Viral infections may cause serious human diseases. For instance, the recent appearance of the novel virus, SARS-CoV-2, causing COVID-19, has spread globally and is a serious public health concern. The consumption of healthy, proper, functional, and nutrient-rich foods has an important role in enhancing an individual's immune system and preventing viral infections. Several polysaccharides from natural sources such as algae, bacteria, and fungi have been considered as generally recognized as safe (GRAS) by the US Food and Drug Administration. They are safe, low-toxicity, biodegradable, and have biological activities. In this review, the bioactive polysaccharides derived from various microorganisms, including bacteria, fungi, and algae were evaluated. Antiviral mechanisms of these polysaccharides were discussed. Finally, the potential use of microbial and algal polysaccharides as an antiviral and immune boosting strategy was addressed. The microbial polysaccharides exhibited several bioactivities, including antioxidant, anti-inflammatory, antimicrobial, antitumor, and immunomodulatory activities. Some microbes are able to produce sulfated polysaccharides, which are well-known to exert a board spectrum of biological activities, especially antiviral properties. Microbial polysaccharide can inhibit various viruses using different mechanisms. Furthermore, these microbial polysaccharides are also able to modulate immune responses to prevent and/or inhibit virus infections. There are many molecular factors influencing their bioactivities, e.g., functional groups, conformations, compositions, and molecular weight. At this stage of development, microbial polysaccharides will be used as adjuvants, nutrient supplements, and for drug delivery to prevent several virus infections, especially SARS-CoV-2 infection. Viruses are the most numerous living organisms on the earth and can be found in terrestrial and aquatic environments. They are infectious agents containing a genetic material within a protein coat—requiring an appropriate host cell where they can replicate  often resulting in diseases. Viruses can infect all types of organisms: prokaryotes (archaea and bacteria), eukaryotes , and giant viruses namely virophages . Like otNidovirales, the suborder Coronavirineae, and the family Caronaviridae. The family was divided into the subfamilies of Orthocoronavirinae and Letovirinae by the International Committee on Taxonomy of Viruses (ICTV) in 2018  are enveloped positive-sense single-stranded RNA (+ ssRNA) viruses with crown-like spikes on their spherical surface . Coronav in 2018 . The forfections , 7. The SARS-CoV-2 belongs to the β-coronaviruses, which include SARS-CoV-1 and MERS-CoV. These viruses are highly pathogenic and have a high mortality rate . The RNAErodium glaucophyllum extracts containing phenolic compounds such as gallic acid, quercetin 3-O-glucuronide, (+)-gallocatechin, and (+)-catechin exhibited antibacterial and antiviral activities , Varicella zoster (VZV), human immunodeficiency viruses (HIV), and human adenoviruses  and heteropolysaccharide (contain more than one type of monomer) . Polysacoviruses –45. Accooviruses . Among moviruses . Althougoviruses . There aoviruses , 47. Micoviruses . As mentAlgae are eukaryotic photosynthetic organisms, often microorganisms. Some algae are unicellular, but some of them are multicellular organisms lacking of specialized tissues. Both micro- and macroalgae are good sources of biomedical compounds, especially polysaccharides . Algal pSargassum trichophyllum  were characterized as laminaran, alginate and fucoidan, observing that only fucoidan showed an antiviral effect against herpes simplex virus type 2 (HSV-2) (50) of the fucoidan was 18 μg·mL−1 when it was added during the viral infection, being lower than adding after the viral infection. Therefore, this polysaccharide might inhibit HSV-2 at the virus adsorption and/or penetration step(s)  . The 50% step(s) . Sargassnd HSV-2 . For insst cells . Moreoveectively . Fucoida protein . In addifections . Moreovefections .Chondrus, Gigartina, Hypnea, and Eucheuma spp. (Gigartina skottsbergii) inhibited the viral attachment of HSV-1 and HSV-2 (50) for ι-carrageenan, λ-carrageenan, and κ-carrageenan against HAV were >400, >222, and >10 μg·mL−1, respectively (G. skottsbergii showed an inhibitory effect on both bovine herpesvirus type 1 (BoHV-1) and Suid herpesvirus type 1 (SuHV-1). The IC50 of this polysaccharide was 0.52 and 10.4 μg·mL−1, respectively -sensitive and -resistant strains of HSV-1 were 5.5, 1.5, and 4.1 μg·mL−1, respectively. The SP-2a had a weak virucidal activity against the standard and ACV-sensitive strains of HSV-1, but not the ACV-resistant strain. During virus adsorption, the SP-2a showed ≥80% inhibition of adsorption against all strains of HSV-1 , HIV-2, Coxsackie B virus type 3 (Cox-B3), and vesicular stomatitis virus (VSV). In addition, the p-KG03 also showed antiviral activity against influenza A virus at the virus adsorption step, but did not inhibit all influenza B virus isolates. The EC50 for p-KG03 against different strains of influenza A virus  ranged from 0.19 to 0.48 μg·mL−1 , produced naviculan (a sulfated polysaccharide). The naviculan is a heteropolysaccharide consisting of fucose, xylose, galactose, mannose, rhamnose, and sulfate with an average MW of ~2.2 × 105 Da. It is a broad-spectrum antiviral against HSV-1, HSV-2, and influenza A virus with IC50 of 14, 7.4, and 170 μg·mL−1, respectively, at the virus adsorption phase. Moreover, it could also interfere with the cell-cell fusion of HIV gp160- and CD4-expressing HeLa cells. Therefore, it might prevent HIV infections.The red micro algae, st cells , 43. In of HSV-1 . p-KG03  μg·mL−1 , 60. Lee μg·mL−1  reportedArthrospira platensis (formerly Spirulina platensis) produced calcium spirulan, a sulfated polysaccharide, with antiviral activity against several enveloped viruses. The calcium spirulan composed of rhamnose, ribose, mannose, fructose, galactose, xylose, glucose, glucuronic acid, galacturonic acid, sulfate, and calcium. This polysaccharide showed antiviral activity against HSV-1, human cytomegalovirus (HCMV), measles, mumps, influenza A, and HIV-1 viruses by inhibiting virus penetration , and HIV-1. Their mechanisms depended on the type of virus. For example, in the case of herpesviruses, spirulan-like substances inhibited virus adsorption and/or penetration steps, while HIV-1 was inhibited after viral entry. For HCMV, the inhibition occurred at intracellular steps, especially the viral protein synthesis step . Reichert et al. , showed an interesting antiviral activity against enveloped viruses: HSV-1, HSV-2, HCMV, and influenza A viruses. The virus infections were blocked when nostoflan was added at the same time as viral infections. Therefore, nostoflan blocked the viruses at the virus adsorption stage. The IC50 values of nostoflan for HSV-1, HSV-2, HCMV, and influenza A viruses were 0.37, 2.9, 0.47, and 78 μg·mL−1, respectively  (Lactobacillus sp. could completely inhibit human adenovirus type 5 (HAdV-5) formation and release  have the ability to synthesize polysaccharides for various purposes such as storage, cell protection, and adhesion. Polysaccharides accumulated in cells are called intracellular polysaccharides (ICP). While those outside of cell are called extracellular polysaccharides or EPS. The latter are secreted by cells or produced extracellularly using cell wall-anchored enzymes . Bacterietration . Spirulasis step . EPS frot et al.  reportedectively . In addis (PBMC) . EPS26a  release .Lactobacillus delbrueckii OLL1073R-1 activated the Toll-like receptor 3 (TLR3) and the expression of interferon (IFN)-α, IFN-β, MxA, and RNase L in porcine intestinal epithelial (PIE) cells, which was associated with the innate antiviral immune response , and C-X-C motif chemokine 10 (CXCL10). Antiviral bacterial polysaccharides are also shown in Bacterial polysaccharides also indirectly inhibited virus infections by modulation of the immune response. For instance, an EPS produced by response . Mizuno response  reportedFomes fomentarius, at 2 μg·mL−1 can prevent tobacco mosaic virus (TMV) infection on the leaf surfaces  produced two antiviral polysaccharides (EP-AV1 and EP-AV2) against HSV-1 and coxsackie virus B3 (CVB3) in Vero and HeLa cells, respectively. The EP-AV2 with a lower MW (~100 kDa) showed more potent antiviral activity than EP-AV1  against CVB3. It was observed how EP-AV1 and EP-AV2 polysaccharides inhibited the plaque formation caused by CVB3 in HeLa cells by 32 and 84% at 1 mg·mL−1, respectively. These polysaccharides specifically inhibited HSV-1 more than CVB3 as indicated by their EC50 values. The EC50 values of EP-AV1 and EP-AV2 for HSV-1 were 0.20 and 0.21 μg·mL−1, respectively, whereas CVB3 were 1 and 0.576 mg·mL−1, respectively (Lentides edodes was able to inhibit poliovirus type 1 (PV-1) and bovine herpes virus type 1 (BoHV-1) with IC50 values of 0.19 and 0.1 mg·mL−1, respectively  infecting rainbow trout (Oncorhynchus mykiss) and several species of salmon. The LNT-I acted both direct inactivation and inhibition of viral replication with 62.3, and 82.4% inhibition, respectively , feline herpesvirus 1 (FHV-1), feline panleukopenia (FPV), feline coronavirus (FCoV), and feline influenza  viruses. These polysaccharides had low toxicity and blocked virus entry by affecting the virions and/or the receptor(s) on host cell surfaces  also showed antiviral activity. Fungal polysaccharides can be derived from culture broth, mycelial culture and/or fruiting bodies . Fungal surfaces . Porodaeectively . Furtherectively . In anoto et al.  reportedectively . Inonotusurfaces .Therefore, polysaccharides from different species show various biological activities with different levels of action. Sulfated polysaccharides derived from marine microalgae and seaweeds showed many different bioactive properties and were effective against viruses at low concentrations, compared to other polysaccharides. In addition, bacteria and fungi are easily grow on simple media or agricultural wastes. The production can be done using controllable conditions and they produce high amounts of polysaccharides. Therefore, it would also benificial if the bioactivities and physicochemical properties of bacterial and fungal polysaccharides could be modified. The molecular modification of polysaccharides is an alternative approach to modulate their properties.In viral replication, there are 6 major steps during the infection: (1) virus attachment, (2) penetration, (3) uncoating, (4) genome replication and protein synthesis, (5) viral assembly, and (6) release of new virions . DiffereAuricularia auricular, a basidiomycete mushroom, can inhibit NDV in CEF cells. During the process of adding polysaccharides and virus simultaneously, the virus inhibitory rates were higher than pre- and post-addition of the polysaccharides. These polysaccharides might be combined with virus particles to block virus attachment to host cells . These polysaccharides were mixed with the viruses for 1 h before adding to the cell lines, decreasing significantly the viral infectivity compared to untreated viruses . Add. Add7). S. patens showed ≥80% inhibition against all strains of HSV-1 when added during virus adsorption (Padina tetrastromatica showed the highest percentage (>70%) inhibition against HSV-1 during the virus adsorption period  cells and macrophages, and increase the production of cytokines, i.e., the type I interferon system (IFN-α/β system) . The micS. thermophilus ST538 was able to induce the expression