CDC has updated its interim guidance for U.S. health care providers caring for infants with possible congenital Zika virus infection  does not rule out infection. Serologic testing is affected by timing of sample collection: a negative immunoglobulin M (IgM) serologic test result does not rule out infection because the serum specimen might have been collected before the development of IgM antibodies, or after these antibodies have waned. Conversely, IgM antibodies might be detectable for months after the initial infection; for pregnant women, this can make it difficult to determine if infection occurred before or during a current pregnancy. In addition, cross-reactivity of the Zika virus IgM antibody tests with other flaviviruses can result in a false-positive test result, especially in persons previously infected with or vaccinated against a related flavivirus, further complicating interpretation American College of Obstetricians and GynecologistsAssociation of Maternal and Child Health ProgramsAssociation of Public Health LaboratoriesAssociation of State and Territorial Health OfficialsCouncil of State and Territorial EpidemiologistsFamily VoicesMarch of DimesNational Association of County and City Health Officials National Association of Pediatric Nurse PractitionersPublic health organizationsCalifornia Department of Public HealthCounty of San Diego Health and Human Services AgencyDepartment of Health of Puerto RicoFlorida Department of HealthNew York City Department of Health and Mental HygieneTexas Department of State Health ServicesFederal agenciesAdministration for Children and FamiliesCenters for Disease Control and PreventionCenters for Medicare & Medicaid ServicesMaternal and Child Health Bureau, Health Resources and Services AdministrationNational Institute of Child Health and Human Development, National Institutes of HealthOffice of the Assistant Secretary for Preparedness and ResponseThis updated interim guidance is based on current, limited data about Zika virus infection, the interpretation of individual expert opinion collected during the Forum, and knowledge about other congenital infections, and reflects the information available as of September 2017. As more information becomes available, this guidance will be updated.The optimal assays, specimens, and timing of testing for congenital Zika virus infection are unknown. A few reports have described infants with clinical findings consistent with possible congenital Zika syndrome but with negative laboratory results , which measures virus-specific neutralizing antibodies, can be used to help identify false-positive results Developmental monitoring and screening using validated screening tools recommended by the American Academy of Pediatrics (http://pediatrics.aappublications.org/content/137/1/e20153596)Vision screening as recommended by the American Academy of Pediatrics Policy Statement “Visual System Assessment in Infants, Children, and Young Adults by Pediatricians”  and assistance with Zika virus diagnosis, testing, and counselingNeurologist by age 1 month for comprehensive neurologic examination and consideration for other evaluations such as advanced neuroimaging and EEGOphthalmologist for comprehensive eye exam by age 1 monthClinical geneticist for confirmation of the clinical phenotype and evaluation for other causes of microcephaly or congenital anomaliesEarly intervention and developmental specialistsFamily and supportive servicesAdditional possible consultations, based on clinical findings of the infant:Endocrinologist for evaluation of hypothalamic or pituitary dysfunction and consideration for thyroid testingLactation specialist, nutritionist, gastroenterologist, or speech or occupational therapist for evaluation for dysphagia and management of feeding issuesOrthopedist, physiatrist, or physical therapist for the management of hypertonia, clubfoot or arthrogrypotic-like conditionsPulmonologist or otolaryngologist for concerns about aspirationThe initial clinical evaluation, including subspecialty consultations, can be performed before hospital discharge or as an outpatient, taking into account hospital capabilities and needs of the family. Transfer to a facility with access to pediatric subspecialty care typically is not necessary unless there is an urgent clinical need. Health care providers should maintain vigilance for the appearance of other clinical findings associated with congenital Zika syndrome. Diaphragmatic paralysis should be considered in an infant who develops respiratory distress or failure or who fails to wean from a ventilator. Infant feedings should be monitored closely, and if there are signs of swallowing dysfunction, such as difficulty breathing with feeding, coughing or choking during feeding, or extended feeding times, an assessment for dysphagia should be performed , there is no laboratory evidence of congenital Zika virus infection , and the clinical evaluation is normal, then congenital Zika virus infection is unlikely. Infants should continue to receive routine pediatric care, and health care providers should remain alert for any new findings of congenital Zika virus infection.This heterogeneous group includes mothers who were never tested during pregnancy as well as those whose test result could have been negative because of issues related to timing or sensitivity and specificity of the test. Because the latter issues are not easily discerned, all mothers with possible exposure to Zika virus during pregnancy who do not have laboratory evidence of possible Zika virus infection, including those who tested negative with currently available technology, should be considered in this group.Laboratory testing. Laboratory testing for congenital Zika virus infection is not routinely recommended for infants born to mothers in this category based on the unknown risk for infection; the lower likelihood of congenital Zika virus infection as a result of the declining prevalence of Zika virus infection; and limitations of infant laboratory testing. If abnormal findings are identified, these infants should receive further evaluation, including evaluation and testing for congenital Zika virus infection.Clinical evaluation and management. Infants without clinical