Tuberculosis (TB) is a major global public health problem which affects poorest individuals the worst. A high proportion of patients incur ‘catastrophic costs’ which have been shown to result in severe financial hardship and adverse health outcomes. Data on catastrophic cost incidence is not routinely collected, and current definitions of this indicator involve several practical and conceptual barriers to doing so. We analysed data from TB programmes in India , Bangladesh and Tanzania to determine whether dissaving  is a useful indicator of financial hardship.N = 96), Tanzania (N = 94) and Bangalore (N = 891). These data were analysed using logistic and linear multivariate regression to determine the association between costs (absolute and relative to income) and both the presence of dissaving and the amounts dissaved.Data were obtained from prior studies of TB patient costs in Bangladesh (p < 0.001). For low-income patients in Bangladesh, an increase in dissaving of $10 USD was associated with an increase in total costs of $7 USD (p <0.001).After adjusting for covariates such as age, sex and rural/urban location, we found a significant positive association between the occurrence of dissaving and total costs incurred in Tanzania and Bangalore. We further found that, for patients in Bangalore an increase in dissaving of $10 USD was associated with an increase in the cost-income ratio of 0.10 (Dissaving is potentially a convenient proxy for catastrophic costs that does not require usage of complex patient cost questionnaires. It also offers an informative indicator of financial hardship in its own right, and could therefore play an important role as an indicator to monitor and evaluate the impact of financial protection and service delivery interventions in reducing hardship and facilitating universal health coverage. Further research is required to understand the patterns and types of dissaving that have the strongest relationship with financial hardship and clinical outcomes in order to move toward evidence-based policy making. Health care utilisation can lead to severe financial hardship, particularly for poorer households in low and middle income countries (LMICs). Hardship can arise even when care is ‘free’, due to direct costs such as transport and medication, and indirect costs (loss of income) . Over 10Definition and measurement of catastrophic costs are important to support the evaluation and monitoring of both service delivery  and finaGiven these challenges, directly measurable proxy indicators of catastrophic costs would be beneficial. Low-income households often take out loans or sell assets to finance health-related expenditure . This isN = 1106) newly registered for treatment in the city of Bangalore in 2005 under the Revised National tuberculosis Control Programme (RNTCP) [Data for Bangladesh and Tanzania were collected as a part of a study examining the potential financial impact of shorter TB treatment regimens . Data on (RNTCP) . Patient (RNTCP) , 23, 24.We reanalysed these patient cost datasets to explore the determinants of high or extreme costs and the relationship between costs and dissaving. SBS and KL were actively involved in the studies which collected these datasets, and granted access to JM to permit this re-analysis. We examined the distribution of costs relative to the median in each study, to identify potential drivers of high costs. We chose median costs as a convenient benchmark for the typical costs faced by participants in each study location. We chose to label costs ‘low’ if below the median value, ‘medium’ if greater than median but less than double the median, ‘high’ if greater than double median costs but less than triple, and ‘extreme’ if greater than triple median costs. These cut-off levels, though arbitrary, allow us to explore the extent of atypically high costs in a comparable way across locations. We carried out logistic and linear regression analyses to determine the relationship between costs and the presence and amount of dissaving. For the Bangalore dataset, we carried out additional regression analyses of the relationship between the level of dissaving and the cost/income ratio, to assess the coincidence of dissaving with ratio-based definitions of catastrophic cost. For the Bangladesh and Tanzania datasets, we performed separate regression analyses of the cost-dissaving relationship for those whose reported income is low, high or missing, as exact incomes were not reported. The explanatory variables considered in the analyses were cost, SES, location, age, gender and hospitalisation. All statistical analyses were carried out in R version 3.0.1.n = 157), 10 % in Tanzania (n = 9), and 3 % in Bangladesh (n = 3). Patients experiencing extreme costs in Bangalore were more likely to be male (p < 0.01), and were more likely to report hospitalisation (p < 0.01), medium/high SES (p < 0.01) and dissaving (p < 0.01). Given the low numbers experiencing extreme costs in the other two sites, a more instructive comparison is between those who experience costs greater than 200 % of the median (i.e. ‘high’ or ‘extreme’ costs), and those who do not. The proportion experiencing ‘high’ or ‘extreme’ costs was 18 % in Bangladesh (N = 17) and 22 % in Tanzania (N = 21). In Tanzania, costs greater than 200 % of the median were significantly associated with hospitalisation (p < 0.01), whereas in Bangladesh, they was significantly associated with income in the higher band (p = 0.03).Mean patient costs were considerably higher than median costs for all locations , reflecting a skewed distribution commonly found for costs. The results of our cost stratification are presented in Tables p = 0.13). Income levels were reported by 62 % of respondents in Tanzania and 67 % of respondents in Bangladesh. Although the questionnaires offered respondents a choice of 4 income bands, only four respondents in Bangladesh and six respondents in Tanzania reported incomes in the higher two bands. We therefore aggregated the higher three levels in the stratification analysis, dividing respondents into low and high income, using the upper limit of the lowest income band in the questionnaires as the threshold . Higher income was associated with cost level in both countries at the 10 % significance level .Dissaving rates overall were comparable between Tanzania and Bangladesh (61 % vs 55 %), and lower in Bangalore37 %). This difference was largely due to dissaving rates in the low cost band, which were lower in Bangalore . Only 6 % of dissavers in Bangladesh and 5 % in Bangalore relied solely on asset sales to raise funds. In Bangladesh, assets were only sold where costs were low or medium (i.e. less than 200 % of the median), whereas there was no clear relationship between costs and type of dissaving in Bangalore. Assets sales were more prevalent in Tanzania, where 40 % of dissavers did not take out loans. The difference in mean income between those reporting ‘low’ versus ‘extreme’ costs in the Bangalore dataset was only 20 % (Table 7 %. Thisp = 0.03) and male gender (p = 0.005). In Bangladesh, these variables were also positively associated with dissaving, but not significantly. No other variables were significantly associated with dissaving in either location. We carried out a similar analysis for Bangalore, with predictors similar except for the lack of rural patients, the availability of income data, and the characterisation of SES as a 3-level factor. We found significant positive associations between the presence of dissaving and cost (p = 0.005), hospitalisation (p < 0.001), and low socioeconomic level (p = 0.011). There was a significant negative association between dissaving and income (p < 0.001). We then explored the association between patient cost and the amount of dissaving among the subset of patients  who reported dissaving at any amount (Table p < 0.001) and Bangalore (p < 0.001). The relationship for Tanzania was positive but not significant (p = 0.201).Results from logistic regressions to predict the probability of dissaving are given in Table  p = 0.00. In Bangp < 0.001). Table p < 0.001). There was no statistically significant relationship between the level of dissaving and patient costs among high-income Bangladeshis, high-income Tanzanians, or low-income Tanzanians. These results were robust to the method used for analysis in the presence of missing data .Of the 891 Bangalore respondents reporting cost and income, 762 (86 %) reported costs greater than 20 % of annual income, and 661 (74 %) reported costs greater than 40 % of total annual income. There was a significant positive relationship between dissaving and the ratio of cost to income, after allowing for age, gender, socioeconomic status and reported hospitalisation  can therefore be seen as a stepping-stone towards the goal of eliminating catastrophic costs entirely.We found consistent evidence of associations between cost-income ratios and both the presence and level of dissaving. In Bangalore, the probability of dissaving increased with costs and decreased with income, and there was a strong association between the amount of dissaving and the cost-income ratio, which supports using the former as a proxy for catastrophic costs. Evidence from Bangladesh and Tanzania was less conclusive, largely because these were smaller studies, and collected income data as bands rather than actual amounts. Even so, there were several statistically significant associations consistent with a relationship between dissaving and catastrophic cost, and none inconsistent with such a relationship. However, the sample size and lack of precise values for income are limitations, as is the fact that none of the studies whose data we used were explicitly designed to evaluate the use of dissaving as a proxy for catastrophic costs. In particular, data from Bangladesh and Tanzania are not available for the first 2 months of the continuation phase (months 3 and 4). This is more likely to be a significant issue for calculating dissaving than costs, as little is known about the timing of asset sales and uptake of loans, whereas it is more reasonable to assume that costs are spread evenly throughout the continuation phase. Given these limitations, further research is required to validate the use of dissaving as an indicator of catastrophic costs, and to explore the timing of dissaving relative to the incurring of costs. Further evidence is also required on how universally dissaving measures could be applied – in some settings, for example, there may be cultural barriers to the take-up or reporting of loans.Our analysis suggests that dissaving can be a useful indicator in the evaluation and monitoring of financial protection and service delivery interventions aimed at reducing catastrophic costs. Further evidence would inform