Older persons are, however, not the only major eHealth stakeholder. eHealth suppliers, caregivers, funding bodies, and health authorities are also likely to attribute value to eHealth applications, but they can differ in their value attribution because they are affected differently by eHealth costs and benefits. Therefore, any assessment of the value of eHealth applications requires the consideration of multiple stakeholders in a holistic and integrated manner. Such a holistic and reliable value assessment requires a profound understanding of the application’s costs and benefits. The first step in measuring costs and benefits is identifying the relevant costs and benefit categories that the eHealth application affects.The aim of this study is to support the conceptual phase of an economic evaluation by providing an overview of the relevant direct and indirect costs and benefits incorporated in economic evaluations so far.We conducted a systematic literature search covering papers published until December 2019 by using the Embase, Medline Ovid, Web of Science, and CINAHL EBSCOhost databases. We included papers on eHealth applications with web-based contact possibilities between clients and health care providers  and applications for self-management, telehomecare, telemedicine, telemonitoring, telerehabilitation, and active healthy aging technologies for older persons. We included studies that focused on any type of economic evaluation, including costs and benefit measures.We identified 55 papers with economic evaluations. These studies considered a range of different types of costs and benefits. Costs pertained to implementation activities and operational activities related to eHealth applications. Benefits (or consequences) could be categorized according to stakeholder groups, that is, older persons, caregivers, and health care providers. These benefits can further be divided into stakeholder-specific outcomes and resource usage. Some cost and benefit types have received more attention than others. For instance, patient outcomes have been predominantly captured via quality-of-life considerations and various types of physical health status indicators. From the perspective of resource usage, a strong emphasis has been placed on home care visits and hospital usage.Economic evaluations of eHealth applications are gaining momentum, and studies have shown considerable variation regarding the costs and benefits that they include. We contribute to the body of literature by providing a detailed and up-to-date framework of cost and benefit categories that any interested stakeholder can use as a starting point to conduct an economic evaluation in the context of independent living of older persons. The use of information and communication technologies in health care is regarded as an important piece of the puzzle of increasing health care costs and demand , particueHealth has shown to be valuable in promoting medication adherence and improving self-management in the population of older persons . In addigains) of an eHealth application. This rationale represents the core of economic evaluations in health care [and what we will gain. The main difference is the way in which gain is incorporated: CEAs consider a one-dimensional measure of the gain, which only allows for a comparison of programs with the same effect measures. CUAs assess gain through utility, frequently in quality-adjusted life years, which is comparable between health programs. CBAs assess the gain monetarily, that is, costs and outcomes are directly on the same scale [Although eHealth is frequently considered a promising development, these applications are not without considerable costs. eHealth equipment must be purchased, and systems must be operated and maintained. Data recorded by eHealth should be monitored. However, frequently, the stakeholder who benefits from the application is not the same stakeholder who is paying for it. Costs and benefits affect different stakeholders and potentially also at different points in time; therefore, the economic interests of stakeholders are often not aligned. From the health provider perspective, such an investment does not make an economic sense, whereas it might be highly valuable from a societal perspective, considering the total benefits and costs regardless of where they occur. Any assessment of the value of an eHealth application, therefore, requires considering multiple stakeholders in a holistic and integrated assessment of all costs  and all benefits  protocols, specifically for scoping reviews. Among other things, scoping reviews are appropriate for identifying key characteristics and factors related to a concept . ConsequFor this study, we identified papers published until December 2019 using the Embase, Medline Ovid, Web of Science, and CINAHL EBSCOhost databases. Additional papers were identified by scanning the references of the identified papers  or if the patient population received care in any institutionalized form . In terms of the eHealth application, we focused on eHealth applications with web-based contact possibilities between clients and health care providers, including mobile health  apps, and applications for self-management, telehomecare, telemedicine, telemonitoring, telerehabilitation, and active healthy aging technologies for older persons. Papers with the following technologies were excluded: papers describing technology not connected to the internet  and papers on health information systems, electronic health records, robotics, and telephone consults only. To obtain a comprehensive overview, we did not use a strict definition of economic evaluation and did not constrain our search to particular types of economic evaluations. The only constraint on which we relied was that economic evaluations required both costs and benefits. Therefore, we included papers that measured at least one monetary aspect and one benefit of eHealth applications in any shape or form . Papers that only described or analyzed costs at an aggregated level or  effects were excluded.not relevant or potentially relevant based on the inclusion criteria. A random sample of the references was blindly double-checked by AW and RH. The random set has been created by selecting every 10th article from the set of annually ordered articles. Interrater reliability was evaluated using the Cohen kappa (κ) index, which is a robust statistic useful for interrater reliability testing [fair overlap between the assessments by SS or HE and AW or RB (Cohen κ index=0.28). After realigning the inclusion and exclusion criteria and rescreening all of the references with previous disagreements (conducted by AW), substantial improvements in the alignment were achieved (Cohen κ index=0.75).Initially, 2 of the authors (SS and HE) screened a small sample simultaneously to align the assessment. Subsequently, SS and HE conducted abstract and title screening, with each screening half of the identified references. The studies were labeled  testing . This dopotentially relevant. This double-blind screening yielded a substantial overlap (Cohen κ index=0.64). SS and HE discussed all of the references for which their assessments diverged and thus resolved disagreements.In the next screening round, SS and HE conducted the screening based on full texts, and both authors went independently through all of the references initially labeled as Two authors (SS and HE) extracted the following information from the studies: patient population, country, type of eHealth intervention, type of analysis that the papers report performing, the specific cost types that the studies considered, and the specific benefits, gains, and consequences that the studies included. Subsequently, we categorized the costs and benefits. We started with 4 categories pertaining to (1) implementation activities for the eHealth application, (2) operating and maintenance activities for the eHealth application, (3) processes of health care delivery, and (4) outcomes. While extracting the information, we further refined these categories depending on activities, stakeholders, and institutions such that the subcategories were mutually exclusive but sufficiently broad to capture related items.The search and screening processes are shown in The patient characteristics were rather broad; however, most studies focused on chronic or cardiovascular diseases. Of the 55 references, 13 had a patient population with various chronic health problems -31. CardThe studies in English were geographically clustered, with 26 studies conducted in North America, among which 20 occurred in the United States ,64,67,68The majority of included studies focused on telemonitoring or remote monitoring involving the measurement of vital statistics and the transmission of patient data followed by an assessment—either automatically or manually—and triggering action by health care professionals if required ,65,68,70cost minimization was used in 4 studies [The included studies indicated various types of analysis. In total, 18 studies reported CEAs ,70,71,73 studies ,49,51,65 studies . The rem studies -58,64,66 studies ,22.Of the 55 included studies, 8 relied on Markov modeling and simulation models with a time frame of 1 year ,65, 5 yeWhen we consider eHealth applications, what direct and indirect costs and benefits (or consequences) might be relevant to consider? Although Comparing the consequences for professional caregivers and informal caregivers, it becomes obvious that certain elements are missing across all included studies. For instance, 4% (2/55) of the included studies considered the satisfaction of professional caregivers  ,25; howeOur final observation relates to the research and development (R&D) costs of eHealth applications. In fact, none of the included studies considered R&D costs, which is understandable from the perspective that these costs have already been spent by the time that the eHealth application is set up and running. However, it implicitly assumes that R&D costs only occur before the eHealth intervention is set up and that there is no ongoing refinement.We conducted this review to establish a framework of costs and benefits considered in the economic evaluations of eHealth applications that support the independent living of older persons. Our search identified 55 papers that conducted economic evaluations. All of the identified papers focused on independent living of older persons in their role as patients with one or more chronic conditions. The identified papers considered a range of different types of costs and benefits. Costs pertain to implementation activities and operating activities related to eHealth applications. Benefits (or consequences) can be categorized according to stakeholder groups, that is, patients, caregivers, and health care provider organizations. These benefits can be further divided into stakeholder-specific outcomes and resource utilization. Some cost and benefit types have received more attention than others. For instance, patient outcomes are predominantly captured via quality-of-life considerations and various types of physical health status indicators. From a resource utilization perspective, a strong emphasis is placed on home care visits and hospital usage. One reason for this emphasis is the frequency in which studies focus on remote monitoring to prevent unnecessary hospital admissions or to substitute for home care visits.Our data extraction also revealed a set of elements that have not been considered across all of the identified papers, including travel time and satisfaction of informal caregivers, emotional burden and well-being of professional caregivers, and last but not least, the R&D costs of the eHealth application. The reasons why these aspects have been neglected can be manifold: they might have been irrelevant from the perspective from which the economic evaluation was carried out, they might have been unobservable because of long time lags beyond the time frame of the evaluation, or it might have been infeasible to capture and quantify these aspects because of methodological obstacles or data unavailability. That the initial R&D costs of the eHealth applications have not been considered can be justified with the sunk cost argument—by the time that the evaluation takes place, the R&D costs have already been spent. In this sense, the eHealth application is considered a static technology. In the longer run, however, the eHealth application might require an upgrade to comply with new laws and regulations, for reasons pertaining to data privacy, data security, data storage, or improvements in usability. Whether these upgrade costs are indeed relevant for future economic evaluations depends on the perspective and time frame.Like any other technology, eHealth applications are subject to change. Fueled by the increasing availability of data, changes in law and regulations and improved usability, new fields, and areas of applications might emerge. Our framework is based on eHealth applications currently in place. Future eHealth applications might generate costs and benefits that are different from the eHealth applications on which our framework is based.Economic evaluations of eHealth applications are gaining momentum, as indicated by the increasing number of publications and reviews ,75. HealIf we consider eHealth, there are many stakeholders involved, such as patients, eHealth suppliers  caregivers, funding bodies, health authorities, and so on. Notably, these stakeholders are likely to attribute different values to eHealth applications because they are affected differently by their costs and benefits. This fact has consequences for investment and funding decisions, and it has long been argued that decision making remains hampered by the lack of reliable cost and benefit estimations ,15. To oFinancial costs directed to patients or informal caregivers might be an obstacle to using the eHealth service or application or continuation of usage of these services, especially in countries where mandatory health insurance coverage is lacking. Although a recent study in the Netherlands identified finance as a factor not significantly related to intention to use medical apps among older persons , future A holistic and reliable value assessment of eHealth applications requires a profound understanding of the applications’ costs and benefits. The first step in measuring costs and benefits is identifying the relevant costs and benefit categories that the eHealth application affects. We conduct a scoping review to support this identification process by providing an overview of the direct and indirect costs and benefits that economic evaluations have incorporated so far. Our cost-and-benefit framework is particularly useful in the context of eHealth applications that support the independent living of older persons. As this patient group is expected to be increasingly targeted to contain health care costs, expanding the scope of eHealth applications to broader populations, rather than only diagnosed patient groups, and assessing the value of eHealth technologies are of the utmost importance for making well-informed investment and funding decisions.