of IFN-β, IL-6, and CXCL10 in response to TLR3 stimulation. These immune factors are associated with antiviral immune responses, which induce the recruitment and activation of immune cells to struggle pathogens  from Cordyceps militaris enhanced TNF-α, IFN-γ, and nitric oxide (NO) production, and induced the expression of several cytokines: IL-1β, IL-6, IL-10, and TNF-α. These cytokines have the potential to prevent influenza A virus infection  and sulfated polysaccharide (A2) with antiviral activity. Matsuda et al.  showed higher antiviral activity against influenza A virus than the natural polysaccharides (A1 and A2). Moreover, a xylogalactofucan (sulfated polysaccharide) from a brown alga Sphacelaria indica also exhibited antiviral activity against HSV-1. The sulfate contents of the polysaccharide affected the antiviral property. The sulfate content of the purified polysaccharide was 4% (w/w). Bandyopadhyay et al.  of S. lomentaria was fractionated to yield fractions A0, A5, A10, A20, A30, and A40, with different components, MW, and monosaccharide composition. A0 was soluble and the fraction A5 was an uronofucoidan. A10–A40 were galactofucans and showed antiviral activity against HSV-1 and HSV-2 with IC50 values in the range 0.76–10.0 μg·mL−1. Among the 4 galactofucan fractions, A30  contained the highest sulfate content (29.5% SO3Na) and the lowest uronate content (1.8%). A30 showed the strongest antiviral activity against HSV-1 and HSV-2 with IC50 values of 0.76 and 1.3 μg·mL−1, respectively. Therefore, the low content of uronic acids and the high content of sulfate was associated with the antiviral activity of these polysaccharides. In conclusion, sulfate content is an important factor influencing biological activities. Adding sulfate groups into polysaccharide structures led to enhance bioactivities, whereas desulfation decreased their bioactivities.Several studies have reported that sulfated polysaccharides could exhibit several biological activities , so the sulfate contents could be an important factor affecting antiviral and other bioactivities. Sulfation has been used for enhancing various biological activities of polysaccharides , 112. Foa et al.  modifiedy et al.  chemicale et al.  also repWeisella confusa on immunomodulatory activity. The EPS with low MW (≤70 × 103 Da) could stimulate RAW264.7 cells to induce NO and production of various cytokines such as TNF-α, IL-1β, IL-6, and IL-10, but the native EPS (MW of ~506 × 106 Da) had no immunomodulatory activity. In addition, Ponce et al.  had effective antiviral activity  . Heparinin vitro . The binin vitro . Type I in vitro , 119. Hain vitro  reportedy organs . Some miy organs –124.ACE2 receptors are expressed by several tissues and organs as described above, especially the respiratory and gastrointestinal tracts. Microbial polysaccharides with antiviral activity can be used as a nasal spray, metered dose inhaler, or delivered orally to prevent the binding of SARS-CoV-2 . SeveralBifidobacterium spp.  through the Royal Golden Jubilee Ph.D. Program, Thailand (grant no. PHD/0185/2560) to WC and PS. Additionally, this work was also partially financially supported along with in-kind support by the Biotechnology Program of the Graduate School of Chiang Mai University; the Cluster of Agro Bio-Circular-Green Industry (Agro BCG) Faculty of Agro-Industry; and Chiang Mai University.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Roniviridae includes the genus Okavirus for three species of viruses with enveloped, rod-shaped virions. The monopartite, positive-sense ssRNA genome (26–27 kb) contains five canonical long open reading frames (ORFs). ORF1a encodes polyprotein pp1a containing proteinase domains. ORF1b is expressed as a large polyprotein pp1ab by ribosomal frameshifting from ORF1a and encodes replication enzymes. ORF2 encodes the nucleoprotein. ORF3 encodes two envelope glycoproteins. ORFX encodes a putative double membrane-spanning protein. Roniviruses infect shrimp but only yellow head virus is highly pathogenic. This is a summary of the International Committee on Taxonomy of Viruses (ICTV) Report on the family Roniviridae, which is available at ictv.global/report/roniviridae.The family  Virions are enveloped, rod-shaped particles (40–60 nm in diameter and 150–200 nm in length) containing three structural proteins . The6–27 kb wRonivirus replication is cytoplasmic. Elongated nucleocapsids are visible in infected cells and bud at membranes of the endoplasmic reticulum/Golgi complex to form mature virions. During infection, genome length RNA (g RNA1) and two 3′-coterminal subgenomic mRNAs (sg mRNA2 and sg mRNA3) are transcribed, each with a 5′-methylated cap and a 3′-poly(A) tail [ictv.global/taxonomy. The family Roniviridae includes the genus Okavirus with the species Yellow head virus, Gill-associated virus and Okavirus 1. Viruses in these species represent only three of eight okavirus genotypes that have been identified in penaeid shrimp [Yellow head virus) is assigned to genotype 1 with two subtypes (1a and 1b), gill-associated virus (species Gill-associated virus) is assigned to genotype 2 and yellow head virus-8 (species Okavirus 1) is assigned to genotype 8. Roniviruses are most closely related to other nidoviruses infecting arthropods, including members of the families Mesoniviridae (from mosquitoes) and Euroniviridae (from crustaceans).Current taxonomy: d shrimp . Yellow Roniviridae: ictv.global/report/roniviridaeCurrent ICTV Report on the family


Policy makers increasingly seek to complement data from clinical trials with information from routine care. This study aims to provide a detailed account of the hospital resource use and associated costs of patients with advanced breast cancer in The Netherlands.Data from 597 patients with advanced breast cancer, diagnosed between 2010 and 2014, were retrieved from the Southeast Netherlands Advanced Breast Cancer Registry. Database lock for this study was in October 2017. We report the observed hospital costs for different resource categories and the lifetime costs per patient, adjusted for censoring using Lin’s method. The relationship between patients’ characteristics and costs was studied using multivariable regression.The average (SE) lifetime hospital costs of patients with advanced breast cancer were €52 709 (405). Costs differed considerably between patient subgroups, ranging from €29 803 for patients with a triple-negative subtype to €92 272 for patients with hormone receptor positive and human epidermal growth factor receptor 2 positive cancer. Apart from the cancer subtype, several other factors, including age and survival time, were independently associated with patient lifetime costs. Overall, a large share of costs was attributed to systemic therapies (56%), predominantly to a few expensive agents, such as trastuzumab (15%), everolimus (10%), and bevacizumab (9%), as well as to inpatient hospital days (20%).This real-world study shows the high degree of variability in hospital resource use and associated costs in advanced breast cancer care. The presented resource use and costs data provide researchers and policy makers with key figures for economic evaluations and budget impact analyses. •Accurate information on the costs of medical treatment is required not only from clinical trials, but also from the real world, to inform health policy decision making, especially in high-cost areas such as cancer therapy.•This study provides a detailed analysis of the real-world medical costs of patients with advanced breast cancer in The Netherlands.•Considerable variation in costs and resource use were observed between and within patient subgroups.•Reported cost estimates can be used to improve health economic evaluations of medical interventions. Many are highly expensive, posing a substantial economic burden on society and raising questions regarding their value for money.Although randomized controlled trials (RCT) are considered the gold standard for supporting preapproval efficacy, their value for health economic evaluations and real-world effectiveness is limited. Resource utilization is rarely being considered in RCTs, and even if relevant data are collected, treatments are often tested under artificial circumstances. In routine care, patients often have more comorbidities, lower compliance, are older, and/or treatment patterns are different from patients included in RCTs.,Under real-world conditions, ABC care is complex: patients are highly heterogeneous and treatment choices and pathways are individualized and depend on patient characteristics, treatment responses, and preferences.This study aims to investigate the real-world resource use and costs of ABC in The Netherlands from the hospital perspective. First, we assessed patients’ resource utilization and the associated costs; second, we estimated the average lifetime costs of patients with ABC; and, finally, we investigated which factors contribute to the heterogeneity of costs between patients.. For this study, we used data from the 5 hospitals, in which information on resource use was collected from 2010 through 2017. These hospitals were selected with the intention to obtain a representative mixture of different hospital types and sizes, and they account for approximately 7% of the hospitals in The Netherlands. Patients were included if they were diagnosed with ABC between 2010 and 2014. No exclusion criteria were employed. Data lock was October 23, 2017.This study used patients included from the Southeast Netherlands Advanced Breast Cancer (SONABRE) Registry.Patients were identified prospectively, and clinical data were, retrospectively, retrieved manually from electronic medical records by trained registration clerks and entered into a registry database. Collected patient and disease characteristics included age, survival time, comorbidities, and tumor characteristics . Moreover, we retrieved data on hospital resource use for the following categories: medicines/systemic therapies , consultations/hospitalizations, radiotherapy, and diagnostic and surgical procedures.Because our study was based on routinely collected data, missingness was unavoidable. This problem was mostly limited to medications, for which the administered dosage was missing, while the number of administrations was reported. To avoid the creation of implausible observations, we used hot deck imputation to replace missing values with observed values from another patient, matched by the resource they used.https://doi.org/10.1016/j.jval.2020.12.007).,For all patients, we assessed the hospital resource use and associated costs from the date of diagnosis  until date of death or censoring. Costs associated with resource consumption were derived by multiplying the units of resource consumption with the respective cost prices. Relevant unit costs were taken from Dutch costing guidelines, medicijnkosten.nl, and, if otherwise unavailable, from individual studies or the financial department of Maastricht University Medical Centre . Alternative generalized linear model specifications (Gaussian distribution with a log link and Gaussian distribution with an identity link) were also tested to validate our model choice.We investigated the association between these variables and 2 outcomes: observed total costs per patient and costs per patient month. Although the former was the main focus of this study, survival time was assumed to explain a large proportion of the variability in total costs, so that inference about other variables may be limited. For both outcomes variables, we fitted generalized