how this indicator is used – we expect it will supplement other measures of financial distress where available. Such measures could be used in combination to identify catastrophic costs, for example by comparing the amount of dissaving to the total amount of healthcare expenditure, using empirically determined thresholds. Dissaving may also capture financial distress that is not reflected in cost-income ratios, for example when households face multiple illnesses that are catastrophic together but not singly .Our results also illustrate different strategies for dissaving – dissavers in Tanzania, for example, were more likely to sell assets than in Bangladesh or Bangalore. It is likely that the nature of dissaving will influence its relationship to financial hardship. It may therefore be useful to distinguish between types of dissaving when using this measure as a signal for financial distress. For example, it may be possible to distinguish between ‘planned dissaving’ and ‘distressed dissaving’. The former would involve measures designed for protecting households from financial shocks . The latter would involve dissaving actions that households adopt due to a lack of alternatives, despite significant immediate consequences for household well-being. Those who take out high-interest loans, or sell assets that generated a high proportion of household income, for example, would seem to be at greatest risk of failing to meet basic subsistence needs as a result. A further aim for future research would be to explore the relationship between the type of dissaving and the consequences for household wellbeing, in order to enhance the value of dissaving measures as an indicator of catastrophic cost.Diseases such as TB, which disproportionately affect poor households, can have a devastating effect on the financial security of those households. The costs incurred in relation to TB have been shown to appear early in the care-seeking pathway, and this has a direct impact on patient health, as it restricts the ability to access and adhere to subsequent care , 22. Dis


Professor Craig Pringle, Emeritus Professor of Virology at the University of Warwick, died suddenly and unexpectedly at home on Saturday 24 September 2015. Craig was born in Glasgow in 1930, and his early academic achievements led to his parents’ expectations that their only child would follow a career in medicine. However, his interests lay firmly in the more fundamental aspects of science, and he undertook a degree in zoology and genetics at the University of Glasgow, followed by a PhD in microbial genetics at the University of Edinburgh. This early passion for genetics remained with him throughout his scientific career, which focused subsequently on virology. After completing his PhD in 1957, Craig undertook a two-year period of compulsory military service, which he spent at the University of Cambridge using his skill in the Russian language at the Joint Services School for Linguistics. This expertise was also utilised subsequently in undertaking translation of two significant scientific texts and many scientific articles into English. It was typical of Craig’s understated and quiet manner that many who knew him were unaware of his linguistic achievements.Craig’s first steps in forging an extremely successful career began by picking up his work in genetics at the University of Aberdeen, but the most significant step was his subsequent appointment to the Animal Virus Research Institute at Pirbright (now the Pirbright Institute), where he began to work on the genetics of foot-and-mouth disease virus, ultimately becoming Head of the Department of Virus Genetics at the Institute. His time at Pirbright from 1961 to 1968, interrupted by a very brief return to Aberdeen as a lecturer in bacteriology and particularly by his collaborations with John Subak-Sharpe, set Craig on the path that he followed for the remainder of his career and beyond. In 1968, he moved to the UK Medical Research Council Virology Unit in Glasgow, where John Subak-Sharpe was the newly appointed Director. It was here that Craig undertook most of the work that forged his international reputation for seminal observations on a number of virus systems, particularly vesicular stomatitis virus and respiratory syncytial virus. Craig’s final position was as Professor of Virology in the Department of Biological Sciences at the University of Warwick from 1983 to 1996, where he became an Emeritus Professor upon retirement.Craig made many pioneering contributions to the field of virology. His careful and meticulous approach in the generation and analysis of virus mutants led to many fundamental observations in the systems he studied. At this time, the use of virus mutants provided the major tool available to virologists for analysis of virus protein functions. Craig utilised his skills and enthusiasm for virology in the exploration of a wide range of different viruses, bringing to each his attentive and critical approach. In particular, his work on vesicular stomatitis virus and other rhabdoviruses laid a foundation for understanding the genetics of these agents. Craig’s work on these and other viruses, including the bunyaviruses, provided unique and invaluable reagents, which he shared generously and without restriction with colleagues across the world. Subsequently, Craig turned his attention to the genetics of pneumoviruses, especially respiratory syncytial virus, and this became the primary focus of his work in the later years of his career. As with all of his areas of interest, Craig developed an international reputation for the quality of this work. Throughout his career, Craig retained a broad interest in virology, and it was a particular pleasure for him to be awarded a Visiting Professorship in the Department of Microbiology at the University of Alabama at Birmingham from 1995 to 1996. During this time, he worked in the laboratory of Gail Wertz, where he returned to his early passion of vesicular stomatitis virus to learn how to manipulate virus genomes using the newly described techniques of reverse genetics. This was a highly successful time, and was a fitting conclusion to a career that had begun by making virus mutants using the traditional approaches of chemical mutagenesis. During his career, Craig was supervisor and mentor to a large number of postgraduate and postdoctoral colleagues. His positive influence is obvious through the successful careers that many of these have had in science since working with him.http://www.promedmail.org) and the International Committee on Taxonomy of Viruses . He served the ICTV in various capacities, including periods as the Paramyxoviridae Study Group chair, a member of the Vertebrate Virus subcommittee, a member of the Executive Committee, and ICTV Secretary – the latter for nine years prior to his retirement. He was also the editor of Virology Division News in Archives of Virology from 1996. He continued to contribute to the work of the ICTV in retirement, with his last published article appearing in 2012.Craig’s passion for all things virological continued throughout his retirement from active research, with contributions through work with ProMED  for his work as an editor of the Journal of General Virology from 1982 to 1987.When away from his research work, Craig’s focus was his family – his wife Judy and three children Kirsty, Iain and Heather. A source of immense pleasure to him was the birth of his first grandchild, Sophia, four months before his untimely death. Outside the laboratory, Craig maintained a keen enjoyment of the remoteness and ruggedness of the Scottish countryside, in particular the Hebridean islands of Colonsay and Jura, where his family spent many holidays. This was a subject that Craig often mentioned, and, after his retirement from Warwick, he returned to Scotland, to the village of Aboyne near Aberdeen. There, he was a keen walker, using his dogs as an excuse to explore the local area while also rekindling an interest in Scottish history and family genealogy. Craig had a rich personal and professional life, with the latter dedicated to the exploration of virology. He will be missed as a good friend, colleague and mentor by all who knew him.http://www.promedmail.org. Accessed 15 December 2015.This obituary was previously published at ProMED-mail. Andrew J. Easton, Obituary: Craig Pringle, ProMED Virology Moderator. Archive Number 20151109.3778621, 9 November 2015,


DelR242 (3R) allele, a truncated 3-arginine residue (3R) [major type: 4 arginine residues (4R)] of the third intracellular loop of GHSR1a, with a high frequency in Japanese Shorthorn bulls (0.43) but with a low frequency in other cattle breeds (0.00–0.09). To further investigate the reasons for the higher frequency of the 3R allele, we performed several experiments. In this study, we found a significant sex difference in the frequency of the 3R allele. Statistical analysis revealed a significant overdominance effect of the DelR242 locus on growth in Japanese Shorthorn weaner bulls. However, additive/dominance/overdominance effects of the 3R allele on carcass traits in adult steers and dams were not significant. The mode of the overdominance effect was estimated to be solely controlled by the single DelR242 locus without any other linked loci using linkage disequilibrium analysis in GHSR1a. These results indicated that 4R/3R heterozygotes had a selective advantage in weaner bulls because of their higher average daily gain than homozygotes. We discussed possible molecular mechanisms involved in the overdominance effect of the DelR242 locus on these traits in weaner bulls using a structural model of the complex consisting of a GHSR1a dimer and Gαq.Ghrelin and the ghrelin receptor (GHSR1a) are involved in growth hormone secretion, food intake, and several other important functions. Ghrelin acts on GHSR1a and induces signal transduction via the Gαq subunit. In our previous study, we identified the  Japanese Shorthorn cattle were developed by crossbreeding indigenous (Nanbu-gyu) and Shorthorn (meat-type and/or dairy-type) cattle imported from the United States, England, Canada, and Australia in the Meiji to Showa eras in the northern Tohoku district  and Hokkaido Island. Japanese Shorthorn cattle are superior in terms of hardiness in a cold climate and grazing ability; however, they show less uniformity in body weight (BW) and body conformation than Japanese Black cattle because of their high genetic diversity and unique crossbreeding histories. Natural mating on regional public ranches (standard herd: 1 sire and 50 dams) is a conventional practice .GHSR1a mRNA is highly expressed in the hypothalamus and anterior pituitary gland  allele, a truncated 3-arginine residue (3R) [major type: 4-arginine residue (4R)] of the third intracellular