West Nile virus disease (WNVD) is a mosquito-borne disease that affects the meninges and central nervous system, causing West Nile virus (WNV) encephalitis, a debilitating, life-threatening condition, especially in the elderly. While there is a lot of research discussing different aspects of the disease, the treatment is mainly unknown. We conducted a literature review to explore the wide variety of treatment options that consolidate the knowledge about the most recent management of WNV encephalitis. We did a combined advanced search and Medical Subject Headings (MeSH) search on PubMed. Inclusion criteria included papers written in the English language and human subjects research for the past 25 years. We initially gather 110 papers, and after applying the inclusion/exclusion criteria, we end up with 30 articles for the paper's discussion. This review aims to provide clinicians with an overview of the latest approach in treating and managing hospitalized WNVD patients. It discusses case reports and the outcome of different treatment regimens done in vitro and in vivo. The study discusses all the advancements in treatment and prophylaxis and compares their effectiveness. However, more research is warranted to gain further insight to develop a single guideline for the management of this disease. This review discusses the following treatment modalities: ribavirin, interferon-alpha, intravenous immunoglobulin (IVIG), and other less-used drugs. More studies about ribavirin are needed to know if the drug is useful for WNV encephalitis. Interferon-alpha has been shown to have both protective and disease limiting properties. At the moment, there are no guidelines for the treatment of WNV encephalitis, nor is there a single Food and Drug Administration (FDA)-approved drug. For the time being, IVIG offers the best results in treating WNV encephalitis The West Nile virus (WNV) is defined by the Centers for Disease Control and Prevention (CDC) as the leading cause of mosquito-borne disease in the continental United States (US) . In 1999Specialists describe two clinical presentations of the infection, West Nile Fever and WNV Encephalitis. West Nile Fever occurs in 25% of those infected, and symptoms include rapid onset of headaches, generalized fatigue, maculopapular rash, fever, and muscle pain. The fever usually lasts a few weeks before the complete resolution of symptoms. A more dangerous presentation is WNV encephalitis; this form occurs in less than 1% of those infected, with incidence showing increased correlation with age . DepressPatients with WNV encephalitis often suffer from muscle weakness and flaccid paralysis due to inflammation of the anterior horn cells in the spinal cord and brainstem, characterized by leukocyte infiltration and loss of neural cells . The parDiagnosis of WNV encephalitis is based on clinical findings and by detecting immunoglobulin M (IgM) antibodies in serum or cerebrospinal fluid (CSF) ,5. RoutiThere are many publications about the clinical features and diagnosis of West Nile fever and encephalitis. However, The management of WNV encephalitis remains mainly unknown. Most clinical trials involve another flavivirus such as Japanese or San Louis encephalitis . There iMethodsA combination of PubMed Medical Subject Headings (MeSH) search was conducted using headings like “West Nile Virus” and “West Nile encephalitis”, and Advanced PubMed search using combinations like (ribavirin[Title/Abstract]) AND (west nile virus[Title/Abstract]), (west nile virus [Title/Abstract]) AND (interferon[Title/Abstract]), (west nile virus[Title/Abstract]) AND (IVIG[Title/Abstract]), (west nile virus[Title/Abstract]) AND (vaccine[Title/Abstract]), and (west nile virus[Title/Abstract]) AND (supportive care[Title/Abstract]). This search strategy was intended to cover all possible articles on WNV encephalitis and its management. Each of the studies that appeared in the search results were later analysed through the study’s inclusion and exclusion criteria.Table ResultsFollowing the recollection of initial data, the results were scanned and filtered by human subjects and papers published in English language in the last 25 years. Then the abstracts were reviewed and assessed according to the study’s inclusion and exclusion criteria. Only articles addressing WNV encephalitis disease and treatment were included. The final search (both MeSH and advanced PubMed search) yielded a database of 110 articles. These articles were narrowed down to 42 after inclusion/exclusion criteria. We excluded an additional 12 papers after removing duplicate papers and studies that did not meet the outcomes of our objectives. Table DiscussionThe Flavivirus genus is a group of highly virulent, widespread, single-stranded ribonucleic acid (RNA) positive viruses and is well known to cause many dangerous infectious diseases. The group includes but is not limited to West Nile virus (WNV), dengue virus (DENV), Zika virus (ZIKV), and yellow fever virus (YFV). The most devastating pathogenic property of these viruses is that they have animal reservoirs that serve as a constant source of outbreaks . In otheInterferon In vitro studies of INF α2b have shown efficacy in decreasing the activity of WNV ,10. INF In a case report with two patients who developed WNV encephalitis, there was benefit from the use of INF α2b on days four and six. On day six, the patient who received treatment had more sequels than those received on day four . In a reIn contrast to these three previous reports, a case of a 76-year-old man receiving interferon-alpha on day 17 of treatment, but he still died . These fINF α2b was effective in vitro against some flaviviruses . For thiRibavarinRibavirin is a guanosine analog that inhibits inosine-5′-monophosphate (IMP) dehydrogenase, limiting viral replication . RibavirRegarding human studies, a four-year-old boy with Hodgkin's lymphoma was admitted to the hospital after his third session of chemotherapy with high fever and no evidence of meningeal irritation; the physical exam was unremarkable. His condition deteriorated three days later as he became lethargic, disoriented, and experienced repeated episodes of generalized seizures. Physical examination showed nuchal rigidity. His mental status deteriorated, becoming somnolent. Serum IgM for WNV came back positive. On the eighth day after admission, he received ribavirin for 14 days. At the beginning of the third week, a slow improvement was noted. With the help of supportive care, he was dismissed 28 days after admission .Two patients receiving ribavirin and INF α2b for the treatment of hepatitis C developed west virus fever. While it is true that the patients did not develop encephalitis, this finding questions the limited utility of both drugs .Immunoglobulins There are two types of IVIG for the use of WNV encephalitis. First, the plasma-gathered immunoglobulins donated by survivors and the second, the pharmaceutical West Nile immunoglobulins (WNIG) . The IVIIn mouse studies, convalescent attained immunoglobulins achieved a protective rate of 44%. At the same time, the WNIG protection levels neared 94% . In anotA patient with a liver transplant developed a fever return to the hospital 15 days after the operation. On day four of hospitalization, he received 0.4 g/kg of IVIG on suspicion of WNV encephalitis. The improvement began on day five of treatment. He was discharged on day 12 of his hospital stay . A case In general, most studies support the administration of IVIG to patients with WNV encephalitis. Data indicate that IVIG should be administered with a dose of 0.4g/kg for five days. The average hospital stay was 15 days but may vary according to the patient's underlying conditions .Other Therapies (Gamma Interferon and ETAR)It is believed that gamma interferon has a protective role against replication and spread of WNV. Research has shown that mice with low levels of gamma interferon or gamma interferon receptors were more susceptible to severe WNND and had lower survival rates than their counterparts with normal levels. Higher levels of WNV RNA were isolated from serum, brain, and spleen tissues of interferon-deficient mice. Interferon-gamma seems to slow down the infection, allowing more time for the adaptive immune response to develop .An analog of 21 nucleosides similar to ribavirin,1-β-D-ribofuranosyl-3-ethynyl- triazole (ETAR) has shown more efficacy comparable cytotoxicity to that of ribavirin in vitro. The medicine covers a wide range of flaviviruses. It requires a lower effective dose than ribavirin when used in vitro, but further research is needed on ETAR to test its efficacy and cytotoxicity compared to ribavirin in vivo .VaccinesProphylaxis measures against WNV have been studied since 1990. One of these measures was the development of vaccines both for human and veterinary use. Equine vaccines have successfully protected the virus, and several have been authorized for veterinary purposes . No vaccAll of these vaccines underwent phase I of development and were then suspended for various reasons. One of the main reasons was the unknown time interval between outbreaks in a given region. Choosing phase III's target population and follow-up with them could be difficult and cost-ineffective ,24. TherSupportive CareTo date, supportive care continues to be the main treatment for WNV encephalitis. Pain management is crucial in these patients since the most common neurological symptom is headaches 69.7% after hospital admission . SupportWest Nile virus is an endemic infection in the United States that continues to be a threat to different communities across the country with no cure to date. Although its neuroinvasive form is relatively rare, it causes serious morbidity and mortality risk to those affected. The length of hospital stay and leave of absence are only two examples of the financial costs that weigh on families and health care systems alike. More studies about ribavirin are needed to know if the drug is useful for WNV encephalitis. Interferon-alpha has been shown to have both protective and disease limiting properties. The drug seems to work better when given nine to 10 days after the onset of symptoms. At the moment, there are no guidelines that determine the course of treatment, nor is there a single FDA-approved drug. For the time being, IVIG offers the best results in treating WNV neuroinvasive disease. As the annual cases continue to increase worldwide, finding a cure is becoming more crucial with time.