linear models, with a gamma distribution and a log link. This method, which is frequently used to model cost data, was chosen to evade the shortcomings of ordinary least squares, specifically with regard to right-skewed data, heteroscedasticity, and the strictly non-negative values in cost data.The Medical Research Ethics Committee of Maastricht University Medical Centre+ reviewed and approved the SONABRE Registry. The need for informed consent was waived because of the observational nature of this study.After the application of the inclusion criteria, 597 patients from the SONABRE registry were included in the study. The number of patients per year of ABC diagnosis varied only a little between 2010 and 2014, with the minimum being in 2014  and the maximum being in 2011 . Overall, 436 patients died and 161 were censored. The median survival time was 24.5 months (95% CI 22.7-27.5). The median follow-up time  was 55.2 months (51.7-58.7). A large majority of the patients in our cohort had a HR+/HER2- receptor status at the time of the initial diagnosis , followed by TN ; HR+/HER2+ , and HR-/HER2+ . A total of 199 patients (33.3%) had any of the following comorbidities: metabolic disease , cerebral disease , cardiovascular disease , other malignancy , or pulmonary disease . Further patient characteristics are provided in https://doi.org/10.1016/j.jval.2020.12.007.A few specific points about the results shown in R2 was 0.47, indicating an excellent model fit. For the cost per patient month model, the Bayesian information criterion value was 10 327.3, and the pseudo R2 was 0.40, suggesting a lower but still good fit to the data.Our study provides an overview of the real-world costs of patients with ABC in The Netherlands. After adjusting for censoring, the average (SE) lifetime hospital costs of ABC were estimated to be €52 709 (405). However, there was large variation in these costs between the HR/HER2 subtypes, ranging from €29 803 (1130) for patients with TN ABC to €92 272 (910) for patients with HR+/HER2+ ABC. Our analyses further revealed that, underlying this variation, there were considerable differences in the structures of costs. In all groups, medicines, and more specifically only a few expensive agents, accounted for a large share of total costs. In addition to the HR/HER2 receptor status, several other patient characteristics were independently associated with the costs per patients and/or per patient month, including age, survival time, locoregional aggressive treatment, death in hospital, and cerebral comorbidity.,To our knowledge, this is the first study to investigate the real-world lifetime costs of ABC in a cohort, including patients with any HER2/HR receptor status as well as de novo and recurrent ABC, in The Netherlands. A previous real-world study by Frederix et al,,,For studies conducted in other settings, similar discrepancies can be observed but are less surprisingThe patient cohort included in our study is somewhat different from other epidemiological cohorts, such as the French ESME,In contrast to previous cost of illness studies, which either focused on a selective ABC population  or in other areas of society  were not taken into consideration. Hospital resource use was also only collected in 5 hospitals in the southeast of The Netherlands, and even though we do not have any reason to expect major systematic differences, those may not be representative of the country as a whole. Moreover, we did not account for vial wastage, and due to the retrospective data collection, some resource uses may have been missed, which may have led to an underestimation of costs. However, because of the financial implications for the hospitals, the amount of not recorded resource consumption is probably low. For some types of resources, especially for surgical interventions, reference pricesOur study provides essential information about the real-world hospital costs of ABC that provides insight into the complex structure of costs in the heterogenous population of patients with ABC. We report several complementary measures of costs, facilitating a comparison of adjusted and unadjusted lifetime costs and monthly costs per patient, which can be used by others in health economic evaluations and to inform health policy. For comparisons with current or past costs, cost estimates can be adjusted using the respective consumer price index.We investigated the real-world hospital cost of patients with ABC in The Netherlands. The comprehensive description of resource use and associated costs provides researchers and policy makers with key figures for economic evaluations and budget impact analyses. Our analyses offer new insights into the structure and clearly shows the large heterogeneity of hospital costs of patients with ABC in The Netherlands. A better understanding of the real-world costs of ABC will be increasingly important to inform priority setting and resource allocation in healthcare, as novel and expensive therapies become available.


Our results suggested that the ankle dorsiflexion range of motion could be related to the stretch tolerance, but not to passive muscle stiffness in community-dwelling elderly population regardless of gender.Range of motion has been widely known to decrease with age; however, factors associated with its decrease in the elderly population and especially its gender difference have been unclear. Therefore, this study aimed to investigate the factors associated with ankle dorsiflexion range of motion in the older population. Both male  and female  community-dwelling older adults participated in this study. The ankle dorsiflexion and passive torque of both legs were measured using a dynamometer, and shear elastic modulus of the medial gastrocnemius muscle at 0° ankle angle was measured using ultrasonic shear wave elastography. In this study, we defined the passive torque at dorsiflexion range of motion (DF ROM) as the index of stretch tolerance, and shear elastic modulus as the index of passive muscle stiffness. The partial correlation coefficient adjusted by age, height, weight, and side (dominant or nondominant side) was used to analyze the relationship between DF ROM and passive torque at DF ROM or shear elastic modulus of MG in each male and female participant, respectively. Our results revealed that dorsiflexion range of motion was significantly associated with passive torque at dorsiflexion range of motion in both male (r = 0.455,  Generally, range of motion (ROM) has been known to decrease with age ,2,3,4, wPassive muscle stiffness has been thought to be a factor related to ROM. However, Magnusson et al. investigated the individual variability of ROM among young participants and reported that those with greater ROM (flexibility) could tolerate a greater passive torque at the end ROM than those with smaller ROM . These rRecently, the shear wave elastography (SWE) function has been used to measure muscle stiffness. Using this method, Miyamoto et al. 2018) have investigated the factors related to ankle dorsiflexion (DF) ROM in young men and women . These r have invIn addition to a study of young adults, Hirata et al. investigated factors related to ROM in community-dwelling male elderly individuals and showed that that stretch tolerance, but not passive muscle stiffness, was associated with ankle DF ROM . HoweverIn total, 42 older adults (17 elderly men and 25 elderly women) participated in this study, and their baseline characteristics (mean ± standard deviation (SD)) were an age of 70.7 ± 4.1 years; height of 160.6 ± 8.0 cm; and body mass of 58.7 ± 9.5 kg in males, and 74.0 ± 4.0 years; 151.2 ± 4.9 cm; and 50.1 ± 5.6 kg in females. The experiments were conducted in the movement laboratory at the Niigata University of Health and Welfare.We measured the DF ROM, passive toque during passive stretching test and shear elastic modulus used by shear wave elastography in both legs in random order to investigate the association between DF ROM and passive torque at DF ROM  or shear modulus in each older males and females. The inclusion criteria in this study were an age of >65 years, residing in the community, and able to walk independently (with or without a cane). The exclusion criteria were cognitive impairment, severe cardiac or musculoskeletal disorders, previous pulmonary disease diagnosis, and hearing impairment. Almost all participants had a sedentary lifestyle, but some participants  were engaging in regular exercise at the time of the experiment. All participants were fully informed of the study procedures and purpose, and all provided written informed consent. This study was approved by the ethics committee at the Niigata University of Health and Welfare, Niigata, Japan (#18104), and conducted in accordance with the Declaration of Helsinki.The sample size required for a correlation analysis (effect size = 0.5 (large), α error = 0.05, and power = 0.80) was calculated using the G* power 3.1 software  based on a previous study , and morEach participant was instructed to sit on a dynamometer chair  with the hip flexion angle at 70° and 0° knee angle . In addition, the thigh, pelvis, and trunk of a participant were fixed with Velcro straps strictly . Based oWe measured the shear elastic modulus of the medial gastrocnemius muscle (MG) via ultrasonic SWE  using a 5–14-MHz linear probe. The measurement position is similar to the DF ROM and passive torque measurement position. The measurement site for shear elastic modulus of MG was 30% of the lower leg length, which was defined from the popliteal crease to the lateral malleolus ,19. We oDescriptive data are presented as mean ± standard deviations. We used SPSS version 24.0  for statistical analyses. The partial correlation coefficient adjusted by age, height, weight, and side (dominant or nondominant side) was used to analyze the relationship between DF ROM and passive torque at DF ROM or shear elastic modulus of MG in each male and female participant, respectively. The significance threshold was set to α = 0.05.p = 0.012) and female , whereas DF ROM was not significantly associated with shear elastic modulus of MG in both male  and female .The outcome variable and results of partial correlation coefficients are shown in This study investigated factors related to the ankle DF ROM in community-dwelling elderly men and women. Our results showed that DF ROM was related to passive torque at DF ROM but not passive muscle stiffness. Hirata et al. (2020) reported that the ankle DF ROM in elderly men was related to stretch tolerance, not to passive muscle stiffness of MG . To the In this study, DF ROM was not significantly associated with passive shear modulus. Miyamoto et al. investigated factors related with ankle DF ROM in young men and women, and showing that DF ROM was significantly associated with passive muscle stiffness in only young men but not in women . Moreovep = 0.012) and females . As previous studies reported that the passive torque at DF ROM is an indicator of stretch tolerance [Conversely, results of this study revealed that DF ROM was significantly associated with age-adjusted passive torque in both males (r = 0.455, olerance ,15,16, oolerance  investigolerance , and thaAs described above, decreased ROM could lead to declined locomotion and balance ,6 and inOur results showed that DF ROM was not significantly associated with shear elastic modulus of MG, but significantly associated with passive torque at DF ROM in both the male and female older population. This suggests that stretch tolerance is an important factor for ROM in elderly individuals.