loop 3 (ICL3) of the GHSR1a protein and showed that it occurred with high frequency (0.43) in Japanese Shorthorn bulls and with low frequency (0.09) in Holstein–Friesian cattle. However, this allele was never found in Japanese Black or Mishima Island cattle . In humans, two missense mutations (p.R237W and p.D246A) adjacent to the 4R region of ICL3 of the GHSR1a protein have been reported in short-stature family lines , a ghrelin receptor, is a typical G-protein-coupled receptor (GPCR) with seven transmembrane domains, and DelR242 locus, the 5′UTR microsatellite [5′nUTR-(TG)], the intron 1 microsatellite [5 > 6MS(GTTT)], and single-nucleotide polymorphisms (SNPs) of the nt-7(C > A), nt70(C > G), nt456(G > A), nt580(G > A), and nt667(C > T) loci were performed as previously described (Table S1) (nt70(C > G), nt580(G > A), and nt667(C > T) loci in exon 1 and the intron 1 microsatellite [5 > 6MS(GTTT)] were fixed for the homozygotes  in 95 sires. To compare allele and haplotype frequencies of the DelR242, n5′UTR-(TG), nt-7(C > A), and nt456(G > A) loci in sires and dams and to perform an association study between these loci and directly tested traits of weaner bulls or carcass traits of shipped half sibs, we collected a total of 661 genomic DNA samples [121 for sires and 540 for shipped half sibs sired by 17 bulls (210 dams and 330 steers)]. Of 121 weaner bulls, 26 individuals had only DelR242 and nt-7(C > A) genotype data. Of 540 shipped half sibs, 3 individuals were excluded from analysis because of insufficient growth. The 540 half sibs were not randomly selected from the shipped steer and dam population because we planned to collect as many 3R/3R individuals as possible for the association study using 540 half sibs sired by 14 4R/3R heterozygotes and 3 3R/3R homozygotes. In addition, the frequencies of the 3R allele of the DelR242 locus in 17 sires and 540 half sibs were significantly higher than those in 95 sires (Table S2). We estimated the allele or haplotype frequency in the dam population by removing the sire allele or haplotype from the 540 half sib genotypes or haplotype combinations.All livestock handling and cattle management procedures were performed in accordance with the guidelines for animal care of the NARO Institute of Livestock and Grassland Science. Genomic DNA was extracted from leukocytes using the standard phenol extraction protocol. Fragment analysis and sequencing of the Figure S3). The selected weaner bulls aged 6–7 months were transported to the direct testing station at the Animal Industry Research Institute, Iwate Agricultural Research Center (IARC). They were fed concentrate . They also had ad libitum access to roughage (timothy-grass hay) with an allowance of 42 d for adjustment and acclimatization, followed by the standard 140 d of direct testing prior to slaughter. The average age at the start of direct testing was 245.1 ± 20.6 d (mean ± SD). Routine management of the animals involved fortnightly recording of BW and BSCM traits at the start and end of direct testing  . Other data included daily concentrate and roughage intakes, average daily gain (ADG) for the direct-testing period, total subcutaneous fat thickness at 8 points (8SFT), and total weight of concentrate and roughage intakes and concentrate and roughage weights per kg of BW gain . Relative percentages (%) of roughage (ROUGH) were calculated from the daily recorded concentration and roughage intakes ([roughage]/[roughage + concentration]) during the direct-testing period. BWs observed at selection (BW_Sel) (average: 187 d of age), at the start , and at the end  of direct testing were used. The 180-d and 365-d adjusted BWs  were estimated using simple linear regression with BW_Sel, BW_S, and BW_E as independent variables. Of 121 weaner bulls, 27 individuals (from 1995 to 2001) had data only for ADG, BW_S, BW_E, 180BW, 365BW, 8SFT, CONC_1, ROUGH_1, and ROUGH.Two experiments were performed for the association study. In Experiment 1 (Exp. 1), data of 121 weaner bulls in a direct-testing program in Iwate Prefecture from 1995 to 2009 (except for 1998) were analyzed. The calves were born between February and May in their respective farmers’ feedlots (birth years: 1995–2009) and grazed on regional public ranches with their dams from May to the end of September. Unfortunately, the birth weights of calves were not recorded. Preliminary selection on the basis of their body shape and conformation measurements (BSCMs) was performed at 4–5 months of age (DelR242 genotype: 14 4R/3Rs and 3 3R/3Rs). These half sibs [24.2 ± 3.5 months of age (mean ± SD)] were shipped to one of five livestock markets from their farms of origin in Iwate Prefecture. The calves were born in the 2002, 2003, and 2004 February-to-May calving seasons (spring) in their respective farmers’ feedlots. Bull calves were castrated at approximately 4–5 months after birth. The calves were grazed in regional public ranches with their dams from May to October each year before being returned to their respective farmers’ feedlots for finishing. The calves had restricted access to concentrate feeds and ad libitum roughage intake until shipping in 2004, 2005, and 2006. The roughage type in public ranches and farmers’ feedlots varied between rearing places. The general feeding conditions for fattening were as follows: (1) preceding term (8–16 months of age), 1.4% of BW concentrate intake per day and grass silage ad libitum; (2) midterm (17–20 months of age), 1.8% of BW concentrate intake per day and 2 kg/d of paddy straw; and (3) later term (more than 20 months of age), 8–10 kg/d of concentrate and 2 kg/d of paddy straw. After slaughter, the carcasses were dissected and evaluated at the sixth and seventh rib sections according to the Japanese meat grading system by a certified grader of the longissimus muscle area , rib thickness , subcutaneous fat thickness , and firmness, texture, and beef marbling score number (BMS No.). Marbling was scored from 1 (poor) to 12 (very abundant) according to the beef marbling standard (In Experiment 2 (Exp. 2), we used 537 half sibs (209 dams and 328 steers) sired by 17 bulls (the standard .DelR242 [or nt-7(C > A)] locus and for the effect of epistasis between the DelR242 and nt-7(C > A) loci. The following models were used:yijkno or yijklmno is an individual phenotypic observation; the effect of year i , the grazing area effect (areaj) , the sex effect (sexl) , and the shipping month effect (shippingm)  were used as fixed effects. b is a regression coefficient of age (xk) at the start of direct testing (Exp. 1) or of month of shipping (Exp. 2). In this analysis, the infinitesimal genetic effect was included and treated as a random effect (uo) with covariance matrix, Aσu2 (where A is the numerator relationship matrix). eijkno and eijklmno are vectors of random residual effects. SNP is the single-locus SNP (including the DelR242) genotypic effect, which was partitioned into additive (a) and dominance (d) effects.A mixed-inherited animal model was used to evaluate the effect of genotype and to compute basic summary statistics on traits of interest. The snp_ad, snp_a, snp_d, and epi_snp options of the Qxpak software  were useP values were obtained by assuming a χ2 distribution of the likelihood ratio test (degrees of freedom = 2).The likelihood ratio test was performed by removing the single-locus SNP genotypic effect from the model, and normal p and q are allelic frequencies, a and d are additive and dominant effects of the DelR242 locus, respectively, and AV is the additive genetic variance of the trait obtained from an animal model ignoring single-locus SNP genotypic effects  with the generalized linear model (GLM) procedure in SAS  fitting DelR242 and intron 1 microsatellite [(GTTT)5 or (GTTT)6] of 23 individuals  were used to estimate local LD and haplotype blocks for a 5.8-kb genomic region that surrounds the DelR242 locus of GHSR1a. The genotype data  of 95 sires and 540 half sibs were also used to estimate local LD. Local LD (2r) and common haplotype patterns were computed with Haploview version 4.2 , nt456(G > A), and n5′UTR-(TG) loci between 17 sires and 540 half sibs were not significant (Table S2). Accordingly, allele and haplotype frequencies of the DelR242, nt-7(C > A), nt456(G > A), and n5′UTR-(TG) loci were compared between 95 sires (as “sires”) and 540 dam haplotype (as “dams”) (3R (DelR242), C [nt-7(C > A)], and A [nt456(G > A)] alleles in sires were significantly higher than those in dams . The χ2 values for the nt456(G > A) and nt-7(C > A) loci were lower than that for the DelR242 locus. There was no significant difference between sires and dams in allele frequencies of the n5′UTR-(TG) locus (P < 0.10). In comparison, it was evident that the haplotype frequencies of the C-3R ([nt-7(C > A)]-[DelR242] haplotype) and the A-3R ([nt456(G > A)]-[DelR242] haplotype) in sires were significantly higher than those in dams . There was no significant difference between sires and dams in the [nt-7(C > A)]-[nt456(G > A)] and [n5′UTR-(TG)]-[nt-7(C > A)]-[DelR242] haplotype frequencies .The frequencies of the  “dams”) . It was DelR242 locus in GHSR1a. We found a haplotype block of approximately 2 kb from the nt667(C > T) in exon 1 to the nt2884 (A > G) in intron 1 (DelR242 locus is not in LD with nt-7(C > A), the n5′UTR-(TG), and the other 27 loci within GHSR1a, except for the nt456(G > A) locus. DelR242 is in LD with the nt456(G > A) locus (2r = 1) (DelR242 and nt456(G > A) was confirmed in 95 sires and 540 half sibs (nt70(C > G), nt580(G > A), nt667(C > T), and intron 1 microsatellite were fixed for the homozygous genotypes  in the 540 half sibs. The 15 markers in intron 1 were considered as fixed for homozygotes on the basis of the result of local LD analysis in Japanese Shorthorn cattle (nt456(G > A) is a synonymous nucleotide substitution in exon 1.We analyzed local LD and common haplotype patterns in a 5.8-kb genomic region around the intron 1 . In addi(r2 = 1) . The stralf sibs . It was n cattle . nt456 and CW (CW_RGR) during the direct-testing period among three genotype individuals (Table S3).enotypes , and domanalysis . In dire4R/3R heterozygote weaner bull has a selective advantage over its homozygous peer in direct testing because of a heterozygous advantage of the DelR242 locus effect on ADG. The selection index formula for direct testing of Japanese Shorthorn bull is as follows :DelR242 genotypes of 11 core sires for insemination at IARC are seven 4R/3R heterozygotes and four 3R/3R homozygotes. The expected ratios of 4R/3R heterozygous individuals in progeny produced by mating of the progeny-tested sire with dams in 0.3 of the 3R allele frequency in the dam population are 30% for 4R/4R, 50% for 4R/3R, and 70% for 3R/3R sires (Table S4). These ratios could explain the significant sex