The deadly pandemic named COVID-19, caused by a new coronavirus (SARS-CoV-2), emerged in 2019 and is still spreading globally at a dangerous pace. As of today, there are no proven vaccines, therapies, or even strategies to fight off this virus. Here, we describe the in silico docking results of a novel broad range anti-infective fusion protein RTAM-PAP1 against the various key proteins of SARS-CoV-2 using the latest protein-ligand docking software. RTAM-PAP1 was compared against the SARS-CoV-2 B38 antibody, ricin A chain, a pokeweed antiviral protein from leaves, and the lectin griffithsin using the special CoDockPP COVID-19 version. These experiments revealed novel binding mechanisms of RTAM-PAP1 with a high affinity to numerous SARS-CoV-2 key proteins. RTAM-PAP1 was further characterized in a preliminary toxicity study in mice and was found to be a potential therapeutic candidate. These findings might lead to the discovery of novel SARS-CoV-2 targets and therapeutic protein structures with outstanding functions. A new global pandemic disease named COVID-19 has emerged and is still spreading at alarming rates at the time of this report. COVID-19 can cause severe symptoms such as damaging inflammatory response, fever, or severe respiratory illness and lead to death. The causative agent of COVID-19 was found to be a novel coronavirus closely related to the severe acute respiratory syndrome coronavirus (SARS-CoV) based on the latest phylogenetic analysis ,3. ThereRicinus communis and leaves of Phytolacca americana, respectively [To lower the costs and speed up the drug discovery phase, numerous researchers have used in silico tools such as protein–ligand docking software to screen for traditional compounds that could bind to and inhibit the key proteins present in SARS-CoV-2, highlighting their potential antiviral activity . The majectively . RTAM-PAectively ,11,12,13https://www.rcsb.org/). A knowledge-based scoring docking prediction was performed for all the compounds against S, S1 RBD, and M using CoDockPP global docking. An additional run was conducted for ACE2 and human SARS-CoV antibody CR3022 against S1 RBD as a reference [The three-dimensional 3D) structure of RTAM-PAP1 prediction was obtained as previously described , and thoeference . The 3D D structueference . B38 wasThe same higher binding affinity behavior for RTAM-PAP1 was observed with Mpro, PLpro, E, and RdRp when compared to PAP1, GRFT, and RTA . All of B38 was found to have a 50% inhibition of the cytopathic effect (EC50) against SARS-CoV-2 simultaneous infection in Vero cells in vitro at the concentration of 0.177 µg/mL. It was further demonstrated that B38 was effective in mice post-infection . RTA wasThis high affinity of RTAM-PAP1 to many key proteins of SARS-CoV-2 is uncommon. Yet, the most surprising part of the generated models was the discovery of unique binding mechanisms of RTAM-PAP1 with potential inhibiting activity by hindering viral entry and cellular machinery. This discovery might explain the previously observed gain of function of RTAM-PAP1  via the For those reasons, the decision to produce highly purified RTAM-PAP1 protein was taken to conduct a short toxicity study in BALB/c mice to determine the potential maximum tolerated dose.The protein production went well and followed a scheme previously used  with theThe mice were administered the highly purified RTAM-PAP1 with the 6-His tag and tolerated up to 1 mg/kg with no observable adverse effects. Adverse clinical signs were observed  at a single bolus intravenous administration of 3 mg/kg of RTAM-PAP1 with up-regulation of IP-10, KC, and MCP-1 chemokines from 14 cytokines/chemokines assessed . These rIn conclusion, given the very high affinity for SARS-CoV-2 key proteins, the previous antiviral results in vitro, the newly discovered mechanisms, the preliminary in vivo profile, potent bioactivities across the assays, and preferential entry into virus-infected cells as opposed to non-infected cells, we opine that this novel chimeric protein composed by two ribosome-inactivating proteins be tested against SARS-CoV-2 in vitro and in vivo. It would be the first therapeutic testing using this particular strategy against COVID-19 and might make a difference at subtoxic dosages as well as open the doors for the discovery of novel SARS-CoV-2 targets, therapeutic protein structures, and foundations for protein engineering. Those types of fusion proteins are able to outperform immunotoxins with lower production costs and less toxicity.https://www.rcsb.org), in PDB format with the following PDB ID: 4MX5, 1PAG, 7BZ5, 6W41, and 3LL2, respectively). The 3D models for S, Mpro, PLpro, ACE2, RdRp, E, and M were retrieved directly from the CoDockPP site (https://ncov.schanglab.org.cn/). The 3D models for the B38-S1, CR3022-S1 and ACE2-S1 complexes were also retrieved from RCSB, 7BZ5, 6M0J, and 6LZG, respectively, for comparison with CoDockPP outputs.The predicted molecular 3D structure of RTAM-PAP1 was already available from previous work  and is ahttp://strcomp.protein.osaka-u.ac.jp/matras/matras_pair.html). Additional models of the RTAM-PAP1-S1 and RTAM-PAP1-M complexes were generated using ZDOCK and HADDOCK2.2 [The structure of the bound complexes was generated by CoDockPP using the ambiguous peptide-ligand computations ,9,10. ThDDOCK2.2 ,12,13 wiDDOCK2.2  and are E. coli BL21 (DE3) cells (NEB). Expression of the proteins was examined from individual clones and analyzed by either Western blot using a monoclonal antibody specific to ricin A chain  or SDS gel stained with Coomassie blue . Optimal conditions were determined and protein production was induced in the presence of 1 mM isopropyl beta-D-1-thiogalactopyranoside (IPTG) from 1 L culture. The bacteria were then harvested by centrifugation, followed by lysing the cell pellets with 50 mL of lysis buffer . After sonication (3 × 2 min), the soluble lysates were recovered by centrifugation at 35,000 rpm for 40 min. The soluble proteins were then purified by the combination of affinity and conventional chromatographic methods from soluble lysates (please contact the authors for more details). The purification of the native RTAM-PAP1 from soluble lysate was achieved by affinity versus His-tag on the Ni-sepharose column . After extensive washing with the lysis buffer, loosely bound proteins were eluted with the lysis buffer containing 40 mM Imidazole (I40). RTAM-PAP1 proteins were eluted with the elution buffer . A second purification step using the hydroxyapatite column  was used to further separate RTAM-PAP1 from co-purified host proteins. A third purification step, gel filtration on a fast protein liquid chromatography (FPLC) column of Superose 12 , was necessary to completely remove degraded or/and premature protein products [2, and 0.5 mM EDTA.RTAM-PAP1 was produced and purified as previously described . The vec® Quick Coupled Transcription/Translation System and the Luciferase Assay System . Each transcription/translation reaction was performed according to the instructions for use (IFU) in the presence of a T7 Luciferase reporter DNA, and the luciferase expression level was determined with a Wallac Microplate Reader. Transcription/translation were run at three different concentrations to confirm bioactivity [The inhibitory activities of RTAM-PAP1 were tested by using the Rabbit Reticulate Lysate TnTFemale BALB/c mice, aged 6–8 weeks , were used in this study. Female mice were housed in groups of five in individually ventilated cages. The mice were maintained at the National Research Council Canada (NRC) in accordance with the guidelines of the Canadian Council on Animal Care. All procedures performed on animals in this study were in accordance with regulations and guidelines reviewed and approved by the NRC Human Health Therapeutics Ottawa Animal Care Committee.p > 0.05.RTAM-PAP1 was administered by intravenous (IV) bolus injection of 0.25 mL into the tail vein in a dose-escalating manner . Control mice received an equivalent volume of vehicle. Dosing was staggered to allow for an initial assessment of tolerability at a particular dose level prior to escalating to a higher dose level. Mice were weighed and evaluated daily for clinical signs for 8 days following administration of RTAM-PAP1. Data were analyzed using GraphPad Prism . Statistical significance of the difference between groups was calculated by 1- or 2-factor ANOVA followed by post-hoc analysis. Differences were considered to be not significant at Hassan, Y. and Ogg, S. WO/2019/204902, The World Intellectual Property Organization (WIPO), 2019.