HIV assisted partner services (aPS), or provider notification and testing for sexual and injecting partners of people diagnosed with HIV, is shown to be safe, effective, and cost-effective and was scaled up within the national HIV testing services (HTS) program in Kenya in 2016. We estimated the costs of integrating aPS into routine HTS within an ongoing aPS scale-up project in western Kenya.We conducted microcosting using the payer perspective in 14 facilities offering aPS. Although aPS was offered to both males and females testing HIV-positive (index clients), we only collected data on female index clients and their male sex partners (MSP). We used activity-based costing to identify key aPS activities, inputs, resources, and estimated financial and economic costs of goods and services. We analyzed costs by start-up (August 2018), and recurrent costs one-year after aPS implementation  and conducted time-and-motion observations of aPS activities. We estimated the incremental costs of aPS, average cost per MSP traced, tested, testing HIV-positive, and on antiretroviral therapy, cost shares, and costs disaggregated by facility.Overall, the number of MSPs traced, tested, testing HIV-positive, and on antiretroviral therapy was 1027, 869, 370, and 272 respectively. Average unit costs per MSP traced, tested, testing HIV-positive, and on antiretroviral therapy were $34.54, $42.50, $108.71 and $152.28, respectively, which varied by county and facility client volume. The weighted average incremental cost of integrating aPS was $7,485.97 per facility per year, with recurrent costs accounting for approximately 90% of costs. The largest cost drivers were personnel (49%) and transport (13%). Providers spent approximately 25% of the HTS visit obtaining MSP contact information , while the median time spent per MSP traced on phone and in-person was 6 min and 2.5 hours, respectively.Average facility costs will increase when integrating aPS to HTS with incremental costs largely driven by personnel and transport. Strategies to efficiently utilize healthcare personnel will be critical for effective, affordable, and sustainable aPS.The online version contains supplementary material available at 10.1186/s12913-022-07479-4. In Kenya, approximately 1.4 million people are living with HIV (PLWH), of whom an estimated 79.5% of individuals aged 15-64 years are aware of their status; with lower rates among men compared to women  [HIV partner services entails trained healthcare workers consenting individuals diagnosed with HIV (index clients) for names and contact information for all sex partners in the last three years to notify these partners of their potential exposure to HIV and linking them to testing and care services . There aPrevious research and implementation projects from sub-Saharan Africa (SSA) demonstrate that aPS is safe, acceptable, and effective in increasing the number of newly testing partners and partners testing HIV-positive compared to client referral –10. In aKenya’s Ministry of Health (MOH) is integrating aPS into the national HTS program, where integration is defined as the creation of linkages between a new intervention (aPS) and existing programs (HTS) to improve healthcare delivery . EstimatWe evaluated the cost of integrating aPS in the HTS program in Kisumu and Homa Bay counties in Kenya by estimating the incremental costs associated with integrating aPS into routine HTS programs, including start-up and recurrent costs. We estimated the average unit cost per male sex partner (MSP) traced, tested, testing HIV-positive, and on antiretroviral therapy (ART). We generated cost profiles of key inputs to identify the key drivers of aPS program costs. We also calculated disaggregated incremental costs, average unit costs per MSP, and median time spent on aPS by facility.This microcosting analysis was conducted within in the aPS scale-up project (NIAID R01AI134130), a collaborative implementation science study between the Ministry of Health (MOH) National AIDS and STI Control Program (NASCOP), PATH-Kenya and University of Washington, conducted in 31 health facilities in Kisumu and Homa Bay counties in western Kenya . DetailsThe aPS scale-up project focused on evaluating aPS as a strategy for increasing HIV testing among men . Though via phone and/or physical (in-person) tracing to notify them of their potential HIV exposure and offer HIV testing. MSPs testing HIV-positive were asked to enroll in aPS and provide contact information for their female sex partners, who were also followed up, notified of their exposure, and offered HTS. Female index clients and sex partners testing HIV-positive were encouraged to link to care and followed up at 6 weeks, 6 months, and 12 months to assess linkage to care, ART initiation, and HIV viral load suppression.Consenting female index clients were asked to provide names and contact information for all MSPs in the last three years, a process called partner elicitation. HTS providers contacted MSPs We estimated the incremental financial and economic costs of integrating aPS into the HTS program using a payer perspective  followinn = 8) in August 2019, and then in Homa Bay (n = 6) in January 2020. Facilities were purposefully sampled based on location  and client volume (based on patient volumes receiving HTS at the facilities) after consultation with the site team.Cost data were collected during three field visits. In August 2018, we collected start-up costs from MOH NASCOP and PATH offices associated with one-time planning, training and awareness activities that took place before the project started. We then collected recurrent costs one year after study initiation from 14 facilities in Kisumu  that were not available from expense and budget reports. We disaggregated costs by facility to evaluate variations in incremental costs and average unit cost per MSP.We included health system costs incurred during provider elicitation of MSPs from female index clients, as well as for phone and physical tracing for MSPs. We excluded costs of eliciting and tracing female sex partners of HIV-positive MSPs as this was not the primary focus of the costing analysis. We included the costs of HIV testing and linking MSPs testing HIV-positive to care, but did not include the costs of ART since these costs are incurred under the national HIV care and treatment program, which is separate from the HTS/aPS program. We also excluded the cost of research activities not part of routine aPS delivery.We differentiated between new aPS costs, and shared program costs to support the integration of aPS services into the existing HTS program. New costs were those related to aPS inputs and activities not conducted prior to aPS scale-up e.g., aPS microplanning meetings, initial trainings, sensitization, transport costs for physical tracing, communication costs for phone tracing, personnel  and aPS supervision. Shared program costs from the current HTS program were allocated based on the share of the activity or input used in aPS. These included the share of program costs for vehicles, equipment, overheads, HTS supplies, health facility administration, and refresher training.We distinguished between fixed and variable costs. Fixed costs included overheads , capital , and non-service delivery personnel costs . We allocated building space based on the proportion of time in the HTS visit taken up by aPS activities at each facility. Rental costs were estimated from MOH rates for government facilities or rental rates from nearby commercial properties. Capital costs were annualized over the expected useful life (assumed to be five years) using a 3% annual discount rate . SimilarWe estimated variable costs by measuring resource use across the 14 facilities. Personnel time was captured as a proportion of full-time work allocated to aPS. Salaries were converted into hourly wages based on the assumption that full-time employment was equivalent to 2080 hours/year. We estimated personnel time using time-and-motion observation for partner elicitation at the clinic, and MSP outreach by phone and physical tracing. To estimate personnel time cost, we multiplied the cost per minute  by the median time spent on aPS activities including: 1) partner elicitation by the number of female index clients seen, 2) phone tracing by the number of MSPs traced on phone accounting for approximately 40% repeat calls, and 3) physical tracing multiplied by the number of MSPs traced physically accounting for 10% repeat physical tracing attempts. Based on facility data reports, we assumed that of the MSPs who were successfully traced, 70% were traced on phone and 30% by physical tracing. Estimates for the phone calls and physical tracing attempts were based on facility reports and staff opinion.Phone call costs were estimated as a percentage of airtime assigned to the facility per year used to call MSPs elicited through aPS. Transport costs were estimated by multiplying the number of expected commutes per year, mainly through public transport, by the average cost of each commute. For supplies and commodity costs, we observed resource use during HIV testing and multiplied the relevant quantities by input costs obtained from program budgets or centralized price lists.Cost data were collected and analyzed in templates designed in Microsoft Excel . We adjusted costs to 2019 currency and converted to US dollars (USD) using the 2019 average exchange rate (1 USD = KSh 101) [We used data collected by the implementation project staff to obtain the number of MSPs traced, tested, tested HIV-positive, and on ART over a one-year period as recorded in the MOH HTS facility registers. These data were compiled from April 1, 2019 to March 31, 2020 to capture costs at least one year prior to the COVID-19 pandemic.For each facility, we first estimated incremental costs by summing the start-up and recurrent costs. We then calculated the average unit cost per MSP traced, tested, testing HIV-positive, and on ART by dividing the incremental costs by the number of MSPs traced, tested, testing HIV-positive, and on ART, respectively. Lastly, we estimated the weighted average incremental facility cost per year by weighting the annual incremental costs in our sample of 14 facilities by the number of MSPs in each facility. We