differences between sires and dams and the higher 3R allele frequency in Japanese Shorthorn cattle than in other cattle breeds. The 3R allele of the DelR242 locus has been reported to be widely distributed at low frequency in both the B. taurus and B. indicus cattle breeds  effects on growth or other traits. The pseudo-overdominance model operates when two or more dominant or recessive mutations in different parents are linked or “in repulsion.” The epistasis model is based on nonallelic interactions between two or more loci that lead to superior phenotypic expression in hybrids  have identified areas of the genome associated with feed intake and growth traits in beef cattle  and found no differences between haplotypes  of the GHSR1a transcripts that are attributable to miRNA regulation.MicroRNAs (miRNAs) are small (approximately 22 nucleotides long) endogenous noncoding molecules that can play important regulatory roles in animals and plants by targeting mRNAs for cleavage or translational repression. miRNAs mainly target complementary sites of 3′UTRs of mRNAs . We prev19-TG allele of the n5′UTR-(TG) locus and the A allele of the nt-7(C > A) locus have been reported to show significant desirable additive effects on CW and ADG in Japanese Black cattle (DelR242 and nt-7(C > A) loci on the traits in direct-tested bulls and shipped half sibs were not significant (Table S5). Furthermore, the nt-7(C > A) locus showed neither additive nor overdominance effects on these traits in direct-tested bulls (Table S5).The DelR242 locus on ADG observed in weaner bulls may be controlled by the DelR242 single locus. Further investigations of GWAS and epistatic effects between DelR242 and other loci are required to shed light on the single overdominance effect of the DelR242 locus on ADG in other Japanese Shorthorn herds.Taken together, these results suggest that the overdominance effect of the DelR242 locus on ADG were confined to the direct testing period (approximately 8 months of age) (Significant overdominance effects of the  of age) . PercentGHSR1a mRNA expression was reported to be higher in the arcuate nucleus, pituitary gland, and liver than in other tissues, and GHSR1a mRNA expression in the arcuate nucleus of postweaning calves was 10-fold greater than that in preweaning calves and cows . We found that the 4R regions of the two GHSR1a protomers simultaneously interacted with Gαq at different sites when GHSR1a was dimerized via interactions between transmembrane helices 5 and 6 (TM-V and TM-VI) . Deletion of an arginine residue from each 4R region will markedly change the structure of the region and the interactions with Gαq. Although it is difficult to predict how the Gαq-activation ability of the GHSR1a dimer is affected by deletion from the model structure, it is possible that the interactions between the GHSR1a(4R)–GHSR1a(3R) or GHSR1a(3R)–HSR1a(4R) “hetero”-dimer and Gαq are more favorable for the activation of Gαq than the interactions with GHSR1a “homo”-dimers. Thus, the activation of intracellular signaling transduction in the GHRH neuron of the 4R/3R heterozygotes becomes greater than that of the homozygotes.We considered a possible molecular mechanism of the overdominance effect caused by the


Eucampsipoda africana) associated with Egyptian fruit bats (Rousettus aegyptiacus) collected in South Africa. Complete sequences of the ten dsRNA genome segments of the virus, tentatively named Mahlapitsi virus (MAHLV), were determined. Phylogenetic analysis places this virus into a distinct clade with Baboon orthoreovirus, Bush viper reovirus and the bat-associated Broome virus. All genome segments of MAHLV contain a 5' terminal sequence (5'-GGUCA) that is unique to all currently described viruses of the genus. The smallest genome segment is bicistronic encoding for a 14 kDa protein similar to p14 membrane fusion protein of Bush viper reovirus and an 18 kDa protein similar to p16 non-structural protein of Baboon orthoreovirus. This is the first report on isolation of an orthoreovirus from an arthropod host associated with bats, and phylogenetic and sequence data suggests that MAHLV constitutes a new species within the Orthoreovirus genus.We report on the isolation of a novel fusogenic orthoreovirus from bat flies ( Bats have been increasingly associated with emerging and re-emerging viruses. The likelihood of possible transmission of these pathogens to humans is ever increasing as a result of human encroachment on animal habitats, climate change and change of human behaviour. Pathogens of particular public health importance are filoviruses ,2, coronStreblidae and Nycteribiidae, and are highly host-specific obligate ectoparasites of bats . Se. SeRouseibiidae)  confirmsReoviridae  precipitated preparation of isolate 06-24 yielded the most viral specific reads and formed 11 contigs aligning to Othoreoviruses using BLASTn and BLASTx. Both the 5' and 3' ends were missing for all the segments, so to obtain complete genomes for each isolate, rRNA depletion and a combination of SISPA and rapid amplification of cDNA ends (SISPA-RACE) was done. Read numbers were also increased by running samples on an Illumina Nextseq 500. Both an increase in the percentage of viral reads aligning to the genome segments and an increase in coverage of the ends were observed. Presence of MAHLV in the original homogenates from which the isolates were obtained was confirmed by SISPA amplification and NGS directly from the homogenates. Expectedly, only a low number of reads from both homogenates mapped to the MAHLV sequence due to the high amount of host sequence obscuring viral specific sequences combined with likely low viral load in the homogenates and the relatively low sensitivity of the SISPA method.Reoviridae  encoding segments of representative viruses from the different genera within oviridae  shows thus genus . A distius genus . Homologus genus .Orthoreovirus, and an identical 5' terminal sequence, 5'-GGUCA which is unique to MAHLV. Non-coding regions (NCRs) are present at both ends of the genome segments, with the 5' NCRs being shorter in nucleotide length than 3' NCRs. The nucleotide sequences of the two isolates of MAHLV, 2511 and 06-24, are not identical. Nucleotide homology of the RdRp encoding segment between the two isolates is 93.5% (99.8% deduced amino acid sequence), and 80.4% (89.0% deduced amino acid sequence) for the Sigma B encoding segment.The genome segments of MAHLV were named according to the nucleotide length, which is consistent with the nomenclature of other orthoreoviruses . A summaAUG codon in close proximity to the 5' end. The L1 segment of MAHLV contains two AUG start codons in close proximity to the 5' end, at positions 14 and 19. The first start codon (position 14) complies with Kozak’s rule (ACTAUGG) and initiates an open reading frame 3885 nucleotides in length, putatively coding for Lambda A protein which is a core structural protein with NTPase, helicase and dsRNA binding ability. The second start codon (position 19) does not comply with Kozak’s rule (TGGAUGG); it initiates a 402 nucleotide open reading frame but the deduced amino acid sequence does not match any known viral protein of note on Genbank. The M2 segment contains two AUG codons at positions 29 and 169, both complying with Kozak’s rule (ACGAUGG and AGCAUGG). The open reading frame initiating at position 29 is 2031 nucleotides in length and putatively encodes for an outer capsid protein involved in membrane penetration during infection (muB). The second AUG initiates a 492 nucleotide open reading frame but the deduced amino acid sequence does not match any viral protein of note on Genbank. The deduced Sigma A protein of MAHLV (segment S1) contains the fusogenic orthoreovirus-wide conserved arginine amino acid at position 273. The S4 segment is bicistronic and encodes for a 14 kDa protein similar to p14 membrane fusion protein of Bush viper reovirus and a non-overlapping 18 kDa protein similar to p16 non-structural protein of Baboon orthoreovirus without a known function  leading to rapid monolayer destruction after inoculation, with a peak in virus RNA  by day 7, followed by a decrease on day 13. The inoculums containing a lower virus dose (104 and 103 TCID50/mL) resulted in a peak of RNA detection on day 13. All three above-mentioned inoculum doses yielded detectable virus RNA by day 4 after inoculation. The inoculum containing 101 TCID50/mL virus did not generate detectable viral RNA until day 7, and was still showing an upward trend on day 13 (last sampling day). The virus did not replicate in the insect cells (C6-36) up to day 13, but adaptation to these cells through serial passaging was not attempted.MAHLV replicated efficiently in Vero cell culture, with the inoculum containing a high dose of virus , Colorado tick fever virus (Coltivirus) and Bluetongue virus (Orbivirus). Our isolation of MAHLV from arthropods might direct some attention to the possible role of insects in the transmission of currently known orthoreoviruses, or possibly the presence of other yet unknown viruses in various arthropods. We have no information on the geographical range of MAHLV, but the wide distribution of Rousettus aegyptiacus in Africa and the Middle East [The arthropod-borne nature of MAHLV transmission needs further investigation, especially to establish whether nycteribiid flies are only involved in mechanical or possibly biological transmission, and if the virus is even transmitted to bats. Various other genera in the dle East , and thedle East ,14,15, din vitro systems cannot be translated directly into replication in a vertebrate host. It is important to note, also, that this was after blind passage and cell culture adaptation (CPE noted after two–three blind passages). Any risk of human infection for now, however, is only likely in individuals who come into close contact with wild Egyptian fruit bats and their ectoparasites. Although highly host-dependent, the bat flies have been noted to leave their bat hosts and crawl on bat researchers . Respiratory disease has been noted in humans infected with Melaka, Kampar and Nelson bay orthoreovirus, including limited human-to-human transmission [We have no data to suggest that MAHLV has any human health implication, but this warrants further investigation. The virus grows to high titers in Vero E6 cells which suggests that it may infect vertebrates, although growth in smission ,23,32,33In conclusion, we have identified a novel orthoreovirus which we propose should constitute a new species within the genus. Two virus strains were isolated from ectoparasitic bat flies collected from Egyptian fruit bats from a South African cave roost. This represents the first isolation of an orthoreovirus from arthropods and the first African virus in this genus with an indirect link to bats.