There is currently little systematic knowledge about the contribution of different factors to the increase in health care spending in high-income countries such as Switzerland. The aim of this paper is to decompose inpatient care costs in the Swiss canton of Zurich by 100 diseases and 42 age/sex groups and to assess the contribution of six factors to the change in aggregate costs between 2013 and 2017. These six factors are population size, age and sex structure, inpatient treated prevalence, utilization in terms of stays per patient, length of stay per case, and costs per treatment day. Using detailed inpatient cost data at the case level, we find that the most important contributor to the change in disease-specific costs was a rise in costs per treatment day. For most conditions, this effect was partly offset by a reduction in the average length of stay. Changes in population size accounted for one third of the total increase, but population structure had only a small positive association with costs. The most expensive cases accounted for the largest part of the increase in costs, but the magnitude of this effect differed across diseases. A better understanding of the factors related to cost changes at the disease level over time is essential for the design of targeted health policies aiming at an affordable health care system. High and rising health care spending dominates the health policy debate in high income countries. OECD countries have experienced a strong increase in spending in the last few years, raising questions about the sustainability of its levels. Switzerland is one of the countries with the highest share of health care spending in percent of its GDP in the world (12.3% in 2017) ),None of these approaches has taken a disease-based perspective, i.e. variation of these trends across diseases is not taken into account. Some studies have shown the usefulness of disease-based analyses to investigate health care cost drivers. These studies used estimates of disease-specific spending that have been published for some countries  and the oldest age group (> 95 years) by sex. Since we aimed at tracking the number of unique patients within each disease group for each year, we used the patient identifier based on the anonymized social insurance number that has been available since 2012. This variable showed missing values for all non-resident patients and for some Swiss residents. To fill these gaps, we used a second patient identifier. This identifier uniquely identifies patients within each hospital and year, but not across hospitals and years. Therefore, we slightly overestimate the number of unique patients because some of them might have been treated at different hospitals for the same disease in a given year. Some cases did not fall completely in one calendar year. Patients admitted at the end of a year but without discharge in the same year had no assigned diagnosis and were thus dropped. Some observations with entry and discharge date in the same calendar year were lacking a diagnosis and, thus, had to be excluded from the analysis. About five cases per year with entry in the last year and discharge in the following year  were also excluded from the analysis.costs refers to production costs of health services and not to the costs charged to the payer, which is based on the DRG case weight. This is a key innovation of the study, as to our knowledge, there has been no previous literature using the production cost information at the inpatient case level in Switzerland. With the introduction of the DRG system in 2012, hospitals applied a unified accounting standard, ensuring consistent accounting rules across hospitals over the whole period. For each case, costs are recorded and distinguished by about 35 cost types. We aggregated the cost types into cost categories with the support of the Department of Health. Five categories of costs are distinguished: physician costs, medical products costs (e.g. drugs), medical costs , other variable costs , and investment or infrastructure costs (depreciation). While the two categories ‘physician costs’ and ‘medical costs’ mainly consist of cost items recorded directly at the case level, the other cost categories comprise fixed costs that are generated through an allocation key. Most hospitals used the same accounting framework . We assume that there has been no change in how fixed costs are distributed between 2013 and 2017. The costs comprise both the part covered by the mandatory as well as the supplementary health insurance plan. Details about the mapping of cost types to cost categories as well as the record types are provided in the appendix.Our data contains rich cost information at the case level. The term (REKOLE® ) with stThe set of health conditions was defined based on the comprehensive and mutually exclusive Global Burden of Disease (GBD) classification. This classification defines three hierarchical levels of diseases. GBD Level 1 distinguishes between communicable and non-communicable diseases and injuries. Level 2 groups major diseases such as neoplasms or cardiovascular diseases. Level 3 defines more specific diseases such as breast cancer or ischemic heart disease. The ICD-10 codes entailed in our data were mapped to a slightly modified version of the GBD disease classification. We grouped the codes according to the classification used in the 2017 Global Burden of Disease Study to obtain groups of disease codes . To obtaWe allocated all the costs based on the primary diagnosis listed in each record. Accounting for concurrent conditions in cost-of-illness studies is essential and may impact cost estimates significantly . NeverthWe used the Das Gupta method for the decomposition of aggregate measures  that wasc). We exploited the fact that the aggregate costs in one year (2013 or 2017) can be re-written as the sum over the costs observed in each age/sex group (a) and disease (d) cell. These costs, in turn, are a product of the six factors.We decomposed the change in disease-specific inpatient care costs between 2013 and 2017 into the changes caused by the six factors population size, population structure (captured in the model by the distribution of age/sex groups), inpatient treated prevalence (number of unique patients within each age/sex group), utilization , average length of stay (LOS), and costs per day of treatment. Treated prevalence and utilization are actually the two components of the admission rate; the first factor represents the number of patients treated for a certain disease (extensive margin), the second refers to the average number of stays of those who were treated (intensive margin). The costs per day component is a sum over the five cost categories , between the 10th and the 25th percentile (group 2), between the 25th and the 75th percentile (group 3), between the 75th and the 90th percentile (group 4) and >90th percentile (group 5). The aim of this analysis was to investigate whether the importance of the factors differs across the distribution and which group of cases contributed most to the observed cost change.g) specific and are "linked" to the three previous factors by including a technical factor case share  would lead to cells with potentially very few observations. In addition, the decomposition would include an additional factor - the share of each age/sex group within each distribution section by disease - which is not easily interpretable. We removed one dimension from the decomposition, namely the population structure. This means that in the second specification, the factors treated prevalence and utilization refer to the whole population (instead of to specific age/sex groups) for each disease. The two factors length of stay and cost per day are distribution group , closely followed by neoplasms (18.2) and musculoskeletal disorders (10.8). 28.3 % of the total cost increase was observed in the treatment of communicable diseases (10.7) and injuries (17.6).Figure Table Plot a on the left-hand side of Fig. There is some heterogeneity in the effect size across diseases, as indicated by Fig. These heterogeneous effects become even more visible if we look at a more granular disease level. Figure The complete results are provided in Tables The sum of the length of stay and the costs per day effect is roughly equal to the effect of costs per case. We checked this with a decomposition analysis including only five factors. The results are very similar, i.e. the costs per case effect is very close to the sum of the length of stay and the costs per day effect  to the total effect of each factor by disease. The contributions of each of the five sections to the total cost change by disease (at GBD level 2) are shown in the appendix patient within each disease group is increasing, which would somehow conflict with the goal to increase efficiency in hospitals.Future research should include other health care sectors to investigate whether there has been a shift to outpatient treatments and if yes to what extent and for which diseases. It is further important to research the reasons for the factor associations we found, e.g. the increased number of treated inpatients relative to the population and the increased number of stays per (in)patient over time. In addition, it would be interesting to assess whether the additional health care use is due to increased care needs or due to hospital-induced demand. Accounting for the cost impact of comorbidities is a very important and demanding task for future research. Some regression-based approaches have recently been proposed by the literature to adjust for concurrent diseases at the patient or the encounter level , 50. Our


Marek’s disease virus (MDV) infects chickens and causes one of the most frequent cancers in animals. Over 100 years of research on this oncogenic alphaherpesvirus has led to a profound understanding of virus-induced tumor development. Live-attenuated vaccines against MDV were the first that prevented cancer and minimized the losses in the poultry industry. Even though the current gold standard vaccine efficiently protects against clinical disease, the virus continuously evolves towards higher virulence. Emerging field strains were able to overcome the protection provided by the previous two vaccine generations. Research over the last few years revealed important insights into the virus life cycle, cellular tropism, and tumor development that are summarized in this review. In addition, we discuss recent data on the MDV transcriptome, the constant evolution of this highly oncogenic virus towards higher virulence, and future perspectives in MDV research. Marek’s disease virus (MDV) mainly infects chickens and causes one of the most prevalent cancers in the animal kingdom ,2. The vMDV is among the diseases with the highest economic impact in modern poultry production worldwide , togetheWidespread vaccination has drastically reduced the incidence of Marek’s disease . HoweverAside from its importance in veterinary medicine, MDV infection of chickens is a versatile small animal model to study herpesvirus-induced disease, latency, and tumor formation in biomedical research. Overall, ‘avian tumor virology has laid the groundwork for much basic cancer research’ as acknowledged in ‘The oncologist’s debt to the chicken’ by R. A. Weiss . Our revThe MDV life cycle is also known as the ‘Cornell model of MDV infection’ and was proposed by Calnek in 2001 . The modMDV secretes a viral CXC chemokine that was initially termed vIL-8, but recently changed to vCXCL13 based in its biological properties ,26,27,28However, we have recently demonstrated that B cells are completely dispensable for MDV pathogenesis and tumor formation . In the MDV not only replicates but also establishes latency in T cells ,38,39. OMDV can reactivate from the latently infected and tumor cells, allowing continuous virus shedding and spread to naïve individuals in the population . SheddinS and UL), flanked by terminal repeats (TRL and TRS), and internal repeats (IRL and IRS) [The MDV double-stranded DNA genome is approximately 180 kb long and consists of short and long unique regions (Uand IRS) . MDV encand IRS) . Among tand IRS) ,52.Previous research has largely focused on the role of those viral protein-coding genes. However, MDV also encodes a rich repertoire of non-coding RNAs (ncRNAs) including micro RNAs (miRNAs) and a viral telomerase RNA (vTR) ,58,59,60MDV also encodes miRNAs that play important roles during latency and tumorigenesis . So far,Recent studies identified additional coding and non-coding sequences that are potentially important for infection, replication, pathogenesis, and spread ,72. For MDV remains a threat to the poultry industry due to its evolution towards higher virulence , with viOne potential selective pressure are the live-attenuated vaccines introduced since the 1970s to control MDV ,86. All Another potential driver of the increased virulence is the industrialization of poultry farming and intensive chicken husbandry ,92. A laDuring the evolution of MDV, specific changes in the genome have been documented that could contribute to the increase in virulence and allow the virus to overcome vaccine protection ,84,94.meq (MDV076), ICP4 (MDV084), and ICP27 (MDV068) directly correlate to the changes in virulence [meq gene is evolving at a much faster rate than most genes in double-stranded DNA viruses [Comparative bioinformatic studies have been performed to identify genes that could contribute to the increase in MDV virulence. Mutations in several open reading frames, including ICP4 MDV0, and ICPirulence . These girulence . The strirulence ,96, it h viruses .Taken together, the association of vaccine breaks and the increase in virulence in MDV infections seems to be a characteristic of MDV and MDV vaccines, rather than a common phenomenon.E. coli and other pathogens [Despite many years of MDV research, various challenges remain to be addressed. Firstly, the leaky MDV vaccines should be improved to provide better protection and to reduce virus shedding. Current vaccines also have immunosuppressive properties that should be eliminated . In turnathogens ,99. A beathogens ,19. Moreathogens . In lineathogens . CVI stoathogens . Moreoveathogens  and the athogens , but morSecondly, MDV infection in chickens will continue to be used as an animal model for herpesvirus research and virus-induced tumor formation. MDV can serve as a model to assess herpesviruses evolution  and to tIn summary, we highlighted the progress in MDV research from previous years, which provided intriguing insights into the lifecycle and cellular tropism of this highly oncogenic pathogen. Furthermore, recent studies shed light on an increasing coding capacity of the MDV genome and polymorphisms associated with increased virulence. Finally, we gained a better understanding of vaccine resistance, virus shedding, and an increase in virulence of this highly oncogenic herpesvirus.