also explored all cost metrics by facility to assess how client volume and location affect total incremental and average unit costs per MSP. We estimated cost shares by activity and input to explore how resources and activities were utilized within aPS.We estimated the costs of integrating aPS under two scenarios: 1) as-implemented, which replicates the current national HTS program where financial support is received from both government and external funding sources, and 2) MOH-only, in which, based on expert opinion from MOH and site staff, we excluded costs associated with international non-governmental organizations (NGO) i.e., we assumed that all HTS providers transitioned into the MOH human resource system, that only MOH staff would supervise aPS delivery, and that no international NGO overhead costs were incurred.This study received ethical approval from the Kenyatta National Hospital Ethical and Scientific Review Committee (P465/052017) and the University of Washington Institutional Review Board (STUDY00002420). This study was conducted in accordance with the Declaration of Helsinki, and all study participants gave informed consent for enrolment and follow-up prior to study participation.The total number of MSPs traced, tested, testing HIV-positive, and on ART across the 14 facilities as well as the number of clients reached through aPS over the one-year study period did not differ substantially by county  , with recurrent costs accounting for approximately 90% of costs Table . PersonnAfter excluding international NGO costs (MOH-only scenario), the weighted average incremental cost of integrating aPS was $5,494.06 per facility per year. The reduction in costs was due to a decrease in personnel costs specifically aPS supervision costs (from 49 to 41%) and overheads especially rental leases for NGO offices (from 9% to 1%) Table .The average unit cost per MSP traced, tested, testing HIV-positive, and on ART (as-implemented) was $34.54, $42.50, $108.71, and $152.28, respectively . The estimated annual budget at a high-volume county referral hospital in Kisumu is $720,000, and facility-level aPS integration accounts for approximately 1% of the budget; therefore, aPS may be affordable in such a large facility, but may be less so in lower volume healthcare facilities with smaller budgets. We estimated higher incremental and lower average unit costs per MSP in larger volume facilities, which is expected as aPS implementation is more costly per client in low volume clinics since overhead costs are spread over fewer clients. This may highlight the need to prioritize resources towards higher volume facilities that can then support aPS in multiple low volume facilities within their vicinity to increase efficiency; however, this may lead to missed opportunities for aPS in lower volume facilities. The majority of the integration costs were direct aPS costs related to personnel  and transport, with approximately 25% of aPS integration costs shared with the existing HTS program , indicating the proportion of pre-existing HTS resources that would be needed to support aPS. Based on staff opinion, this 26% did not seem to overwhelm the facility healthcare system; they reported that aPS led to more optimal use of facility resources as more clients could be targeted to receive not only HTS, but also other available healthcare services .Across facilities, personnel made up the largest portion of total costs (49%), followed by transport (13%). Kisumu County had higher personnel costs than Homa Bay as HTS providers spent more time physically tracing partners in Kisumu - where MSPs were harder to trace since they more frequently changed their places of work and residence, compared to those in Homa Bay - a rural county where clients change residence less often. This finding is consistent with qualitative results on aPS from our study . The higThis study complements previous estimates by providing an accurate estimate of the resources needed to scale up aPS as part of a routine HTS program in Kenya. Our unit cost estimates were slightly lower to prior studies that estimated aPS implementation cost as part of randomized control trials (RCT) settings , 12. In Compared to previous estimates, our unit costs may have been lower as we utilized HTS providers who are paid lower than health advisors or nurses used in prior aPS costing studies , 12. ThoSimilar to other aPS costing studies, personnel was a major cost driver accounting for 40-70% of total costs , 12. In There are several limitations in our study. By focusing only on MSPs, we were not able to estimate the cost of aPS for female sex partners. However, we anticipate most unit costs would be similar, apart from partner elicitation costs and physical tracing costs that may vary by target group. Secondly, our study focused on only 14 facilities in Kisumu and Homa Bay counties, which have the highest HIV prevalence in Kenya (>15%) and might not be representative of other counties or settings or easily generalizable .Our study has several strengths. We evaluated the cost of integrating aPS into HTS programs within real-world settings, giving a realistic estimate of the implementation costs. We disaggregated costs to identify variations across facilities and propose strategies to improve cost efficiency. Finally, through detailed time-and-motion studies, we estimated the median time and cost of providing aPS during HTS, which will facilitate resource planning particularly human resource allocation and transport reimbursements.This study contributes to the growing literature on the cost of integrating aPS, and while average facility costs are expected to increase when integrating aPS to HTS, this increase is within the expected range , 12, 31.Additional file 1.


Culicoides midges. This virus was first isolated from a horse in South Africa in 1967 and until 2008 was believed to be restricted to southern Africa. In 2008–2009, isolation of EEV in an outbreak reported from Israel demonstrated the emergence of this pathogen into new niches. Indeed, further testing revealed that EEV had already spread outside of South Africa since 2001. Although EEV normally does not cause severe clinical disease, it should be considered important since it may indicate the possible spread of other related, much more pathogenic viruses, such as African horse sickness virus (AHSV). The spread of EEV from South Africa to central Africa, the Middle East, and India is an example of the possible emergence of new pathogens in new niches and should be a reminder not to limit the differential diagnoses list when facing a possible outbreak or a cluster of undiagnosed clinical cases. This review summarizes current knowledge regarding EEV structure, pathogenesis, clinical significance, and epidemiology.Equine encephalosis (EE) is a febrile disease of horses caused by EE virus (EEV) and transmitted by Orbivirus of the Reoviridae family transmitted by Culicoides. Within the EEV serogroup, seven serotypes (EEV-1–7) have been identified to date. This virus was first isolated from a horse in South Africa in 1967 and until 2008 was believed to be restricted to southern Africa. In 2008–2009, isolation of EEV in an outbreak reported from Israel demonstrated the emergence of this pathogen into new niches. Indeed, testing in retrospect sera samples revealed that EEV had already been circulating outside of South Africa since 2001. Although EEV normally does not cause severe clinical disease, it should be considered important since it may indicate the possible spread of other related, much more pathogenic viruses, such as African horse sickness virus (AHSV). The spread of EEV from South Africa to central Africa, the Middle East and India is an example of the possible emergence of new pathogens in new niches, as was seen in the case of West Nile virus, and should be a reminder not to limit the differential list when facing a possible outbreak or a cluster of clinical cases. This review summarizes current knowledge regarding EEV structure, pathogenesis, clinical significance, and epidemiology.Equine encephalosis (EE) is an arthropod-borne, noncontagious, febrile disease of horses. It is caused by EE virus (EEV), an  Orbivirus of the Reoviridae family, closely related to several other important pathogenic and emerging viruses affecting livestock, including bluetongue virus (BTV), African horse sickness virus (AHSV), and epizootic hemorrhagic disease virus (EHDV), all transmitted by Culicoides species [Equine encephalosis (EE) is an arthropod-borne, noncontagious, febrile disease of horses. It was first described over a century ago by Theiler, as a mild form of African horse sickness (AHS), under the name “equine ephemeral fever” , and was species .Orbiviruses in Asia and Europe due to the combination of animal transport and climate changes leading to changes in Culicoides habitat [Orbiviruses, including AHSV [The clinical significance of EEV is probably low, as it usually manifests as mild, transient, febrile disease, which is rarely fatal ,4. The r habitat ,7. Sinceing AHSV .Orbivirus, subfamily Sedoreovirinae, and family Reoviridae, transmitted by hematophagous Culicoides spp. [Orbivirus consists of over 20 serogroups and is the largest genus within the family Reoviridae [EEV is an arbovirus of the genus des spp. . The genoviridae . Within oviridae .The viral genome consists of 10 segments of linear double-stranded RNA (dsRNA), surrounded by three layers of capsid proteins, forming a double-layered core particle or inner capsid, surrounded by an outer capsid layer. Virus particles are 60–80 nm in diameter, have icosahedral symmetry, and appear spherical in shape ,15 Figu.Orbiviruses, EEV has seven structural proteins (VP1–7) and four non-structural proteins  [Similar to other 3, NS3a) ,15,17  . The dou3, NS3a) ,15,17. T3, NS3a) ,15,17,183, NS3a) ,15,19.Orbiviruses [Orbiviruses, and phylogenetic studies identified two distinct clusters that correspond with the geographical distribution of different species of Culicoides vectors [Orbiviruses to undergo gene reassortment within a single serogroup has resulted in the absence of correlation between virus serotypes and sequence variations in other genomic segments [The 5′- (5′-GUU(U/A)) and 3′- (A(U/A/G)(A/U/C)GUUAC-3′) terminal