Chimgoogyeongheombang. Using a term frequency-inverse document frequency (tf-idf) scheme, the present study extracted valuable data regarding the indications of each acupoint according to the frequency of the cooccurrences of eight Source points and eighteen disease sites. Furthermore, the spatial patterns of the indications of each acupoint on a body map were visualized according to the tf-idf values. Each acupoint along the different meridians exhibited different constellation patterns at various disease sites. Additionally, the spatial patterns of the indications of each acupoint were highly associated with the route of the corresponding meridian. The present findings demonstrate that the indications of each acupoint were primarily associated with the corresponding meridian system. Furthermore, these findings suggest that the routes of the meridians may have clinical implications in terms of identifying the constellations of the indications of acupoints.The indications of acupoints are thought to be highly associated with the lines of the meridian systems. The present study used data mining methods to analyze the characteristics of the indications of each acupoint and to visualize the relationships between the acupoints and disease sites in the classic Korean medical text  Mingtang Diagram, Diagram of Meridian and Collaterals, and Bronze Statue were also gradually influenced by Western-style anatomy. However, despite decades of research and a merging of Western and Eastern ideals, an anatomical map of the meridians on the human body has yet to be fully realized [) refers to the number of times that term “t” occurs in document “d” and, therefore, tft,d)( represents how relevant term “t” is to document “d”. Document frequency (dft) is the number of documents that contain term “t” and, therefore, dft represents the rarity of a term within the system of documents. Across the document system, rare terms are more informative than frequent terms and, thus, the inverse document frequency of “t” (idft) is positively related to the informativeness of “t”. Arithmetically, idf is defined as log(N/dft) instead of N/dft to where N is the number of whole documents in order to diminish the effect of idf. Tf-idfd,a). Finally, the calculated tf-idf weights of each acupoint were normalized by the following cosine normalization: . The tf-idf values were overlaid on a human figure template using matplotlib, which is a plotting library for python  values.The algorithm was intended to identify the disease sites that were related to the acupoints described inlib.org/ ). A variy-axis of the array in x-axis of the array in The 8 Source points are presented on the In the Foot-Yin meridian, acupoint SP 3 showed superior tf-idf values with the abdomen (tf-idf: 0.85) and the chest (tf-idf: 0.53), acupoint KI 3 showed superior tf-idf values with the abdomen (tf-idf: 0.60), the lower limb (tf-idf: 0.40), and the throat (tf-idf: 0.40), and acupoint LR 3 showed superior tf-idf values with the abdomen (tf-idf: 0.52), the lower limb (tf-idf: 0.52), and the back (tf-idf: 0.40).In the Hand-Yin meridian, acupoint LU 9 showed superior tf-idf values with the heart (tf-idf: 0.64), the upper limb (tf-idf: 0.57), and the chest (tf-idf: 0.51), acupoint HT 7 showed superior tf-idf values with the heart (tf-idf: 0.41) and the chest (tf-idf: 0.40), and acupoint PC 7 showed superior tf-idf values with the heart (tf-idf: 0.63), the chest (tf-idf: 0.50), and the face (tf-idf: 0.41).In Hand-Yang meridian, acupoint LI 4 showed superior tf-idf values with the teeth (tf-idf: 0.60) and nose (tf-idf: 0.50) and acupoint SI 4 showed superior tf-idf values with the head (tf-idf: 0.64), the ears (tf-idf: 0.53), and the eyes (tf-idf: 0.46).Eight Source points that represented each meridian system, as assessed using the tf-idf value, were visualized on a human body template. Thus, it was possible to visually display the spatial patterns of the various disease sites as they related to each acupoint .The Source points on the left part , which are representative acupoints of the Foot-Yin meridian system, were highly associated with the truncus (including the abdomen and the chest) and the lower limbs. The Source points in the middle part , which are representative acupoints of the Hand-Yin meridian system, were highly associated with the upper truncus (including the heart and the chest) and upper limbs. The Source points in the right part (LI 4 and SI 4), which are representative acupoints of the Hand-Yang meridian system, were highly associated with the head regions  and the upper limbs. Illustrations of Meridians and Collaterals in Ancient Times and Diagram of the Circulatory Course of Meridians.Additionally, there were similarities between the spatial patterns of the constellations of the indications of each acupoint and the routes of the corresponding meridians according to texts such as Chimgoogyeongheombang. Using the frequency of cooccurrences among 18 disease sites from Chimgoogyeongheombang and 8 Source points and the normalized relationships  among these factors, the present study identified valuable data regarding the indications of each acupoint , were not used frequently in the text, we cannot fully rule out the possibility of tf-idf values from the acupoints being exaggerated or distorted.The present study has several limitations. First, the characteristics and spatial patterns of the indications of the acupoints were extracted from a single classic Korean medical text with limited bibliographical data. There are large variations from text to text when describing the relationships between disease sites and acupoints. Thus, it is necessary to further investigate the similarities and/or differences of the indications of acupoints using a variety of classic medical books from several cultures. Second, the present study assumed that the spatial patterns of the indications of each acupoint in terms of the 18 selected disease sites were highly associated with the routes of corresponding meridian systems but the available spatial data for the body were limited and did not include detailed spatial location information, such as the medial or lateral parts of the hand. However, based on the global distribution of the spatial patterns of the indications of each acupoint, it is possible to utilize the characteristics of the meridian systems as medical infographics. Third, the present findings were obtained based on the description of one individual's clinical observations from a classic medical textbook and not using outcomes extracted from well-structured clinical data. In order to fully characterize the characteristics of the indications of each acupoint to properly inform clinical assessments, it is necessary to investigate the relationships among the disease sites and acupoints using detailed spatial information from large-scale clinical investigations. Last but not least, when the Source points, that is, SP3 or LU 9 (In conclusion, the present findings demonstrate that the indications of each acupoint are primarily associated with their corresponding meridian system. These findings also suggest that the routes of the meridian systems have clinical implications regarding the constellations of the indications of acupoints. The present authors strongly believe that the characteristics of the meridian system can act as an ancient infographic that will aid in the development and characterization of the clinical implications of acupoint selection for the treatment of various diseases.


Female circumcision, sexual amputation, or Female Genital Mutilation (FGM) is an action existing in some cultures and regions of the world. For instance, in Africa and some little communities in Middle East use this operation for many reasons. This operation is forbidden in those countries and is never linked to religious attitudes.The purpose of the following research was to determine and compare marital satisfaction, mental health and sexual satisfaction between Kurdish genital mutilated and non-genital mutilated females.To achieve the goal of research, a sample of 200 married females of Ornament area in Kermanshah province were selected by non-randomized sampling Enrich Marital Inventory, and General Health Questionnaire was used for data gathering. Data was analyzed between the two groups by utilizing independent t- test. The significant level was P < 0.05.The findings indicated that there was a significant difference between genital mutilated females and non-genital mutilated females. Besides, the results revealed that two groups of participants had significant difference in mental health and the other subscales like physical symptom and sleep disorder from general health.It is noteworthy to point out that there is strong relation between sexual desire and marital satisfaction and their fulfillment reflects in mental health of people. So, when women experience the FGM in their lives, in fact they lose the gratification of their whole life. Awareness of the mental and psychical dangerous results of this operation could help women and prevent doing this inhuman action to others. Family is the most important institution of the society and it is the most significant unit of social behavior among human beings. Many researches in humanities point out the impact of this institution on forming the behavior of its members. Many of the mental health professionals and researchers improved that in person life satisfaction is related to fulfill most of the needs in family environment. When a couple decide to make their life the role of each spouse is very important. Couples do their efforts to create an atmosphere which can satisfy all their needs. The marital satisfaction consists of a sense of consent, experiencing consent and enjoyment by husband and wife, concerning all different aspects of life . But occIs there any difference between marital satisfaction of genital mutilated females and non-genital mutilated females, especially sexual satisfaction?Is there any difference between mental health of genital mutilated females and non-genital mutilated females?The current research aimed to determine and compare marital satisfaction, mental health and sexual satisfaction between genital mutilated and non-genital mutilated females.Participants were 200 married females of Oramanat area of Kermanshah Province, 100 genital mutilated females and 100 non-genital mutilated females, who were selected by non-randomized sampling, completed ENRICH marital satisfaction questionnaire and 28-questions General Health Questionnaire (GHQ). ENRICH questionnaire: The questionnaire was designed by Olson, Fournier, and Druckman . The queIn Regarding the results of Regarding to this reality that low grade showed the high mental health and considering the comparison of both groups’ averages, it was indicated that non-genital mutilated females had more mental health .As shown in


To the Editor: The outbreaks of dengue virus (DENV), chikungunya virus (CHIKV), and Zika virus infection that occurred on islands in the Indian Ocean, the Pacific, and the Caribbean over the past decade have demonstrated the potential of these arboviruses to pose a global public health threat. All 3 viruses were first isolated in the mid-20th century in either African or Asian countries; however, until 2005, only DENV  was considered a global public health concern  caused several outbreaks in the Indian subcontinent, Asia, and Central Africa, and autochthonous transmission was reported in Europe (http://www.paho.org/hq/index.php?option=com_docman&task=doc_download&Itemid=&gid=30198&lang=en).In 2005, CHIKV infection, which typically manifests as fever, joint pain, rash, and polyarthralgia, emerged on islands in the Indian Ocean. During the next 10 years, CHIKV , which typically manifests as fever, joint pain, rash, and conjunctivitis, emerged for the first time outside Africa and Asia, in Yap State in Micronesia. Six years later, the virus caused a large outbreak in French Polynesia and then spread to other Pacific islands (http://www.paho.org/hq/index.php?option=com_docman&task=doc_download&Itemid=&gid=30198&lang=en).In 2007, Zika virus . SIDS are characterized by environments that are particularly sensitive and prone to natural disasters, populations that often lack safe water supplies and sanitation, and local governments that have limited resources to implement vector control and manage outbreaks. The increasing volume of travel between SIDS and continental regions where CHIKV and Zika virus are endemic has facilitated the spread of these viruses to previously unexposed populations.The emergence of CHIKV and Zika virus in the Indian Ocean, the Pacific, and the Caribbean might result from multiple drivers. One factor is the presence of competent vectors, including the widely distributed Ae. albopictus mosquitoes  were documented by Renault et al. (Other lessons learned from the emergence of CHIKV and Zika virus in small tropical islands include evidence of nonvectorborne virus transmission and its associated public health implications. Perinatal transmission of Zika virus to a neonate was first described in infected pregnant women in French Polynesia, and possible transplacental transmission was further corroborated by the detection of the virus in amniotic fluid samples of 2 pregnant women in Brazil whose fetuses had been diagnosed with microcephaly (When we observe the geographic distribution of DENV, CHIKV, and Zika virus over the past decade, DENV expansion appears to have been a continuous process. However, the emergence of CHIKV, first in the Indian Ocean and later in the Caribbean, and the emergence of Zika virus in the Pacific has dramatically expanded the reach of these viruses .