Flavonoids are now considered as an indispensable component in a variety of nutraceutical and pharmaceutical applications. Most recent researches have focused on the health aspects of flavonoids for humans. Especially, different flavonoids have been investigated for their potential antiviral activities, and several natural flavonoids exhibited significant antiviral properties both in vitro and in vivo. This review provides a survey of the literature regarding the evidence for antiviral bioactivities of natural flavonoids, highlights the cellular and molecular mechanisms of natural flavonoids on viruses, and presents the details of most reported flavonoids. Meanwhile, future perspectives on therapeutic applications of flavonoids against viral infections were discussed. Flavonoids comprise one of the largest groups of secondary metabolites found in biologically active plants, including vegetables, fruits, seeds, nuts, wine, and tea. Flavonoids are low molecular weight compounds with a simple 15 carbon backbone, and there are more than 9000 varieties of flavonoids that have been structurally identified. The natural flavonoids are an important source of medicines [Typically, flavonoids are divided into flavones, flavonols, flavanones, flavanonols, flavanes, flavanols, chalcones, anthocyanidins, aurones, isoflavones, biflavones . The carMatricaria chamomilla), leaves of parsley (Petroselinum crispum), celery (Apium graveolens) and spinach (Spinacia oleracea), roots of plants, propolis, and honey and so on [Most flavonoids, except for the subclass of catechins, are present in plants bound to sugars as β-glycosides. The common sources of natural flavones were the vegetables such as Chamomile tea 3). The oMany reports on the antiviral activity of naturally occurring flavonoids are available. The structure–function relationship between flavonoids and their enzyme inhibitory activity has been observed. Baicalin was reported to interfere with the viral neuraminidase activity . Flavan-The flavonoids with anti-virus activities act on various targets, which are known targets with some anti-virus drugs. And some proteins and enzymes which some flavonoids interacted and include in the virus replications may be a candidate target for new anti-virus drugs. Fig. .dglucoside. Naturally occurring quercetin compounds are mainly glycosides such as IQ and are commonly found in plants and the human diet.Quercetin is widely distributed in angiosperms such as Threevein Astere, Golden Saxifrage, berchemia lineata, gold, rhododendron dauricum, seguin loquat, purple rhododendron, Rhododendron micranthum, Japanese Ardisia Herb and Apocynum. Isoquercitin (IQ), a naturally occurring glycoside of quercetin also known as hirsutrin, isoquercetrin, quercetin3glucoside (Q3G), quercetin3OβThe quercetin and IQ differ in their structures, bioavailability, absorption, and biological actions. Quercetin and IQ have various kinds of pharmacological functions and are mainly used for treating clinical bronchitis and phlegmatic inflammation. Currently, quercetin/IQ are reported antiviral activities by many researchers Table .Table 2AScutellariabaicalensis Georgi is a medicinal plant with multiple pharmacological activities. Scutellariabaicalensis is the main component of Chinese patent medicine preparations for clinical use, such as Shuanghuanglian injection and Qingkailing injection. Baicalin and its active metabolite baicalein are the main pharmacologically active compounds in Scutellariabaicalensis. Modern research shows that baicalin has certain antiviral activity. Its antiviral pharmacological effect is a concrete manifestation of the heat-clearing and detoxifying effect in the classics of traditional Chinese medicine. With the development of research, details of the antiviral activities of baicalein were reported  contains a hydroxyl group in its B-ring, and hydroxyl groups in its C-ring. The apigenin contained plants are used for the treatment of different diseases and infections like diabetes, dysentery, hepatitis, blennorrhagia, cancer arthritis, inflammation, woods, hemorrhoids, and leishmanial ulcers. Especially, apigenin exhibits various antiviral activities against numerous viruses in vitro and in vivo: enterovirus 71 (EV71), hepatitis C virus (HCV), Human Immunodeficiency Virus (HIV), and adenoviruses. Apigenin exerted inhibitory effects on HCV replication by decreasing mature miR122 expression levels. Apigenin also inhibited FMDV (Foot and mouth disease virus) infection by suppressing IRES-driven translational activity inhibited FMDV infection at the post-entry stage. Apigenin inhibits EBV reactivation into the lytic cycle and virion production by EBV-positive NPC cells. The antiviral activity of apigenin is currently reported, as shown in Table Luteolin  is a pure yellow crystal representing the category of bioflavonoid. It is abundant in various medicinal herbs, fruits, and vegetables, e.g., broccoli, onion, parsley, green peppers, citrus, celery, and chamomile. Luteolin has many beneficial properties, including antioxidant, anti-inflammatory, anticancer, anti-diabetic, and cardio-protective effects and widely used in the development of different traditional medicines for the treatment of diseases. It is also well known to have good effects on anti-angiogenesis, anti-metastasis, anti-inflammation, and estrogenic regulation and can regulate many signal pathways. Besides, luteolin is considered to have potential clinical value for cancer prevention and therapies. Luteolin can obstruct the later stages of the DENV viral life cycle in infected cells by inhibiting the host proprotein convertase furin. Luteolin also exhibits inhibitory effects on Epstein-Barr Virus, Japanese encephalitis virus, HIV-1, Hepatitis B virus, Hepatitis C virus, enterovirus 71, coxsackievirus A16, and chikungunya virus  showed the methyl group located on the B ring of isorhamnetin might contribute to its strong antiviral potency against the influenza virus in comparison with other flavonoids. In addition, isorhamnetin treatment reduced virus-induced ROS generation and blocked cytoplasmic lysosome acidification and the lipidation of microtubule associated protein1 light chain 3-B (LC3B). The evidence for the anti-virus activity of isorhamnetin was shown in Table Isorhamnetin (Iso) is a flavonoid compound extracted from the Chinese herb Glycinemax L.), red clover (Trifoliumpratense), and kudzu. Isoflavones exhibit antioxidant, anticancer, antimicrobial, anti-inflammatory, antiosteoporotic, and estrogenic properties. Especially, isoflavones and their related flavonoid compounds exert antiviral properties both in vitro and in vivo against a wide range of viruses. Targets of Isoflavones reported affecting virus binding, entry, replication, viral protein translation, and formation of certain virus envelope glycoprotein complexes. Isoflavones also affect a variety of host cell signaling processes, including induction of gene transcription factors and secretion of cytokines , the highest concentrations of isoflavones have been observed in soy (es Table .Table 7ACamelliasinensis (C.sinensis) and C.assumica. There are eight catechin: C ((−)-catechin), EC ((−)-epicatechin), ECG ((−)-epicatechingallate), EGC ((−)-epigallocatechin), EGCG ((−)-epigallocatechin gallate), GC ((−)-gallocatechin), CG ((−)-catechingallate), and GCG ((−)-gallocatechingallate). Because of the hydroxyl in the gallate group, Epigallocatechin-3-O-gallate (EGCG) and ECG are highly effective free-radical scavengers compared with many other standard anti-oxidants. According to the relationships between structure and antiviral activity of catechin derivatives, the 3-galloyl and 5′-OH group of catechin derivatives appear critical to antiviral activities. Most Catechin/EGCG were reported not to affect cell viability and proliferation but interfered with herpes simplex virus cell penetration and adhesion. Among these catechins, EGCG is the major catechin component of green tea (Cameriasinensis) and known to possess antiviral activities against a wide range of DNA viruses and RNA viruses. EGCG has been reported to possess a broad spectrum of antiviral activities against DNA viruses such as herpes simplex virus  adenovirus (Adenoviridae), human papilloma virus , and hepatitis B virus , and against (+)-RNA viruses such as hepatitis C virus , Zika virus , dengue virus , West Nile viruses , Chikungunya virus , and Porcine Reproductive and Respiratory virus , and (−)RNA viruses such as human immunodeficiency virus , Ebola virus  and influenza virus (Table Catechins are important ingredients from tea leaves and account for more than 75% of the polyphenol compounds in tea leaves. Catechins are members of the group of polyphenol compounds found in many medicinal plants, with a ring and the basic structure of flavan-3-ol and have intensive anti-oxidant and representative physiological activities.The major sources of catechins are us Table .Table 8AThe study of flavonoids is complex because of the heterogeneity of the different molecular structures and the scarcity of data on bioavailability. An important effect of flavonoids is the scavenging of oxygen-derived free radicals. Flavonoids possess anti-inflammatory, antiallergic, antiviral, and anticarcinogenic properties from the evidence obtained in vitro experimental systems. However, the clinical application of flavonoids is restricted by its low solubility and poor bioavailability. Although there are lots of advances in the antiviral pharmacology of natural flavonoids, further study is needed to elucidate the effects of flavonoids within the body and the degree and rate of absorption for the evaluation of druggability.With the development of preparation techniques, newly developed flavonoids preparations exhibit better absorption and thus have higher bioavailability. Since flavonoids are frequently prescribed with other medications, understanding the compatibility of co-administrated drugs is of importance for clinical applications, and requires further research for better clarity. Furthermore, pharmacokinetic changes of flavonoids under different pathological conditions indicate clinical considerations of drug safety and the possible requirement of individualized antiviral therapy.