sequences of gene segments are conserved for all segments within the EEV serogroup ,15. Eachiviruses ,19. Seg- vectors . The abiOrbiviruses, and involves: (1) cell attachment and penetration, which occurs soon after inoculation (and involve VP2); (2) uncoating and formation of replicative complexes after entry into the cell, the virus is enclosed in endosomes, in which the outer capsid is removed (involving VP5), resulting in the release of transcriptionally active core particles into the cytoplasm; (3) formation of cellular tubules (consisting NS1 and involving VP3 and VP7) with unknown functions that possibly interact with the cellular cytoskeleton, and formation of virus inclusion bodies ; and (4) movement of virus and its release from the cell surface  and NS3 (Seg-10). Seven EEV serotypes have been characterized in South Africa based on the variable protein VP2 (and corresponding genomic sequence Seg-2). The serotypes were assigned numeric values based on the alphabetic order of the location in South Africa where the reference strain originated, namely: EEV-1 , EEV-2 , EEV-3 , EEV-4 , EEV-5 , EEV-6 , and EEV-7 E21/20, 2000) . Phyloge, 2000 . Until 2008, EE had only been reported in southern Africa. Since its first isolation in 1967, additional isolations and epidemiological surveys demonstrated the widespread circulation of EEV in horses and donkeys in South Africa and identified seven serotypes ,14,22,23Culicoides vector species [Culicoides in the same area [EEV is endemic in Africa and in the Middle East, with seroprevalence ranging between 60% and 100% in Gambia, Ghana, Ethiopia, Israel, South Africa, and Zimbabwe ,10,29. S species ,6,22,23. species ,22,23. A species ,14,22. Hame area . It has ame area ,14,22,30Culicoides during the same period and area [Culicoides and NS3 phylogenetic clusters [Sequence analyses of genomic segments provide additional information to serotype classification (which is based on serologic reaction to VP2 protein). Sequencing of the VP2 serotype 4 gene of isolates from Gambia and Israel found them unique to South African isolates and grouped them together, suggesting a common source outside of South Africa ,27. Charand area , supportclusters . Recent clusters . For exaclusters ,32. FielCulicoides biting midges, of which C. imicola and C. bolitinos have been shown to play an important role in South Africa [Culicoides genus includes over 1400 described species that inhabit a wide range of habitats. Only a small proportion of these species are known vectors of Orbiviruses; however, most studies only focus on certain species [Culicoides blood pools of several species [Culicoides species, suggesting that certain species have served as better vectors to specific serotypes [EEV is biologically transmitted by h Africa ,33,34. T species ,36. In S species ,33,34,37 species . The meaerotypes  . The success of Culicoides to serve as vectors is related to their population size and means of dispersal, which are highly influenced by climate and weather [Culicoides, may influence the prevalence of certain EEV serotypes in specific geographical areas or during an outbreak [Orbiviruses share the same Culicoides vectors, their spread and outbreaks often coincide. Several studies demonstrated similar infection patterns of EEV and AHSV in equids, with usually higher prevalence of EEV than of AHSV in both hosts and vectors [Orbiviruses, especially AHSV, against which many horses in southern Africa area are routinely vaccinated. The global changes in climate have led to changes in vectors’ habitat and range and to the expansion in the habitat of Culicoides species, namely C. imicola, which is a major vector of EEV, AHSV, BTV, and other veterinary important Orbiviruses. These changes led to the emergence and spread of various Orbiviruses into more temperate regions and to an increase in global incidence and virus diversity [The epidemiology of l region . Culicoi weather . Therefooutbreak . Althougoutbreak ,30. Longoutbreak ,8,22. Inoutbreak ,22. Thesoutbreak  and AHS outbreak ,40. Thisoutbreak . Since s vectors ,24,25,37 vectors . Therefoiversity ,36,42. Siversity ,43,44. Iiversity ,43.Herd immunity has also been suggested to serve as a protective factor against EEV infection. In Israel, lower annual incidence was recorded in farms with initial higher seroprevalence . In SoutCulicoides abundance is low due to the combination of high numbers of susceptible foals and sufficient numbers of Culicoides vectors during winter [EEV has been reported to infect various equid species, including horses, donkeys, and zebras in southern Africa, with similar prevalence rates and serotype distribution ,23,24,25The clinical significance of EEV infection is difficult to determine but is probably low. Generally, EEV is associated with mild or subclinical disease in horses with low mortality rates ,4. CharaThe name “equine encephalosis” is misleading, as the disease is not primarily neurologic. The name was given when the virus was first isolated from the organs of a mare that died during an outbreak at the farm in which three mares were affected, and two died. All three mares suffered from a peracute, febrile, nervous disease, and both fatal cases were diagnosed with edema and congestion of the brain, focal catarral enteritis, and mild fatty generation of the liver ,14. In tThe clinical signs of EE are non-specific and could be easily confused with that of other viruses. Initially, EE symptoms were described as a mild manifestation of AHS, and EE outbreaks often coincide with outbreaks of AHS or other arboviruses. Therefore, to confirm the diagnosis of EEV as the cause of disease, the virus should be directly identified, and other potential pathogens should be ruled out ,32. In aThere is no sufficient data of possible associations between specific clinical signs and EEV serotypes. The “original” neurologic syndrome could only have been experimentally reproduced once, using the EEV-2 (Cascara) serotype . Full geNo specific treatment is available against EEV. Most symptomatic cases recover with no complications. Supportive treatment may be administered to decrease fever and inflammation or relief other clinical signs. No vaccine is currently available against EEV ,27.Culicoides vectors. Vector control is usually based on a combination of mechanical, chemical, biological, and genetic methods used to limit the vector’s habitat and reduce vector-host contact. Such methods are most relevant to stabled horses and include stabling horses at dusk and dawn (when the vectors are more active), reducing light at night, screening windows, treating or removing animal waste, and using vector repellents on horses and the environment [EEV is considered noncontagious, and prevention strategies mainly focus on reducing exposure to ironment ,45.To prevent the introduction of EEV into new areas, transportation restrictions should be applied . HoweverRapid and accurate diagnosis is important, especially during disease outbreaks, with sufficient specificity to distinguish between closely related pathogens in order to implement appropriate treatment and control. Different methods have been developed for the detection and classification of EEV, including virus isolation, serological assays, and molecular assays.Historically, EEV was identified by virus isolation in baby hamster kidney (BHK) cells, suckling mice brain, embryonated chicken eggs, and Vero cells (African green monkey kidney cells) ,19,29,32Orbiviruses. These methods include competitive ELISA (cELISA) and indirect sandwich ELISA (S-ELISA), both having 100% sensitivity and specificity [Several serological methods detecting anti-EEV antibodies have been developed, which are most useful for screening and epidemiological surveys. Some of these assays are group-specific enzyme-linked immunosorbent assays (ELISA) detecting antibodies against all EEV serotypes, but not of other cificity ,47. Othecificity .Orbiviruses, at a serogroup and serotype level. Genomic probes have been developed for the detection of EEV. The NS1 (Seg-5) gene was the most sensitive for the detection of EEV at a serogroup level, while the VP2 (Seg-2) gene was serotype specific [Molecular assays are usually very specific and sensitive and are increasingly being used for the identification and classification of EEV, as well as other specific ,48. Realspecific ,38. Fullspecific ,27,32,49specific .Between October 2008 and January 2009, a febrile horse disease was observed in hundreds of horses in more than 60 equine premises across Israel. Initial serological results indicated that the disease was equine viral arteritis (EVA), but this virus was not isolated, and PCR tests were all negative. Using a novel DNA array technique, with subsequent RT-PCR and sequence analysis in the Veterinary Laboratories Agency (VLA) in the United Kingdom (U.K.), the virus was identified as EEV . PhylogeThis sequence of events resembles the events leading to the first description of EEV in South Africa in 1967, in which the EEV outbreak was initially described as a mild case of AHS   and was reported in horses from different breeds, ages, and sexes, no fatalities were reported . Since tCulicoides-borne pathogens, such as AHSV and BTV. For the time being, the virus has been reported from southern and central Africa, Israel, and India but has not spread to moderate climate countries in Europe or the Americas. The lower virulence of this virus, in combination with uncharacteristic clinical signs, makes its diagnosis challenging, especially in areas when it is not known to be endemic. Future research is needed to better understand the epidemiology and pathogenesis of EEV, as well as the dynamics of the circulation of various Culicoides-borne arboviruses.Although EEV is probably not of major clinical importance, its emergence in areas outside southern Africa may precede the spread of other, closely related,