Zika virus (ZIKV), first isolated in Uganda in 1947, is currently spreading rapidly through South America and the Caribbean. In Brazil, infection has been linked with microcephaly and other serious complications, leading to declaration of a public health emergency of international concern; however, there currently are only limited data on the virus (and its possible sources and manifestations) in the Caribbean.From May, 2014-February, 2015, in conjunction with studies of chikungunya (CHIKV) and dengue (DENV) virus infections, blood samples were collected from children in the Gressier/Leogane region of Haiti who presented to a school clinic with undifferentiated febrile illness. Samples were initially screened by RT-PCR for CHIKV and DENV, with samples negative in these assays further screened by viral culture.Of 177 samples screened, three were positive for ZIKV, confirmed by viral sequencing; DENV-1 was also identified in culture from one of the three positive case patients. Patients were from two different schools and 3 different towns, with all three cases occurring within a single week, consistent with the occurrence of an outbreak in the region. Phylogenetic analysis of known full genome viral sequences demonstrated a close relationship with ZIKV from Brazil; additional analysis of the NS5 gene, for which more sequences are currently available, showed the Haitian strains clustering within a monophyletic clade distinct from Brazilian, Puerto Rican and Guatemalan sequences, with all part of a larger clade including isolates from Easter Island. Phylogeography also clarified that at least three major African sub-lineages exist, and confirmed that the South American epidemic is most likely to have originated from an initial ZIKV introduction from French Polynesia into Easter Island, and then to the remainder of the Americas.ZIKV epidemics in South America, as well as in Africa, show complex dissemination patterns. The virus appears to have been circulating in Haiti prior to the first reported cases in Brazil. Factors contributing to transmission and the possible linkage of this early Haitian outbreak with microcephaly remain to be determined. Zika virus is currently spreading rapidly through the Americas, including the Caribbean, where it has emerged as a major public health problem due to the linkage with birth defects, including microcephaly. We report the isolation of Zika virus from 3 children in rural Haiti in December, 2014, as part of a study of acute undifferentiated febrile illness that was being conducted by our research group; from one of these children, we also isolated dengue virus serotype 1. On analysis of nucleotide sequence data from these and Zika strains from other locales, the South American/Haitian sequences cluster within the Asian clade and clearly branch out from a sequence circulating in Easter Island, which originated, in turn, from French Polynesia. On further analysis of one specific gene sequence for which more data were available, there appeared to be slight separation of Haitian strains and the strains from Brazil, Suriname, Puerto Rico and Guatemala, with molecular clock analysis suggesting that Zika virus was present in Haiti as early as mid-2013. These findings raise questions about the origin of Zika virus in the Caribbean, and subsequent patterns of circulation of the virus within the Americas. Zika is a mosquito-borne flavivirus initially isolated in the Zika forest of Uganda in 1947 . Zika inInfection with Zika virus (ZIKV) has traditionally been associated with asymptomatic or mild illness. Clinical manifestations, when they occur, include acute onset of fever, headache, maculopapular rash, arthralgias, myalgias, and/or non-purulent conjunctivitis ,2. In anAs a step in monitoring and understanding spread of the epidemic, we report here the isolation of ZIKV from three children in Haiti in December, 2014, before the first reported Brazilian cases.Our group has been involved in studies of CHIKV and DENV transmission in Haiti since May, 2014, when CHIKV swept across the island of Hispaniola. Work was done in collaboration with the Christianville Foundation, which operates 4 schools in the Gressier/Leogane region of Haiti (some 20 miles west of Port-au-Prince) with a total of approximately 1,250 students from pre-kindergarten to grade 12; students attending the school receive care at no cost in an outpatient school clinic staffed by a physician and two nurses . As part2EDTA) tubes , the collected blood centrifuged to pellet red and white blood cells, and the resulting plasma transferred to sterile screw-top vials and stored at -70°C pending tests.Blood samples were obtained from a total of one hundred seventy-seven (n = 177) Haitian children presenting with a history of acute undifferentiated febrile illnesses between May, 2014, and February, 2015. Blood smears were prepared for microscopic analyses for malaria parasites. To obtain plasma for virologic analysis, whole blood (5 mL) was collected into purple top . The extracted vRNAs were tested using primers described by Lanciotti et al  for CHIKl [et al  for DENVl [et al . No viruZika virus RNA effectively detected [As virus-specific CPE were observed in LLC-MK2 and Vero E6 cells inoculated with plasma, but the identity of the agent unknown, spent cell growth media was treated with cyanase nuclease to degrade nucleic acids external to that packaged (and thus protected) in virions using a Nucleic Acid Removal Kit , and vRNA once again extracted from the treated material using a QIAamp Viral RNA Mini Kit. A panel of PCR and RT-PCR tests were performed; for RT-PCR, first-strand synthesis was performed using random 9-mers and Accuscript High Fidelity 1st strand cDNA kit . The presence of flavivirus RNA was detected using the Flav100F-200R, and detected , 9271–93detected , and 835detected . For conZika virus genome of one isolate (from the first patient), designated Haiti/1225/2014, was accomplished using a genome walking strategy with the PCR primers described in Sequencing of the complete http://www.ncbi.nlm.nih.gov/) and four data sets were assembled  ;. The NSThe protocol for sample collection was approved by the University of Florida IRB and the Haitian National IRB. Written parental informed consent was obtained from parents or guardians of all study participants.Zika virus was identified in plasma from three students seen in the Christianville Foundation Schools clinic. Patient #1 (described below) appears to have been infected simultaneously with DENV-1. The three case patients were from two different schools within the four-school Christianville school system; all lived in different towns/neighborhoods, within a radius of approximately 20 miles. All case patients presented within a one-week period in December, 2014. Cases of DENV-1 had been identified among children in the school clinics in the weeks before occurrence of the ZIKV cases, which, in turn, were followed by a small cluster of DENV-4 cases.The first patient was a 15 year-old boy who presented to the clinic on December 12, 2014, with a history of subjective fever, headache, and generalized arthralgias, myalgias and asthenia. When seen, temperature was 37 degrees C, with a pulse of 92 and respiratory rate of 24, weight 51.5 Kg. He had no rash, and physical exam was unremarkable. The second patient was a 7 year-old girl who was seen on December 15, 2014 at the clinic for subjective nocturnal fever, abdominal pain, anorexia, and cough. Temperature was 37 degrees C, pulse 116, RR 28, and weight 22.8 Kg. There was no rash, and physical exam was again unremarkable. The third patient was an asymptomatic 4 year-old boy who came in December 17, 2014 for follow up after being treated for tonsillitis on November 25, when he had presented with a fever of 39 degrees C. In none of the cases would it have been possible to have identified the illness as a ZIKV infection based on clinical presentation, rather than DENV or CHIKV . All patients received supportive care for reported symptoms, in keeping with standard practices within the clinic.In tissue culture, viral agents from all three patients induced subtle CPE within 4–8 days post-inoculation of human  and more pronounced CPE in simian (LLC-MK2 and Vero E6) cells incubated at either 33° and 37°C. Prior to cell death, the CPE consisted of perinuclear vacuoles . ElectroOn phylogenetic analysis, likelihood mapping showed that all data sets  displayed relatively low phylogenetic noise <20%,  and no rThe pattern is confirmed by the Bayesian phylogeographic analysis showing the Asian origin of the South American sequences Figs  and S2, Our data are consistent with the occurrence of an outbreak of Zita virus infection in rural areas of Haiti west of Port-au-Prince in December of 2014. Virus was isolated from three students, coming from two different schools and different towns, suggesting that the infection was relatively widespread in the community. In keeping with prior descriptions of ZIKV infection [Officially, no cases of ZIKV infection were reported by the Haitian Ministry of Public Health and Population (MSPP) until January 6, 2016, when 5 cases were confirmed in patients in the metropolitan Port-au-Prince area, based on RT-PCR assays performed at the Caribbean Public Health Agency “CARPHA” Laboratory at Trinidad and Tobago. While it is difficult to assemble an accurate timeline for Zika in Haiti, given the close similarity in symptoms with DENV and CHIKV cases and their apparent co-circulation, we would hypothesize that there was an initial “wave” of ZIKV cases in the late fall of 2014 in the Leogane/Gressier region, possibly emanating from near-by Port-au-Prince. Case numbers may have been reduced by relatively low rainfall amounts at that time, with persistence in the population and, in the setting of heavy rains in the fall of 2015, occurrence of a larger epidemic in the fall of 2015/spring of 2016. Alternatively, there may have been a reintroduction of the virus in late 2015; analysis of additional sequence data, from Haiti as well as from other countries, will be necessary to reconstruct the geographic progression of strains.th century [Our phylogenetic analysis highlights the relative indolence of the global Zika epidemic prior to its introduction into Asia and the south Pacific in 2007. In agreement with previous reports, the virus probably emerged in Africa at the beginning of the 20 century , where i century –12, remaS1 Text(DOCX)Click here for additional data file.S1 FigThe tree was obtained using the best fitting nucleotide substitution model (TN93+G) selected by a hierarchical likelihood ratio test. Branches are drawn to scale in nucleotide substitutions per site according to the bar at the bottom of the tree. Significant posterior probability support (p≥ 0.9) is indicated by the number along the branch. The Haiti sequence is in bold.(PDF)Click here for additional data file.S2 FigMonth (when available) and year of isolation are also indicated for each strain.(PDF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.