Gliomas are associated with significant healthcare burden, yet reports of costs are scarce. While many costs are unavoidable there may be treatable symptoms contributing to higher costs. We describe healthcare and societal costs in glioma patients at high risk for depression and their family caregivers, and explore relationships between costs and treatable symptoms.Data from a multicenter randomized trial on effects of internet-based therapy for depressive symptoms were used (NTR3223). Costs of self-reported healthcare utilization, medication use, and productivity loss were calculated for patients and caregivers separately. We used generalized linear regression models to predict costs with depressive symptoms, fatigue, cognitive complaints, tumor grade (low-/high-grade), disease status (stable or active/progression), and intervention (use/non-use) as predictors.M = €20,587.53  for patients and M = €5,581.49  for caregivers. In patients, higher healthcare utilization costs were associated with more depressive symptoms; higher medication costs were associated with active/progressive disease. In caregivers, higher overall costs were linked with increased caregiver fatigue, cognitive complaints, and lower patient tumor grade. Higher healthcare utilization costs were related to more cognitive complaints and lower tumor grade. More productivity loss costs were associated with increased fatigue .Multiple assessments from baseline through 12 months from 91 glioma patients and 46 caregivers were used. Mean overall costs per year were There are substantial healthcare and societal costs for glioma patients and caregivers. Associations between costs and treatable psychological symptoms indicate that possibly, adequate support could decrease costs.Netherlands Trial Register NTR3223. N = 43; median $1341 per month) [Gliomas cause not only a high disease burden that greatly affects patients’ and their family caregivers’ lives, but are also associated with a high healthcare burden . Reportsr month) .N = 131), depressive symptoms, fatigue, and cognitive issues accounted for 65% of the variance in work limitations [N = 45) [Depressive symptoms, fatigue, and cognitive deficits are common symptoms in glioma patients and may impact on patients’ and family caregivers’ quality of life –8. But, [N = 45) . Despite[N = 45) –17, deprMost brain tumor specific studies described above were carried out in the US, many did not link productivity loss to costs, none have presented patient and caregiver costs in one report, and none have investigated the relationship between costs and potentially reversible symptoms. We therefore aimed not only to describe costs in glioma patients and family caregivers, but also to explore associations between patients’ and caregivers’ depressive symptoms, fatigue, cognitive complaints and both patient and caregiver costs during a 12 month period. More knowledge on the costs associated with potentially treatable symptoms in a population with disproportionately high burden, will strengthen the case for further investigation of effectiveness of support programs to improve the lives of patients and family caregivers.Patient-caregiver dyads were invited to participate in a Dutch nation-wide randomized controlled study to investigate the effectiveness of an internet-based guided self-help intervention in glioma patients with depressive symptoms , 19. RecFollowing consent procedures, assessments consisting of online questionnaires took place at baseline, 6 weeks, 12 weeks, 18 weeks, 24 weeks, 6 months, and 12 months . PatientThe Trimbos/iMTA questionnaire for Costs associated with Psychiatric Illness (TIC-P)  was admiAll analyses were performed using STATA (v. 15) and SPSS software (v. 23). Medication costs per four weeks were calculated based on the Defined Daily Doses (DDDs) from the 2015 GIP databank, with €6 added per case to account for pharmacy prescription costs and a further 6% for taxes. Costs for healthcare utilization per four weeks were calculated based on the values published in the updated 2015 Cost Manual , plus trDescriptive statistics were generated for sociodemographic characteristics, and baseline assessments of healthcare utilization, productivity loss, depressive symptoms (CES-D), fatigue (CIS), cognitive complaints (MOS), and costs in patient and caregiver groups. As cost data has a positively skewed distribution, we used generalized linear regression models  to identify statistically significant explanatory variables. We used multiple observations per participant  and robust standard errors based on participant to account for this. We included patients’ and caregivers’ self-reported depressive symptoms (CES-D), fatigue (CIS), and cognitive complaints (MOS) as potentially reversible symptoms. We included tumor grade (low-/high-grade) and disease status (stable/progression/active treatment) to cover important clinical differences within individuals. In patients only, intervention (use/non-use) was included to account for potential impact of the internet-based therapy—caregivers did not undergo any intervention. Variables associated at P < 0.10 and those of theoretical importance providing improvement in model fit were included in a multivariate model with backward selection to yield final prediction models, based on best fit according to the Akaike and Bayesian Information Criteria. We derived marginal effects for the included covariates and here, P < 0.05 was considered statistically significant. Missing data were not imputed, and no corrections for multiple testing were made due to the exploratory nature of the project.sd = 4.84, range 0–26) years prior to enrolment. Nearly all caregivers were the patient’s spouse/partner (86.7%). Both patient and caregiver groups had relatively high baseline scores for depressive symptoms .In total, 90 patients (291 observations) and 45 family caregivers (95 observations) completed at least one assessment and were included. Average age was 45 for patients and 48 for caregivers, see Table M = €1604.43 (sd = €2377.73) for patients and M = €429.34 (sd = €1007.91) for caregivers. On a yearly basis this translates to M = €20,857.53  for patients and M = €5581.49  for caregivers. This is broken down into separate costs for healthcare utilization, medication, and productivity loss as described below.At baseline, on average, the total direct and indirect costs per 4 weeks amounted to M = €422.94  per four weeks. The majority of patients (77.8%) used antiepileptic drugs (AEDs), for which the DDD ranged between €0.11 (phenytoin) to €5.38 (lacosamide), with many taking multiple drugs concurrently. Some patients were taking chemotherapeutic drugs, often in combination (12.2%) for which the DDD ranged between €3.88 (lomustine) and €17.63 (vincristine).Healthcare service use per four weeks yielded a total per patient cost of M = €142.21 (sd = €397.01). About a fifth of caregivers (21.2%) had visited their GP, and 13.3% had attended an outpatient hospital appointment. Psychology or psychiatry services were accessed by 20.0% of caregivers. Home care services were used with highest frequency per service user (up to 22 visits in four weeks). Medication was used by 48.9% of caregivers with an average cost of €14.13 (sd = €22.54) per four weeks.For caregivers, average costs associated with healthcare service use per four weeks were M = €1264.95 (sd = €2299.97) per patient (employed and unemployed) per four weeks.At baseline, over a third of patients reported to be in paid employment (37.4%). Others described their productivity status as being declared unfit for work , taking primary care of the household (13.3%), retired (5.6%), student (3.3%), or ‘other’ (11.1%). Many reported to be hindered by health problems in everyday tasks: domestic work (54.4%), grocery shopping (45.6%), chores around the house (44.4%), and taking care of children (24.4%). Absenteeism was reported by 48.9% of patients, and presenteeism (productive hours lost while working) by another 7.8%. Together, the costs for productivity loss were sd = €901.15) per four weeks.Most caregivers reported they were in paid employment at baseline (66.7%). Others were retired (13.3%), declared unfit for work , taking primary care of the household (2.2%), or reported ‘other reasons’ (4.4%). A minority of caregivers reported to have been hindered by health issues in domestic work (6.7%), grocery shopping (8.8%), chores (6.7%), or child care (4.4%). Absenteeism was reported by 24.4% of caregivers, and presenteeism by another 6.7%. In total, productivity loss in caregivers was on average €337.42 (P < 0.05). In the final multivariate model which included depressive symptoms and tumor grade, depressive symptoms remained significantly associated with increased healthcare costs .All significant associations based on univariate and multivariate analysis in patients are shown in Table