Surprisingly, though many aspects of their innate and adaptive immune responses differ from that of the human immune response, such as a contraction of the IFN locus and reduction in the number of immunoglobulin subclasses, variations could also be observed between Jamaican fruit bats and other bat species.A specialized and fine-tuned immune response of bats upon infection with viruses is believed to provide the basis for a “friendly” coexistence with these pathogens, which are often lethal for humans and other mammals. First insights into the immunity of bats suggest that bats have evolved to possess their own strategies to cope with viral infections. Yet, the molecular details for this innocuous coexistence remain poorly described and bat infection models are the key to unveiling these secrets. In Jamaican fruit bats  Artibeus jamaicensis, is a frugivorous bat species that is native to Central America. Its main habitats are the rainforests extending from Southern Mexico throughout the Caribbean and northern regions of South America, yet they inhabit a wide range of elevations from subalpine to sea level [Ficus spp. figs, although they will occasionally resort to eating flowers and insects if fruit is unavailable [The Jamaican fruit-eating bat, ea level ,2. Jamaiea level ,2. Like ea level . Charactvailable . As a revailable .Artibeus species, did not transmit to other bats under experimental conditions [Artibeus species and the virus was, moreover, found to serially transmit between experimentally infected Jamaican fruit bats, consistent with its role as a putative reservoir species. Studying the relationship of these viruses and their (putative) natural host, the Jamaican fruit bat, has shed some light into the mechanisms of how these bats can tolerate viral infections and avoid severe symptoms of disease in contrast to dead end hosts such as humans.A number of studies since the 1950s found that Jamaican fruit bats have an important role in viral ecology as well. They were found to be infected with multiple viruses in nature, including dengue virus (DENV) ,7, West nditions . In contArtibeus lituratus) in Port-of-Spain, Trinidad [(Artibeus planirostris) [Artibeus spp. Despite efforts to preserve all eleven isolates, only one of these viruses remains: TRVL-11573, which was isolated from a great fruit-eating bat [(Carollia perspicillata) and the yellow-shouldered fruit bat (Sturnira lilium) [TCRV is an arenavirus that was first isolated in the 1950s, reportedly from Jamaican fruit bats and great fruit-eating bats (Trinidad . Subsequrostris) . In tota lilium) , it is s lilium) .4 TCID50), either subcutaneously or via an intranasal route, resulted in an asymptomatic, apathogenic infection, and virus clearance. In contrast, a high dose of virus (106 TCID50) administered subcutaneously or intranasally resulted in severe neurological disease , an inability to fly, and high mortality. Despite a clear pattern of virus progression in high-dose infected bats, TCRV-specific RNA and infectious virus were first identified in the spleen before their detection in various other organs, including the lungs, liver, intestine, and brain, the latter of which appeared to be especially associated with a fatal outcome. Histopathological analysis revealed that the bats suffered from pneumonia together with tissue damage present in the liver and spleen, as well as (in most cases) lesions in the brain [Artibeus bats in nature and how it achieves widespread circulation among these bats.Experimental infection of Jamaican fruit bats with a low dose of TCRV  were upregulated in at least two of the three tissues analyzed. Furthermore, transcripts for type II IFN, but not type I IFN, were increased over the uninfected controls. Additionally, transcripts for cytokine  and chemokine genes  were elevated. Expression signatures of apoptosis, which is generally associated with antiviral activity, was increased in the kidneys, though decreased in the spleen and liver, based on transcript levels for the anti-apoptotic marker BCL-2. Sera collected from both high- and low-dose infected bats were mostly negative for neutralizing antibodies. However, three bats, in which TCRV-specific RNA was not detected, tested positive for neutralizing antibodies. Despite abundant expression of transcripts coding for the immunoglobulin (Ig) isotypes IgM, IgE, IgA, and IgG in the spleen, infected bats showed no induction of genes involved in somatic hypermutation and affinity maturation, which may account for low antibody titers. As expected, genes associated with T and B lymphocyte activity were upregulated, yet no upregulation was observed in transcripts associated with the activation of NK cells [Subsequent transcriptome studies of the spleen, liver, and kidneys of infected Jamaican fruit bats revealed organ-specific differences in the induction of the innate and adaptive immune responses . IntriguNK cells .Artibeus species, including the flat-faced fruit bat and great fruit-eating bat. Artibeus bat colonies in Grenada are therefore believed to be reservoirs of RABV [RABV is a rhabdovirus that is found globally in many mammalian species, particularly associated with canines and bats . Infecti of RABV ,14,15,16(Artibeus intermedius) with different vampire bat-derived RABVs did not cause clinical signs of disease and most of the experimentally infected bats seroconverted with neutralizing antibodies [RABV is a lethal neurotropic virus, replicating in the brain and salivary glands. Virus-containing saliva enters the body intramuscularly via a bite, scratch, or while grooming, after which it progresses to the central nervous system . In accotibodies . Howevertibodies , immunoltibodies .Recent serological examinations that aimed to identify exposure of bats to RABV in Trinidad revealed flat-faced fruit bats, at the time misidentified as Jamaican fruit bats, to be most seropositive of the species tested . Interes(Artibeus obscurus) from Bolivia and great fruit-eating bats from Brazil, indicating a widespread circulation of the H18N11 virus among Artibeus spp. [In 2010, a genome sequence belonging to a previously unknown bat IAV of the H18N11 subtype was isolated from flat-faced fruit bats in the Peruvian Amazonia. In the following years, H18N11 genome sequences were also found in dark fruit-eating bats eus spp. .5 TCID50 of H18N11, some bats displayed mild clinical signs of disease, such as nasal and ocular discharge. However, unlike conventional IAVs (subtypes H1-16 and N1-9), which predominantly replicate in the epithelium of the respiratory organs, the bat IAV H18N11 targeted the squamous epithelium of the palatine tonsils, the lamina propria of the small intestine, and the follicle-associated epithelium of the jejunal Peyer’s patches. Histological staining of the infected intestinal tissue revealed viral RNA in both enterocytes and antigen-presenting cells (macrophages or dendritic cells). In line with the observed intestinal replication, infected bats shed virus-containing feces, resulting in a most likely fecal–oral horizontal transmission of the virus to naïve contact bats [+ T cells need to be addressed.Following intranasal inoculation of Jamaican fruit bats, a likely reservoir of bat IAV , with 5 act bats . Previouact bats ,32. The act bats . In the act bats , presumaArtibeus spp. and, secondly, the presence of IgGs directed to the H18 HA and N11 NA surface glycoproteins, with titers of 1000 and, in some bats, even 16,000 [Serological testing of bats captured in the Peruvian rainforest region showed, firstly, that the proportion of seropositive bats was highest among n 16,000 . Upon exn 16,000 .Jamaican fruit bats are a widely distributed New World bat species that share overlapping habitats with multiple other species and, increasingly, humans. Consequently, as mentioned above, Jamaican fruit bats have been found to be infected with a multitude of different viruses in nature ,15,16,30 and Egyptian fruit bat (Rousettus aegyptiacus) harbor 500 and 407 immune-related genes corresponding to 3.5% and 2.75%, respectively, of the whole transcriptome [(Myotis lucifugus), 28 genes, as well as the Old World large flying fox (Pteropus vampyrus), 33 genes, and the Egyptian fruit bat, 46 genes [Although preliminary, the current data available allow for drawing first conclusions about the immunity of Jamaican fruit bats and its differences to other bat species, as well as to humans. Transcriptome studies revealed that the Jamaican fruit bat encodes 466 immune-related genes, corresponding to 2% of the total transcriptome . Similarcriptome ,46. In ccriptome . One strcriptome . Only tecriptome ,49. Jama46 genes , in Jama46 genes ,53. Impo46 genes , both of46 genes , is yet 46 genes , tend to46 genes . TherefoIsg15 and Irf7 [A number of previous reports proclaimed the “always-on IFN hypothesis” as one part of an explanation for the special ability of bats to cope with often lethal and human-pathogenic viruses ,57,58. Fand Irf7 . Interesand Irf7 . Thus, tand Irf7 .Myotis davidii) have a dampened NLRP3-inflammasome activation, accompanied by either a reduction in caspase-1 or IL-1β activation, while NF-κB signaling and its regulated genes  appeared to be unaffected [Il6, Il8, Il1a, Il1b, and Ifng) were observed in Jamaican fruit bats upon infection [A previous study revealed that the IFN response is dampened in black flying foxes in comparison to humans, due to the replacement of a highly conserved serine residue (S358) with a histidine (S358H) in the stimulator of IFN genes (STING) protein , which iaffected ,62. Acconfection .(Cynopterus sphinx) [(Eptiscus fuscus), and the greater short-nosed fruit bat [(Eonycteris spelaea) showed comparable B and T cell percentages in the spleen, bone marrow, and blood. However, cave nectar bats completely lacked NK cells in both the spleen and bone marrow, despite the fact that this cell population was prominent in the spleen and bone marrow of the black flying fox [Aside from the innate immune response, intriguing features of Jamaican fruit bat adaptive immunity could be identified. As in all vertebrates, viral infections were found to trigger a humoral immunity, although titers varied depending on the virus, as described above. As described for other bat species ,65,66,67 sphinx) ,63. Only sphinx) , which iruit bat ,58. Thisruit bat . Interesruit bat . The blaruit bat . In addiruit bat . In lineruit bat ,71, wereruit bat . Furtherruit bat , tended ruit bat ,49. Prevruit bat ,73. In hruit bat . Follow-ying fox ,21. EspeTherefore, to fully understand their response to viral infection, future experiments need to address the missing information about Jamaican fruit bat immunity. First, it should be determined whether the innate immune response in these bats is dampened upon infection. This includes characterizing baseline IFN levels, as well as components of the STING and inflammasome activation pathways, both before and upon infection. Additionally, organ-specific and cell-specific differences in the antiviral response need to be taken into account. Future transcriptome studies should therefore focus not only on gene expression in infected organs, but in individual infected cells as well. Conversely, the immunomodulatory functions of viral proteins, such as the bat IAV IFN antagonist NS1 ,75,76,77Taken together, the observations made for different bat species indicate that many generalizations about bat immunity are unlikely to hold true and suggest a more varied immune response to viral infection. This is not surprising, considering there are more than 1400 species of bats in the order Chiroptera that emerged at least 64 million years ago . Given t