In the vast state of Queensland, Australia, access to specialist paediatric services are only available in the capital city of Brisbane, and are limited in regional and remote locations. During home-based palliative care, it is not always desirable or practical to move a patient to attend appointments, and so access to care may be even further limited. To address these problems, at the Royal Children’s Hospital (RCH) in Brisbane, a Home Telehealth Program (HTP) has been successfully established to provide palliative care consultations to families throughout Queensland.A cost minimisation analysis was undertaken to compare the actual costs of the HTP consultations, with the estimated potential costs associated with face-to face-consultations occurring by either i) hospital based consultations in the outpatients department at the RCH, or ii) home visits from the Paediatric Palliative Care Service. The analysis was undertaken from the perspective of the Children’s Health Service. The analysis was based on data from 95 home video consultations which occurred over a two year period, and included costs associated with projected: clinician time and travel; costs reimbursed to families for travel through the Patients Travel Subsidy (PTS) scheme; hospital outpatient clinic costs, project co-ordination and equipment and infrastructure costs. The mean costs per consultation were calculated for each approach.Air travel (n = 24) significantly affected the results. The mean cost of the HTP intervention was $294 and required no travel. The estimated mean cost per consultation in the hospital outpatient department was $748. The mean cost of home visits per consultation was $1214. Video consultation in the home is the most economical method of providing a consultation. The largest costs avoided to the health service are those associated with clinician time required for travel and the PTS scheme.While face-to-face consultations are the gold standard of care, for families located at a distance from the hospital, video consultation in the home presents an effective and cost efficient method to deliver a consultation. Additionally video consultation in the home ensures equity of access to services and minimum disruption to hospital based palliative care teams. The need for specialist paediatric palliative care is rare; in developed nations approximately only 15 in 10’000 children aged 0–19 will require such services , and mayTo address this, in 2009 a PPCS was established in Queensland, Australia, which routinely uses telehealth to communicate with families and primary care clinicians who are dispersed across the state. As well as using standard hospital-based videoconferencing systems to connect with regional facilities, a Home Telehealth Program (HTP) was established using Internet video-links to facilitate a specialist PPCS consultation directly into families’ homes. While the accepted gold-standard of care is a face-to face consultation, where it is impractical for this to occur, the HTP is able to facilitate a consultation, ensuring a family is not disadvantaged by location. The effectiveness of the HTP in increasing equity of access to care has been previously described elsewhere .Understanding the economic effects of the HTP is also important. Other economic evaluations for telehealth services have not always identified savings to the health service . Health The aim of this cost minimisation analysis was to compare the costs of paediatric palliative care medical consultations conducted via the HTP with in-person consultations. This evaluation is provided from the perspective of the savings to the Children’s Health Service, a state-wide service and assumes comparable outcomes irrespective of how services were delivered.Permission was obtained from Queensland Health PPCS director, and approval granted from the Royal Children’s Hospital Human Research Ethics Committee (reference number HREC/03/QRCH/16 AM02) to access the PPCS patient database. Records were retrieved from the database to identify the number of HTP consultations that had occurred over a 24-month period (July 2009 - June 2011). Data collected included the location of the family, participants and duration of the consultation. The actual costs of providing the HTP were compared to potential costs if in-person consultations had occurred. Outcomes were assumed to have been equivalent whether the consultation had occurred in person or via the HTP. The methods used in this analysis have been reported in other telehealth studies and are described in full for the benefit of other researchers [A. HTP consultation (intervention)B. Home visit consultation C. OPD consultations The fixed and variable costs for all three approaches were determined. Fixed costs were those independent of the number of consultations that occurred. Variable costs were those associated with the activity of the program and therefore vary depending on the number of consultations. Marginal costs were calculated by taking the sum of all variable costs and dividing the total variable costs by the number of consultations .Costs were obtained for the HTP consultations by calculating the fixed and variable costs of providing the HTP over the 24-month study period. Data was obtained for the comparator groups by estimating the costs that would have been incurred by the health service, based on the resource implications of an OPD appointment or home visit consultation.The model included both fixed and variable costs associated with the HTP  and estimated costs for in-person consultations . Costs were sourced for resources from departmental records and data available from publically accessible web sites -19, and The HTP equipment has been previously described . Fixed cThe costs to families for equipment and Internet were not included in the valuation as these items were already available in the household and were not specifically purchased in order to access the HTP.A project officer was employed on a casual basis three days per week . As well as other duties, subject to demand, the project officer set up, organised and facilitated the HTP consultations. These activities involved:•establishing individual family’s requirements•providing instructions on downloading, installing and running software•creation of accounts and passwords•test video-calls with the family•co-ordination with clinicians and family regarding date and time for consultations•documentation of video-consultation summaryHTP consultations occurred approximately once per week and an estimated 10% of the project officer’s time was allocated this. Therefore 6% of FTE was allocated as a fixed cost to establish the HTP .To enable a comparison between all three models, it was assumed the same clinicians (PPCS Pediatrican and Nurse Consultant) were present for each HTP consultation, and that each consultation went for 30 minutes duration, the expected duration of an outpatient consultation. Clinician’s time costs were based on Queensland Health hourly rates ,13 and wThe cost of outpatient appointments at the RCH was based on the Australian National Efficient Price (NEP) as a proxy for costs. The NEP is determined by the Independent Hospital Pricing Authority through analysis of data on activity and costs in Australian public hospitals, and provides a set amount for each activity or service. For a paediatric medical outpatient consultation code 20.11) this equates to $351 per consultation [ this equFor travel costs associated with attending a hospital outpatient consultation, it was assumed that travel would have occurred by car for locations less than 300 km from the RCH. For locations greater than 300 km it was assumed that the child and caregiver would travel by air to attend the RCH and require accommodation for one night. These travel costs are subsidised by the health system through the Patient Travel Scheme (PTS) for patients who reside further than 50 km from the hospital; at the time of the study, families were reimbursed $0.15/km travelled by road, and the full cost of air transport . EstimatOther cost minimisation studies have reported additional costs to families such as time off work, child care arrangements and meals . As all The duration of a consultation was assumed be identical between HTP and in-person consultations (30 minutes). The extra time required for travel for a home visit was calculated. To calculate the assumed costs for home visits, the same locations of families used in the calculations for OPD consultations. Calculations were based on the same clinicians attending a home visit as in the HTP consultations, i.e. the PPCS paediatrician and the PPCS nurse consultant. Clinician time costs were based on Queensland Health hourly rates ,13. It wUnderstanding the effect each variable has on the overall costs and the best efficient price is important for decision makers and health services. The threshold point was calculated to determine the point at which the cost of the HTP was equal to the cost of either alternative service model.The total costs of each approach were calculated by summing all fixed and variable costs. As it is acknowledged that it is not practical or feasible for air travel to occur for only a single consultation, this analysis was also completed for the costs associated with travel by road only. The costs of both options are presented separately. A sensitivity analysis was used to examine the decision analytical models and determine the effects of varying a particular cost. The sensitivity analysis therefore is able to provide an assessment that takes into account the costs that may differ from the assumed costs in the broader analysis. The sensitivity analysis was undertaken using the total of all consultations, i.e. both road and air travel.The total cost of the HTP was:Where:HTP is the fixed cost of the HTPFx is the number of consultationsHTP is the marginal cost per HTP consultationVx) for OPD consultations occurred when:The threshold  for home visit consultations occurred when:The threshold  for comparison of HTP and OPD appointments:The following formula was used for the calculation of the threshold point , this equates to:A. HTP consultation = $10,438B. OPD consultation = $12,682C. Home visit consultation = $18,036Using the calculations from Table For this evaluation, the threshold point for OPD consultations was:For this evaluation, the threshold point for home visit consultations was:The threshold point was reached with 19 patients for HTP consultations versus OPD consultations and at 11 patients for HTP versus home visit consultations  would have been possible. The costs associated with air travel make an in-person consultation by usual care expensive; additionally it is not desirable for a child receiving palliative care to travel by air for a simply for one consultation, nor practical for the PPCS to travel by air to visit only one family. The resources required and practicalities of achieving in-person consultation when distance is great, outweighs the benefits.The HTP is therefore not only an economical method of providing a consultation, but also a practical solution to providing care when a family resides at a distance from the hospital.The threshold calculations demonstrated that the HTP is cost effective after 19 patients for OPD consultations and only 11 patients for home visits. As 95 patients received a clinical consultation via the HTP during the two year study period, the HTP is an economically feasible and sustainable program, even if fewer patients were seen per annum. This is important to note, as cost effectiveness of telehealth services has been debated . SimilarThe sensitivity analysis revealed that changes to the costs associated with salaries for the project co-ordinator to co-ordinate the program had more effect on the threshold point than travel or the cost of OPD consultations. Embedding the HTP into the PPCS as a routine part of service delivery could reduce the need for a co-ordinator for the program, further increasing the viability of the HTP as an economical approach to patient care.This evaluation reflects the minimum saving to the health service that is achievable by using the HTP. The calculation of clinician time for consultations included two clinicians; the PPCS paediatrician and the nurse consultant. The comparator cost for OPD appointments was based on the NEP which accounts for only one clinician’s time, therefore this evaluation is likely to be under estimation of costs avoided. Additionally, since the end of this study period, the Australian government has introduced incentive payments for telehealth consultations as rebates through the Medicare system. These rebates would further support the economic benefits of the HTP for the health system. Other factors not accounted for in these calculations include the presence of other primary health care providers attending the consultation; in 18 (24%) of HTP consultations, multiple health care professionals were in attendance at the family home and participated in the home video-consultation. These additional benefits for undertaking a consultation via telehealth are difficult to value, and have not been included in this analysis, but certainly from a societal perspective the educational opportunity and ability for peer-to-peer support for primary care clinicians are factors that are facilitated by the use of telehealth. While in-person consultations are the deemed gold standard of care, for families located at a distance from the hospital, video-consultation in the home presents an effective and economical method to ensure equity of access to these specialist services.This study has several limitations. Firstly, all costs for wages for the project co-ordinator and PPCS clinicians have been estimated, as well as costs associated with travel. Additionally the potential additional overhead costs to the RCH for the HTP have not been included. Secondly, the assumption related to travel requirements for patients and clinicians for in person consultations may be atypically of what would actually happen in conventional practice. In some cases, patients in remote locations may have not had access to these services if the telehealth option was not offered. Thirdly, this analysis assumes that equivalent outcomes would have occurred in all three approaches, there may be other benefits and limitations of all three approaches which are not able to be valued.This analysis however does provide a more accurate reflection of the value of the HTP beyond the costs of the HTP itself. The HTP services a small group of families who require palliative care for their child, and the need for home telehealth services are not likely to increase beyond the activity seen during this study period. While these findings may be generalisable to other services, this study has confirmed that high activity levels are not required for a telehealth service to be economically efficient and sustainable.The purpose of this cost minimisation analysis was to compare the actual costs of the HTP with the potential costs of consultations undertaken either by the patient and caregiver attending the RCH for an OPD consultation, or home visits by the PPCS. The analysis demonstrated that based on the activity undertaken over a 24-month period, there were significant costs avoided to the Children’s Health Service. As well as providing an economical approach for delivering a paediatric palliative care consultation, the HTP is able to provide other practical benefits to families and health care clinicians, which are not able to be valued. This study has therefore provided valuable information regarding the effectiveness of the HTP.The authors declare that they have no competing interests.NB collected the data, undertook the analysis and drafted the manuscript. NR interpreted the data analysis and revised the manuscript. JY participated in the design of the study, its coordination and revised the manuscript. AS conceived of the study, and oversaw the statistical analysis and revised the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/14/328/prepub