P < 0.05). The final multivariable model included cognitive complaints, tumor grade and disease stage. Active/progressive disease remained a statistically significant predictor of medication costs .In univariate analysis of medication costs, there were significant associations between higher medication costs and decreased depressive symptoms (−€2.48 per 4 weeks with each unit increase in scores), fewer cognitive complaints (−€1.89), higher tumor grade (+€56.53 for high-grade glioma vs. low-grade glioma), and active disease status . In the final multivariate model, higher overall costs were associated with increased fatigue (+€5.60) and lower patient tumor grade .All significant associations based on univariate and multivariate analysis in caregivers are shown in Table P < 0.05). In the final multivariate model which included cognitive complaints, fatigue, and tumor grade, only increased caregiver-reported cognitive complaints (+€4.80) and lower tumor grade (−€125.81) remained statistically significantly associated with higher healthcare costs (P < 0.05).In univariate analysis of healthcare utilization costs, there were significant associations with increased caregiver-reported depressive symptoms (+€8.03 per 4 weeks with each unit increase in scores), fatigue (+€3.99), cognitive complaints (+€5.57), and lower patient tumor grade  only.Medication costs were significantly associated with lower caregiver depression scores . The final multivariate model included fatigue, cognitive complaints, and tumor grade: only fatigue (+€5.60) and lower tumor grade (−€384.95) remained significantly associated with increased productivity loss costs (P < 0.05).In univariate analysis, higher productivity loss costs were significantly associated with increased caregiver-reported depressive symptoms (+€12.80), fatigue (+€21.66), cognitive complaints (+€16.01), and patient tumor grade  approaches the yearly Dutch median income per household [Very little is known about the true costs of primary brain tumors for patients, caregivers, the healthcare system and society. Our study is one of the first to provide meaningful quantitative data by focusing on the costs associated with self-reported healthcare utilization, medication, and productivity loss of glioma patients and caregivers. The healthcare costs measured excluded most anti-tumor procedures, but included adjuvant chemotherapy—thus essentially reflect maintenance costs only. We found that on average 3 years after diagnosis, healthcare utilization, medication use, and productivity loss resulted in yearly costs of ousehold .Costs varied greatly between participants as evidenced by the large standard deviations. Interestingly, while only 1/3rd of patients and 2/3rds of caregivers were in paid employment, productivity loss costs accounted for > 78% of costs. Of note, most costs are not directly absorbed by patient-caregiver dyads. Rather, costs are divided evenly across the Dutch population through the social security system, and thus reflect a societal cost rather than a personal cost.Many consequences of brain tumors are unavoidable or difficult to manage. We therefore investigated associations between those symptoms that are potentially reversible  and costs. Despite being a patient-caregiver group at high risk for depression, less than a quarter of participants had accessed psychology/psychiatry services. In patients, reversible symptoms were not very strongly related to costs: in multivariate analyses, increased healthcare costs were associated with increased depressive symptoms. The association between medication costs and cognitive complaints approached statistical significance. In part, this could be explained by the relative homogeneity of our patient sample, as all were at increased risk of depression. Previous studies found associations between depressive symptoms, fatigue, cognitive complaints, and work limitations , 14. WorIn caregivers, higher overall costs were linked with increased fatigue and cognitive complaints; higher healthcare utilization costs were related to more cognitive complaints; and higher productivity loss costs were associated with increased fatigue. As caregivers did not suffer from a direct physical cause of cognitive complaints, these may have been an indirect consequence of increased burden. Our results seem to confirm the large role of fatigue in work productivity found in the general working age population . InteresStrengths of the current study are the detailed self-reported use of healthcare services, medications, and productivity loss parameters; the longitudinal nature of the data; and our robust modelling techniques. Our analyses are exploratory and not corrected for multiple testing. The self-report nature of the data may have introduced some bias, leading to over- or underestimation of costs. For example, productivity loss costs are based on self-reported absence or reduced productivity—which may not completely overlap with an employer’s records. Finally, our patients were at high risk for depression, thus findings may not be generalizable to all glioma patient-caregiver populations. However, the RCT was intended to have high external validity and thus few exclusion criteria were employed. This is reflected in a relatively heterogeneous sample of glioma patients in terms of grade, localization, and treatment, as well as the reasons for attrition .Nevertheless, we were able to show that potentially treatable symptoms are linked with higher healthcare utilization costs in patients, and higher overall costs, healthcare utilization costs, and productivity loss in caregivers. More generally, we demonstrated that healthcare service and medication use, and productivity loss costs for patient-caregiver dyads are substantial and vary greatly between individuals. This study provides evidence that the true cost of brain tumors is a burden shared between patients, caregivers, the healthcare system, and society as a whole.


Coronavirus disease 2019 (COVID-19) is an emerging condition threatening the biosecurity of all nations on the planet. This pandemic of respiratory disease, caused by a novel β-coronavirus , has high sequence similarity to SARA-CoV, which was responsible for a major outbreak in 2002–2003 . EmployiThe SARS-CoV-2 virus can be detected in variety specimens such as bronchoalveolar lavage fluid (BLF) , sputum et al. concluded that nucleic acid test (NAT) is a rapid, easy to conduct and widely used laboratory diagnostic test for identifying the RNA of SARS-CoV-2. According to their findings, BLF exhibited the highest (100% cases) true positive results where nasal and pharyngeal swabs showed low (61% cases) true positive results for targeting the ORF1ab gene of the virus [ORF1ab. The researchers collected different clinical specimens from patients across multiple sites and demonstrated that the type of sample collected can affect the result of virus diagnosis as well as influence accurate identification of patients with COVID-19. According to their results, the BLF specimen showed the highest rate of true positive results  to identify patients, with the lowest false negative results. However, it should be considered that this cannot be recommended for all cases in the screening stage as this is an invasive sampling procedure and requires highly skilled professionals to collect the BLF samples. BLF is collected by a bronchoscope passed through the mouth or nose into the lung, then a given volume of a sterile solution  is introduced to the lung and the fluid is collected for further biochemical examinations [A retrospective analysis of different respiratory specimens  was carried out to determine the reliability of the test at detecting SARS-CoV-2 in patients with COVID-19 infections . Liu et he virus . This ishe virus . Furtherhe virus , biodist® or RTube®) or even using a tube passing water–ice mixture. The mechanism of sample collection by these devices is cooling down the temperature of the collection chamber from 0 to -25°C as has been reviewed in recent works [et al. [Since the virus spreads via respiratory droplets, and the success rate of BLF is better than sputum, nasal and pharyngeal swabs ,11,13, ent works ,20. Ahma [et al.  comparedWe propose that EBC samples should be tested as a noninvasive sampling method in clinics, since it seems a promising specimen for diagnosis of patients with COVID-19 infections. EBC sampling could be performed as many times as needed in follow-up investigations of patients, which is not possible with BLF sampling. Unfortunately, our team does not currently have access to a safety level 3 laboratory in our research center to test the applicability of this hypothesis. There is also a possibility of developing microfluidics or other single-use technologies to collect and analyze the samples to provide faster screening tools in pandemics such as COVID-19.