Adverse drug reactions will always be a companion to the prescribing of medications. Their occurrence depends on multiple factors including dose of drug, time of administration, genetic factors, age and sex of the patient, and the medical condition for which the medication was prescribed.The present retrospective observational study by Kuula and colleagues examines tendon injuries caused by fluoroquinolones over the period 2002 to 2012. This expands the conclusions from their recent systematic review of health service costs related to fluoroquinolone‐related adverse events.Of 160 claims for fluoroquinolone‐related injury, 146 were considered compensable under the Act, one was excluded as it was not in the Finnish health system, leaving 145 patients eligible for compensation. The 160 reported cases may be less than actually occurs as the authors comment that the compensation system “remains relatively unknown” and there is probably under reporting of tendon injuries.Most injuries occurred within 3 weeks of commencing fluoroquinolone therapy. Achilles tendons were involved in 97%, 52% received fluoroquinolones for respiratory infections. Of the prescribed fluoroquinolones, 83% received levofloxacin, 9% ciprofloxacin, 5% norfloxacin, ofloxacin, and moxifloxacin 1% each. The prescribed doses are not reported. The increased occurrence of levofloxacin was probably due to the high incidence of pulmonary pathology in the claimants as levofloxacin is often the preferred fluoroquinolone for patients with this condition. Not surprisingly the predisposing factors of age and coadministration of corticosteroids were associated with tendon pathology with odds ratios of 1.03 and 2.25, respectively. About 51% of the patients were hospitalized and the same number of patients were considered to have permanent lesions due to fluoroquinolone use. Surgical treatment was undertaken in 23%. Total direct costs among claimants were 2,146,057 Euros, direct societal costs pre claimant including 14,800 Euros with incapacity and 8744 Euros without incapacity. Fourteen percent (20) of claimants were employed at the time of injury. The insurance pool compensated losses for six claimants aged 39–66 years at an average cost of 50,000 Euros. The average work time lost was 435 h with a final estimate of cost per employed person being 9077 Euros.Many previous pharmacoeconomic analyses have focused on a single aspect relating to the event such as the extra length of hospitalization, so this wide ranging pharmacoeconomic study is important. It was conducted in a country with a comprehensive system of medical record retrieval from hospitals and outpatient services combined, as well as access to the details of indirect nonmedical societal costs derived from the compensation mechanism. The compensation system in Finland may be unique it its coverage, but similar costs would be occurring wherever similar adverse effects occur. The societal and direct medical costs reported are considerable and as the authors suggest actual costs may well have been higher.The total costs of adverse drug reactions are rarely considered by prescribing physicians. The present costs may well be different as therapeutic guidelines for the use of fluoroquinolones now recommend a more cautious approach and hence the incidence of fluoroquinolone prescribing is now less than at the time covered in this study.The author has no conflicts of interest financial or otherwise.


MicroRNAs are small non-coding RNAs that regulate eukaryotic gene expression at the post-transcriptional level and affect a wide range of biological processes. Over the past two decades, numerous virus-encoded miRNAs have been identified. Some of them are crucial for viral replication, whereas others can help immune evasion. Recent sequencing-based bioinformatics methods have helped identify many novel miRNAs, which are encoded by RNA viruses. Unlike the well-characterized DNA virus-encoded miRNAs, the role of RNA virus-encoded miRNAs remains controversial. In this review, we first describe the current knowledge of miRNAs encoded by various RNA viruses, including newly emerging viruses. Next, we discuss how RNA virus-encoded miRNAs might facilitate viral replication, immunoevasion, and persistence in their hosts. Last, we briefly discuss the challenges in the experimental methodologies and potential applications of miRNAs for diagnosis and therapeutics. Since the discovery of the first miRNA,  elegans , numerou elegans ;2018. Sh elegans . To dateogenesis . In contReoviridae), single-stranded positive-sense RNA , and single-stranded negative-sense RNA  viruses. In addition, Retroviridae possesses the (+)ssRNA genome that is reverse transcribed into DNA and then integrated into the host genome to establish a persistent infection. Most RNA viruses replicate in the cytoplasm, whereas others including Orthomyxoviridae and Retroviridae complete transcription and replication of their genomes in the nucleus.Viruses are classified into two main groups, DNA and RNA viruses, depending on their genetic materials. RNA virus can be subdivided into three groups in terms of their genome orientation, such as double-stranded RNA ssRNA viruses undergo transcription of the entire genome to form a polyprotein complex. This complex is then proteolytically cleaved to generate functional viral proteins, suggesting that mature miRNAs derived from the viral genome may target their own genome, leading to a negative impact on viral replication. On the contrary, cytoplasmic translocation of Drosha was demonstrated during virus infection, allowing the robust biogenesis of miRNAs in the cytoplasm . MoreoveRetroviridae, Orthomyxoviridae, Flaviviridae, Filoviridae, and Coronaviridae, as described below. An overview of representative rv-miRNAs encoded by these RNA viruses is summarized in In this review, we describe the current insights into rv-miRNAs, including their underlying physiological functions involved in the viral life cycle and pathogenesis. To date, rv-miRNAs have been identified in several RNA virus families, such as Retroviruses are enveloped RNA viruses that reverse transcribe their (+)ss RNA genomes into dsDNA and then integrate into host chromosomes for a persistent infection . To dateThe trans-activation responsive (TAR) element, which forms a stable miRNA precursor-like hairpin structure of ∼50 nucleotides in length, is expressed during virus infection and activates HIV-1 gene transcription . It was Interestingly, TAR-derived rv-miRNAs are detected in exosomes released from HIV-1-infected cells as well as in the serum from HIV-1-positive patients , suggestComputational analyses also identified rv-miRNAs encoded by other retrovirus species, such as simian foamy virus (SFV) and bovine leukemia virus (BLV) . Unlike Bovine foamy virus (BFV) is highly prevalent in cattle, although no obvious disease is associated with viral infection . BFV encAvian leukosis virus (ALV) belongs to the alpha retrovirus family and causes various types of neoplastic diseases in birds . A highlOrthomyxoviridae and possesses a (-)ssRNA genome with eight distinct gene segments. IAV replicates and transcribes its genome in the nucleus  is a member of  nucleus . H5N1 is nucleus . Deep se nucleus . Further nucleus . Strikinrv-miRNA .West Nile virus and DENV are cytoplasmic RNA viruses with a (+)ssRNA genome. Both viruses are mosquito-borne and can cause a range of mild to lethal diseases with substantial public health impacts . WNV- anEbola virus is a (-)ss RNA virus, which causes the severe and often fatal Ebola virus disease (EVD) in humans and NHP as reviewed in Severe acute respiratory syndrome coronavirus and SARS-CoV-2 cause respiratory or intestinal infections in humans and other animals and are responsible for the SARS epidemic in 2003 and the currently ongoing COVID-19 pandemic, respectively . MoralesIn the past few years, several lines of evidence have demonstrated that RNA viruses encode miRNAs. However, the physiological significance of these rv-miRNAs in viral life cycles and pathogenesis remains largely unclear and warrants further investigation. The reliability of the reported data is limited by the low expression levels of some rv-miRNAs as well as the available detection methods. Although recently developed comprehensive computational prediction has significantly contributed to the identification of rv-miRNAs with low expression levels, currently available algorithms are still suboptimal and often produce a significant number of false predictions . TherefoA few rv-miRNAs are incorporated into exosomes and stably exist extracellularly in the serum and plasma of EBOV and HIV-1-infected patients . It is wAs evident from the latest outbreaks, emerging RNA viruses have posed an increasingly serious threat to public health. Due to lack of availability of therapeutic treatments against most of these emerging viruses, miRNA-based therapeutics are considered a new class of drugs with potential applications for various diseases including infectious diseases . A majorAN contributed to the conceptualization, drafting, and revising the manuscript. WF and ZL contributed to the conceptualization and manuscript revision. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.