To analyse and compare the costs of hepatic tumor ablation with computed tomography (CT)-guided high-dose rate brachytherapy (CT-HDRBT) and CT-guided radiofrequency ablation (CT-RFA) as two alternative minimally invasive treatment options of hepatocellular carcinoma (HCC).An activity based process model was created determining working steps and required staff of CT-RFA and CT-HDRBT. Prorated costs of equipment use , costs of staff, and expenditure for disposables were identified in a sample of 20 patients (10 treated by CT-RFA and 10 by CT-HDRBT) and compared. A sensitivity and break even analysis was performed to analyse the dependence of costs on the number of patients treated annually with both methods.Costs of CT-RFA were nearly stable with mean overall costs of approximately 1909 €, 1847 €, 1816 € and 1801 € per patient when treating 25, 50, 100 or 200 patients annually, as the main factor influencing the costs of this procedure was the single-use RFA probe. Mean costs of CT-HDRBT decreased significantly per patient ablation with a rising number of patients treated annually, with prorated costs of 3442 €, 1962 €, 1222 € and 852 € when treating 25, 50, 100 or 200 patients, due to low costs of single-use disposables compared to high annual fix-costs which proportionally decreased per patient with a higher number of patients treated annually. A break-even between both methods was reached when treating at least 55 patients annually.Although CT-HDRBT is a more complex procedure with more staff involved, it can be performed at lower costs per patient from the perspective of the medical provider when treating more than 55 patients compared to CT-RFA, mainly due to lower costs for disposables and a decreasing percentage of fixed costs with an increasing number of treatments. From the perspective of a healthcare provider, CT-guided high-dose rate brachytherapy (CT-HDRBT) of HCC is less expensive to perform than the standard therapy of CT-guided radiofrequency ablation (CT-RFA) when treating only a relatively small number of 55 patients annuallyThe cost advantage of CT-HDRBT is mainly based on the much lower cost of disposables compared with the high costs of probes for CT-RFAThe personnel involvement is higher for CT-HDRBT, but extra staff costs are negligible compared to the costs of disposables for CT-RFAThe use of hepatic tumor ablation has significantly increased during the past two decades, especially for the treatment of hepatocellular carcinoma (HCC) , 2. In tCurrently radiofrequency ablation (RFA) is the most commonly used ablation method . HoweverHealth care organizations and policy makers are increasingly interested in the costs of health care, leading e.g. to the implementation of diagnosis related groups (DRG) for reimbursement of hospitals in an increasing number of countries  and evidActivity based cost analysis (ABC), originally invented by Cooper and Kaplan , has beeTherefore, the purpose of this study was to analyse the costs of both ablation techniques and to identify cost factors of the two different procedures. This mainly on the background that CT-RFA is typically performed by interventional radiology alone whereas the newer method of CT-HDRBT has to be performed as an interaction of interventional radiologists and radiation oncologists.This study concentrates on the costs of activities in the interventional radiology unit and the radiation oncology department in a German university hospital. The overhead costs for the hospital, wards and the whole radiology unit were not included.The cost evaluation was based on the recommendations on trial design provided by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) , 12.The information concerning costs was based on the purchase prices provided by the hospital controlling department and the effective consumption documented in the department’s documentation system . The local ethical committee approved the study protocol (EA1/144/11).Staff costs were derived from standard personnel rates provided by the German scientific society  [ft, DFG)  as costsft, DFG)  and 9 daCost for equipment usage included purchase costs, depreciation, and maintenance costs  who were treated with CT-guided RFA and 10 patients  who underwent CT-HDRBT working steps and time involvement of all participants were recorded. All patients had single HCC target lesions below the size of 3 cm. Uni- and multivariate analysis comparing age, sex, tumor size, tumor location and surround etiology did not show any significant differences between both groups of patients.Before any ablation of the liver performed at our hospital the lesions had been classified as unresectable by consensual decision of the institutional interdisciplinary tumor board or if patients rejected a possible resection.The day before the intervention written informed consent was obtained from each patient after extensive explanation of the treatment procedure, possible complications, and alternative treatment options. The local institutional review committee approved the study.All patients were treated under conscious sedation using 3–5 mg midazolam  and 75–200 μg fentanyl  and monitored by a physician experienced in conscious sedation  from the radiation oncology department had to be consulted and transfer times between different rooms had to be included. In the setting of our hospital the interventional radiologist has the qualification to perform brachytherapy which is approved by the responsible medical association, but to make data applicable for other institutions we included a radiation oncologist in our calculations.Fixed annual costs are higher for CT-HDRBT, as the iridium source has to be changed every eight weeks due to the half-life of 74 days of iridium-192 and the radiation room has to depreciated . During With regard to the prices for disposables, our hospital profits from overall low prices as we are a part of a large purchase network of private and university hospitals. Therefore, our purchase prices do not differ significantly in relation to the amount of items purchased. Therefore, the prices for disposables did not vary with regard to the amount of consumed disposables. However, small hospitals may have to pay much higher prices for high priced disposables like RFA probes. In relative terms the use of a therapy option like HDBRT with low costs for disposables would especially be useful for smaller hospitals in the case they do not have the opportunity to get low prices for high priced disposables like RFA probes as long as their amount of consumed items is low. A break-even for a new treatment option like HDBRT may then be reached even with lesser patients than in our clinic as we already profit from low purchase prices for RFA probes. In Germany, the health care system has a dual financing : investmOur study has limitations: The sample size of patients treated by RFA was limited. This is because CT-HDRBT is preferred to CT-RFA in our department – mainly because of the subjectively higher accuracy. Reported prices and staff costs are from the year 2015, and participation of different team members were reflected as they are typical in the German health care system. In other countries, certain activities might also be performed by other staff groups.We are aware that both the costs for medical devices and personnel and also the reimbursement for healthcare services differ significantly between different countries throughout Europe and worldwide. However, as our focus was on relative and not absolute costs for the two different techniques for the treatment of HCC, we expect the main result of our cost comparison to be valid in many different countries.We did not take into account “overhead” costs like costs for energy, administration, and cleaning and other rooms beside the radiation room. The exact assessment of these costs usually is very difficult and, as they are mainly the same for both procedures, we did not expect them to influence the overall result.In this context, it is arguable why we assumed an exclusive utilization of the RFA generator, the radiation therapy planning station and the brachytherapy room. We were aware the RFA generator and the brachytherapy device can not only be used exclusively for the two different HCC therapy techniques but for many other indications such as radiofrequency ablations of osteoid osteomas and the brachytherapy of gynaecological tumors. This underlines the importance of interdisciplinary cooperation for therapeutic decision making  and an eHowever, this shared usage may be a major confounding variable as especially the costs for CT-HDRBT differ substantially depending on the number of patients treated. We could not expect that other clinics and especially providers that have to consider to begin with HDBRT will treat the very high number of about 480 patients / year as we do. Therefore, our own low costs for HDBRT may be misleading for the reader. With the aim to provide a more realistic overview of the own costs also for clinics considering to start with both procedures, we assumed that the RFA and HDBRT equipment  would be exclusively acquired for the two treatments.In contrast, most clinics nowadays have CT scanners available which usually are intensively used for diagnostic purposes and the use for CT-guided interventions is mostly only in a much lesser proportion. Therefore, we did not assume an exclusive utilization of the CT scanner for our two CT-guided therapy options, but assumed a proportionate utilization of the overall 200.000 min per year.Finally, the prices quoted in this paper are specific to our hospital and may differ for other hospitals. However, the idea of the study was to give the reader a model for a quick analysis of the own costs for the standard treatment option of RFA and a new technique like CT-HDBRT. Personal differences in prices may easily be adapted by the reader. In this context, we did not consider “hotel” costs in our analysis. For both RFA and HDBRT the mean duration of a hospital stay is about 2–3 days, and it would be easy to calculate the hospitality costs which are about 450 EUR per patient and day. As we performed a cost comparison with relative costs, we did not expect a difference in these costs for both procedures and did not take “hotel” costs into account. We also expected a significant variation in reimbursement for both procedures in different countries. This is why we focused exclusively on a model to evaluate the own costs for both procedures which can then be compared with the individual reimbursement scheme.From the provider’s perspective, the costs of CT-HDRBT of liver lesions are much lower than those of CT-RFA treatment as soon as at least 55 patients are treated annually. This is mainly due to relatively high fixed cost per CT-HDRBT treatment but much lower costs for disposables compared with CT-guided RFA treatment.


Introduction: Zika virus has appeared in the Americas in the form of a majoroutbreak, and is now known to cause birth defects when pregnant women areinfected. As a result, the Centers for Disease Control and Prevention issuedtravel guidelines, in the form of an elevational risk definition: destinationsbelow 2000m are considered as at-risk.Methods: We explored the distribution of known Zika virus vector mosquito speciesin relation to climatic conditions, elevation, latitude, and air trafficconnections to the United States.Results: In view of the tropical and subtropical nature of the mosquito speciesthat are the primary Zika virus vectors, we point out that climate varies ratherdramatically with respect to elevation and latitude, such that a singleelevational criterion will be a poor predictor of potential fortransmission.Discussion: We suggest an initial adjustment would consider latitude in additionto elevation; a more definitive, quantitative analysis of risk would considervariables of ecology, climate, human condition, and connectivity of areas. Zika virus is a flavivirus that is transmitted by aedine mosquito vectors, and thatis showing a clear trend towards “emergence” in recent yearsAedes aegypti—are from below 2000 m, in a recentcompilation, occurrences of the species above 2000 m were documented from Venezuela,Peru, Colombia, and MexicoAe. aegypti, with records fromthe previous range of the virus,,However, we believe that simplicity in this case may come at the expense of clarityand good planning. As early as 1889, the concept of life zones had been proposed,which emphasizes the point that latitude mediates elevational trendsClearly, development of simple and clear guidelines for travel advice regarding Zikavirus is desirable. However, as the CDC report acknowledged,High-elevation travel destinations in the Americas are relatively few in number, withsome  being equatorial, and others at higher latitude . Hence, we believe that a more nuanced risk mapping that takes associatedenvironmental variation into account would be markedly more effective. As commentedby CDCEquatorial destinations is not at all without risk of Zikatransmission, such that 2000 m is too low for those regions, whereas 2000 m will betoo high for higher-latitude regions. At a minimum, travel guidelines should takeinto account the interaction between elevation and latitude; detailed climate data,suitability for key mosquito species, and information on mitigation efforts shouldbe used to assemble a still-more-realistic approach for identifying risk areas forZika virus transmission.We present this exploration not as a final analysis or set of recommendations, butrather as a suggestion to reconsider the too simple “elevational cutoff,” as itneglects the complex phenomena that drive disease transmission. The real-worldtranslation of this concern is that travel to high-elevationThe authors have declared that no competing interests exist.All data underlying the analyses presented in this publication are available athttp://hdl.handle.net/1808/20727.