserved genes  or mitochondrial intergenic regions that are shared across a group or sub-groups of a selected organism. The diversity of the resulting sequences are used to assign operational taxonomic units (OTUs). In the case of viruses which lack these conserved regions, the latter method is used to study viral communities in environmental samples .In conclusion, virus interference is an old phenomenon that implies the interaction of two viruses within a host cell, resulting in the inhibition of replication of at least one of the viruses. This phenomenon may have various mechanisms, of which three have been reported. The exclusion interference may be common in viruses infecting animals. Heterologous virus interference between a low and a highly pathogenic viruses has been reported in farmed shrimp and it could be used as a natural control strategy against highly pathogenic viruses. As sequencing technology advances, better knowledge on environmental and crustacean virus diversity will be gained, and also in virus genome organization and gene interactions between host - pathogen and virus - virus interactions, may help elucidate the mechanisms that drive this phenomenon.The author confirms being the sole contributor of this work and has approved it for publication.The present work was supported by Instituto Politecnico Nacional projects SIP20200533 and SIP20210092. COFAA-IPN provided financial support to publish this article.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The infection caused by novel beta-coronavirus (SARS-CoV-2) was officially declared a pandemic by the World Health Organization in March 2020. However, in the last 20 years, this has not been the only viral infection to cause respiratory tract infections leading to hundreds of thousands of deaths worldwide, referring in particular to severe acute respiratory syndrome (SARS), influenza H1N1 and Middle East respiratory syndrome (MERS). Although in this pandemic period SARS-CoV-2 infection should be the first diagnosis to exclude, many other viruses can cause pulmonary manifestations and have to be recognized. Through the description of the main radiological patterns, radiologists can suggest the diagnosis of viral pneumonia, also combining information from clinical and laboratory data. Viral pneumonia is one the most frequent respiratory diseases among very young people and the elderly, contributing to an increase in the number of hospitalizations and deaths, mainly in subjects over 60 years of age ,2. Many SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) began to expand in 2019 in China and spread worldwide, with the first reported cases in Italy in February 2020. This virus belongs to the coronavirus family and is highly infectious, being able to cause severe pneumonia up to acute respiratory distress syndrome (ARDS). Its recognition is very important for a prompt diagnosis, involving real-time reverse transcription-polymerase chain reaction (RT-PCR) of viral nucleic acid . DespiteMERS is an illness caused by the Middle East respiratory syndrome coronavirus (MERS-CoV) belonging also to the coronavirus family. It was first found in Saudi Arabia in September 2012, reaching the maximum number of countries in 2015 . ClinicaSARS also belongs to the coronavirus family and was first discovered in China in 2002 . After iThe influenza virus belongs to the Orthomyxoviridae family. It generally manifests itself during the winter period, causing infections of the upper airways and, in patients with chronic diseases and in the elderly or immunocompromised, may lead to the onset of pneumonia . The chaAdenovirus is a DNA virus, responsible for 5–10% of respiratory infections in children . This maRSV is a virus belonging to the Pneumoviridae family and is the most frequent cause of hospitalization in children and also causes disease in the elderly . The virThe herpes virus family is composed of DNA viruses, which can cause both acute infections and remain latent in tissues, causing chronic infections. Although HSV infections can be found in both immunocompetent and non-immunocompetent patients, associated pneumonia occurs predominantly in immunocompromised subjects.HSV pneumonia is predominantly caused by type 1 virus and, more rarely, type 2 ,62. HSV Varicella-zoster virus belongs to the herpes virus family. It normally manifests itself as a self-limiting benign infection that predominantly affects the pediatric age, although it may result in a mortality rate of 9–50%, with pneumonia as the most frequent and severe complication. As in other respiratory tract infections, the possibility of severe disease increases with immunocompromised states, haematological malignancies, and pregnancy . ClinicaCMV belongs to the herpes virus family, generally responsible for infections that are asymptomatic or with moderate flu-like manifestations in immunocompetent patients. However, this virus can cause pulmonary infections in immunocompromised patients, especially after transplantation, immunosuppressive therapies, and in diseases such as AIDS. The most frequent radiological findings on CT examination are interstitial and alveolar infiltrates as bilateral and asymmetric GGO areas in association with areas of parenchymal consolidation  Figure . McGuinnEBV typically infects B lymphocytes and pharyngeal epithelial cells, causing mononucleosis infection: it usually manifests with fever, weakness, tonsillar pharyngitis, and lymphadenopathy often accompanied by splenomegaly . PulmonaHPIV is an RNA virus belonging to the Paramyxoviridae family and is one of the most common causes of upper respiratory tract infection in adults and children with a typical seasonal pattern. There are four serotypes, although the last three are the major cause of disease . In addiMeasles is an RNA virus belonging to the Paramyxoviridae family. It was one of the major causes of infection among pediatric patients, causing 2–3 million deaths per year. Thanks to the advent of the vaccine, these numbers have been significantly reduced, but it remains a cause of infection capable of causing serious complications, especially in immunocompromised patients and pregnant women ,83. EvenLast year has been a period characterized by the emergence of a new infection belonging to the coronavirus family, SARS-CoV-2, which has caused a severe worldwide pandemic with the need to develop effective methods in its diagnosis and evaluation, to ensure rapid management and treatment of patients affected by this pathology. Radiology has an important role in this task, being, together with RT-PCR nasopharyngeal and throat swab, the diagnostic method, especially in emergency departments, to provide a rapid assessment of pulmonary involvement. CXR is used in many countries, including Italy, as first-line imaging ,16. Many