In recent years, oncolytic virotherapy has emerged as a promising anticancer therapy. Oncolytic viruses destroy cancer cells, without damaging normal tissues, through virus self-replication and antitumor immunity responses, showing great potential for cancer treatment. However, the clinical guidelines for administering oncolytic virotherapy remain unclear. Delivery routes for oncolytic virotherapy to patients vary in existing studies, depending on the tumor sites and the objective of studies. Moreover, the biosafety of oncolytic virotherapy, including mainly uncontrolled adverse events and long-term complications, remains a serious concern that needs to be accurately measured. This review provides a comprehensive and detailed overview of the delivery and biosafety of oncolytic virotherapy. The intimmunity , 15. Theimmunity , 15.Since the antitumor activity of an oncolytic virus is not enough to effectively eliminate tumors, various strategies have been designed to improve their efficacy. The main strategies have been genetic modification, combined treatment and increasing the extent of virus replication and transmission.Genetic manipulation of the viral genome to create non-pathogenic viruses has become the main technique of oncolytic virus development with the goals of weakening virus pathogenicity, enhancing target selectivity, reducing adverse reactions, and/or inserting exogenous therapeutic genes into the virus genome, thereby increasing their expression in tumors and enhancing the treatment effect of the oncolytic virus . DeletioE. coli expressing the vaccinia type 1 IFN antagonist B18R augmented subsequent therapy with oncolytic VSV by overcoming innate immunity against oncolytic viruses in an athymic nude mouse model  lines with PI3K/AKT pathway mutations  was safely applied by direct intratumoral delivery . Dimethyutations . Jung et upon intratumoral injection of a novel recombinant myxoma virus (vPD1), thus enhancing the effect of the oncolytic virotherapy . KicieliAt the clinical trial level, Hirooka et al. conducted a phase I clinical trial by intratumoral injection. It was shown that HF10 injection of oncolytic virus was effective for unresectable locally advanced pancreatic cancer . On thisMany researchers prefer using intravenous injection to intratumoral injection in the clinical trial stage, which may be related to the complexity of the operation as well as the hurdles for distant metastasis of intratumoral delivery. Intravenous delivery of oncolytic virus represents a more simplified administration route for physicians.For central nervous system tumors, Samson et al. demonstrated that oncolytic reovirus (ORV) vaccination by intravenous administration can block subsequent immune checkpoints in patients with brain tumors . The comIn addition to central nervous system tumors, intravenous administration has been applied to tumors in other organs and systems of the body. Saito et al. demonstrated that intravenous delivery of oncolytic adenovirus-carrying tumor vaccine into mouse squamous cell carcinoma models can inhibit the growth of multiple lung tumors . Oncolytin vivo experiments  in clinical trials , 87–89. Few oncolytic virotherapies caused virus infection symptoms in trials. Oncolytic HSV led to herpes in patients, and pustules were observed in trials of pox virus , 102–104The common adverse events of oncolytic virotherapies are summarized in Although current clinical trials of oncolytic virotherapies have led to severe uncontrollable adverse events, further oncolytic virotherapies needs to be promoted with caution. T-VEC, the first oncolytic virus approved by the FDA after a phase III clinical trial, has been used as a novel cancer therapy modality for only 4 years. Moreover, the potential safety issues and long-term adverse events of oncolytic virotherapies remain unclear.Oncolytic virotherapies can cause latent infections and more severe potential safety problems that may manifest as long-term adverse events in the future. T-VEC is an oncolytic viral drug developed from HSV-1 that can be latent in nerves and thus induce latent infection. Corrigan et al. indicated that the DNA of oncolytic HSV may persistently remain in neuron bodies surrounding the injection site and may induce severe neurological HSV infection from a long-term perspective , 97.Shedding and transmission of oncolytic viruses during therapy have also caused potential safety issues. Currently, T-VECs kill tumor cells through intratumoral delivery and are mainly used for melanoma treatment. However, during T-VEC therapy, the virus may transfer to other body parts of patients or to people in close contact with patients , 115. InStudies on the safety of oncolytic virotherapies for specific populations are currently insufficient. The T-VEC guidelines clearly indicate that people with low immunity or pregnancy should avoid using T-VECs. Wild-type HSV-1 that infects pregnant may cross the placental barrier and influence the fetus , 87. PreBR can kill central nervous system (CNS) tumor cells specifically and effectively without causing damage to normal cells and other kinds of tumor cells, which means ZIKVBR have possibility to treat CNS embryonal tumors, and ZIKVBR caused very few infective cases of infants and adults in clinical trials , which can increase the tumor selectivity of parvoviruses , 118. Inl trials .The second approach involves attenuating the pathogenicity of oncolytic viruses to normal cells by genetic modification of the viruses, many of which have been used in studies. To develop oncolytic HSV-1 drugs, such as T-VEC and G207, the ICP-34.5 gene in HSV1716, which is a neurovirulence factor of HSV, was deleted, attenuating the infectivity of HSV in normal neurons , 125. MuThe third approach involves the recombination of different kinds of oncolytic viruses for therapy. The recombination of vesicular stomatitis virus (VSV) and Newcastle disease virus (NDV), named recombinant VSV-NDV (rVSV-NDV), greatly reduced cytotoxicity in healthy hepatocytes and neurons and was not pathogenic to the embryonated eggs. In the rVSV-NDV, the backbone of the VSV is retained. However, its glycoprotein is replaced by hemagglutinin-neuraminidase (HN) and the envelope proteins of the NVD. The adverse events caused by the off-target effects in brain and liver, which were observed in the trials of wild-type VSV, were significantly decreased because of the replacement of the glycoprotein . AdenoviAfter analysis of the clinical trials of different types of oncolytic virotherapies, we concluded that oncolytic virotherapies are generally safe, and have a low incidence of adverse events, and cause only slight damage, which can be controlled or spontaneously regress . ClinicaIn the past decade, oncolytic virotherapy, as a tumor immunotherapy, has emerged as a promising approach because of its selective killing of tumors . However, the best application of oncolytic virotherapy is related to personalized medicine; that is, specific viral delivery to specific tumors forms a one-to-one precision therapeutic mode and may be the direction of oncolytic virotherapy development.With regard to biosafety issues, a great majority of oncolytic virotherapy remains in phase II/III clinical trials. There is still a long road ahead before virotherapy is widely applied in tumor therapy. Although oncolytic virotherapy rarely caused fatal adverse events in recent clinical trials, continued studies should actively seek a balance between enhancing efficacy and reducing adverse events through virus modification or other means, with the goal of minimizing the adverse events as much as possible on the basis of ensuring treatment efficacy, which would also show the absolute advantage of oncolytic virotherapy over traditional tumor therapy such as surgical resection and adjuvant chemoradiation. Future studies should increasingly focus on the specific mechanism of the interaction between oncolytic viruses and the human immune system and the tumor immune microenvironment, thus preventing adverse events from the source of these viruses and latent virus infection and virus shedding and transmission, which would result in overall improved patient safety. In addition, more attention should be paid to the tumor selectivity of specific oncolytic virotherapies. By developing new viral vectors targeting tumor cells, oncolytic viruses can attach to tumor lesions with affinity but not to normal tissues, thereby eliminating adverse events and ensuring safety.The need to choose the delivery mode and ensure the biosafety of the oncolytic virotherapy provides an important impetus to transform existing research results into clinical translations and plays a decisive role in guiding future clinical applications. It is expected that oncolytic virotherapy will become a powerful weapon for the therapy of malignant tumors. In the future, if oncolytic virotherapy can be developed into an oral preparation instead of an injection, delivered through a novel vector, specified by genetic modification or recombination, and effectively reach tumor lesions or reach an effective concentration through intestinal absorption, such that it exerts resistance against cancer cells and does not harm to normal tissues, then oncolytic virotherapy will be a revolutionary development in the new generation of tumor immunotherapy.LL, SL, DH, BT, and JM analyzed the literatures and studies and wrote the manuscript.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.


Aphis citricidus. The 20,300 nucleotide (nt)-long viral genome contains five open-reading frames and encodes six conserved domains . Phylogenetic analysis and amino acid sequence analysis revealed this virus might belong to an unassigned genus in the family Mesoniviridae. The presence of the virus was also confirmed in the field population. Importantly, analysis of the virus-derived small RNAs showed a 22-nt peak, implying that viral infection triggers the small interfering RNA pathway as antiviral immunity in aphids. This is the first report of a mesonivirus in invertebrates other than mosquitoes.We report a new positive-sense single-stranded RNA (ss RNA+) virus from the brown citrus aphid  Aphid lethal paralysis virus  citricidus (Aphis citricidus meson-like virus (AcMSV). On further analyses of bases on virus-derived small RNAs, we found 22-nt peak of AcMSV, implying that the infection of this virus triggers the antiviral immunity of the host aphids that infest on Rutaceae plants and is the vector of Citrus triseza virus  viruses including nine families  . The Intis virus , Brevicoae virus , Rosy apid virus , Aphis g virus 2 , Aphis g virus 1 , and Aphtricidus , were reza virus . Our stuAphid species were collected from citrus trees in the greenhouse of Southwest University, Chongqing, China in 2012 and were raised to date in a chamber of artificial climate at 60%−65% RH (relative humidity), with a 14:10 (light:dark) h photoperiod .Twenty adults and 20 nymphs were selected and their total RNA was isolated using the TRIzol reagent . From total RNA, two libraries were constructed: i) an RNA-seq library to find possible RNA virus sequences. The Ribo-zero Magnetic Kit  was used to remove rRNA from the total RNA. Next, the TruSeq Total RNA sample preparation kit  was used to construct the RNA-seq library and a HiSeq X Ten platform with PE 150 bp was used for sequencing to generate ~8 Gbp of original data. ii) A small RNA library for analyzing small RNAs from potential viruses. The redundant overlapping sequences were removed to obtain a unique sequence.For full genome sequencing, we designed nine pairs of primers to obtain nine fragments  by RT–PCR for sequence confirmation, and each fragment had a 100−300 nt overlap with other fragments .http://linux1.softberry.com/berry.phtml?topic=virus0&group=programs&subgroup=gfindv). The isoelectric point and molecular weight were predicted by ExPASy (https://web.expasy.org/compute_pi/). The presence of conserved protein domains in Aphis citricidus meson-like virus was determined using the SMART tool (http://smart.embl-heidelberg.de/smart/set_mode.cgi?GENOMIC=1) and the Conserved Domain Database (CDD) in NCBI (https://www.ncbi.nlm.nih.gov/Structure/cdd/cdd.shtml). The neighbor-joining (NJ) phylogenetic tree was constructed using MEGA5.1 based on the amino acid alignment of the highly conserved domain RNA-dependent RNA polymerase. Analyses of the deduced aa homologies of the three conserved protein domains and two ORFs of AcMSV and other representative mesoniviruses were carried out using the DNAstar MEGalign tool. The pairwise evolutionary distance (PED) was used to further determine the species boundary criteria for AcMSV in the family Mesoniviridae  and Huaxi District of Guiyang  on 18 October 2019, and 11 December 2019, respectively. From each population, 20 adult brown citrus aphids were selected (5 aphids per citrus tree and 4 replicates), and RNA from a single aphid sample was used to synthesize cDNA. A pair of primers was designed based on the genomic sequence of AcMSV to amplify an 1,101-bp fragment  were analyzed. In total, eight positive samples were detected from laboratory population (n = 20) (n = 20) (n = 20) . The highest viral titer was found in salivary glands in alate morph , while the highest viral titer was observed in the gut  were generated symmetrically from the viral genome and the anti-genome. The size of vsiRNAs differs in different insects . In aphiieaa022_suppl_Supplementary_MaterialClick here for additional data file.