findings consistent with congenital Zika syndrome born to mothers without laboratory evidence of possible Zika virus infection during pregnancy should have a standard evaluation ; and maternal factors, including the presence and timing of symptoms, and type, location, and length of possible Zika virus exposure. Older infants in whom maternal Zika virus exposure was not assessed at birth and who are evaluated later might also have more clinical data available  to guide the evaluation. If findings consistent with congenital Zika syndrome are identified at any time, referrals to the appropriate specialists should be made, and subsequent evaluation should follow recommendations for infants with clinical findings consistent with congenital Zika syndrome .While much has been learned about congenital Zika syndrome, limitations of laboratory testing exist and the full spectrum of congenital Zika virus infection is not yet known. Similar to other congenital infections, prenatal diagnostic evaluation can inform the clinical evaluation of infants with possible Zika virus exposure. Current CDC guidance regarding prenatal diagnosis is reviewed below (Ultrasound. Routine screening for fetal abnormalities is a component of prenatal care in the United States. Comprehensive ultrasound examination to evaluate fetal anatomy is recommended for all women at 18–22 weeks’ gestation (Questions remain about optimal timing of ultrasound among pregnant women with possible maternal Zika virus exposure. Abnormalities have been detected anywhere from 2 to 29 weeks after symptom onset (Amniocentesis. The role of amniocentesis for the detection of congenital Zika virus infection is unknown. Data regarding the positive and negative predictive values and optimal timing for amniocentesis are not available. Reports of the correlation between positive Zika test results in amniotic fluid and clinical phenotype or confirmatory infant laboratory testing are inconsistent (Summary of prenatal diagnosis of congenital Zika virus infection. Given the limitations in the available screening modalities and the absence of effective interventions to prevent and treat congenital Zika virus infection, a shared decision-making model is essential to ensure that pregnant women and their families understand the risks and benefits of screening in the context of the patient’s preferences and values. For example, serial ultrasound examinations might be inconvenient, unpleasant, and expensive, and might prompt unnecessary interventions; amniocentesis carries additional known risks such as fetal loss. These potential harms of prenatal screening for congenital Zika syndrome might outweigh the clinical benefits for some patients; therefore, these decisions should be individualized (


Dengue is a common arthropod-borne viral infection in Sri Lanka which is spread by the mosquitos of the genus Aedes. The clinical features of dengue include high-grade fever associated with arthralgia and myalgia. However, dengue virus is not considered an arthritogenic virus. We report a case of a previously healthy young female who presented with imaging-confirmed right-sided sacroiliitis 10 days after developing dengue fever. This is the first reported case that shows a possible link between dengue infection and development of arthritis.A 14-year-old Sri Lankan female presented to our medical unit with right buttock and hip pain of 3 weeks’ duration. She had serologically confirmed dengue infection 10 days prior to the onset of buttock pain. A clinical examination revealed features of right sacroiliitis. An X-ray of her sacroiliac joint showed joint space widening and reactive bone changes. Magnetic resonance imaging of her pelvis and sacroiliac joint confirmed the diagnosis of acute sacroiliitis. She had an erythrocyte sedimentation rate of 110 mm first hour with a normal C-reactive protein. Her human leukocyte antigen-B27, rheumatoid factor, antinuclear antibody, chikungunya antibody, hepatitis serology, Brucella serology, and tuberculin skin test were negative. She was treated with nonsteroidal anti-inflammatory drugs and showed gradual improvement.After excluding possible causes for sacroiliitis, we postulated that sacroiliitis in the index case could have been caused or triggered by dengue virus infection. However there is a possibility that the sacroiliitis merely coincided with the dengue virus infection. This case illustrates the possibility that dengue virus could have a link with the development of arthritis in the same manner as other arthritogenic viruses; possible mechanisms for this include direct invasion of the synovium and the joint tissue by the virus, immune complex formation and deposition in the joint tissue, and immune dysregulation. Further studies are needed in this field to gain more knowledge, as dengue infection is highly prevalent in Sri Lanka. Dengue is a common arthropod-borne viral infection in Sri Lanka which is spread by the mosquitos of the genus Aedes: Aedes aegypti and Aedes albopictus. It has a high global prevalence with 128 countries being affected and a 3.9 billion people at risk [The clinical manifestations of dengue infection have a wide spectrum although many who are infected with the virus remain asymptomatic. The clinical syndrome can vary from mild undifferentiated fever to life-threatening dengue hemorrhagic fever and dengue shock syndrome. The virus can affect the heart, liver, and nervous system giving rise to clinical sequelae of myocarditis, hepatitis, dengue encephalopathy, and various other reported neurological complications such as Guillain–Barré syndrome, acute disseminated encephalomyelitis, and brachial neuritis , 5. It cThe fever that occurs in dengue virus infection is associated with severe arthralgia and myalgia. However, dengue virus is not considered an arthritogenic virus. Arthritogenic viruses include rubella virus, hepatitis B and C, parvovirus, and alphaviruses such as chikungunya virus . Dengue We report a case of a previously healthy young girl who presented with imaging-confirmed right-sided sacroiliitis 10 days after developing dengue fever. To the best of our knowledge this is the first reported case that shows a possible link between dengue infection and development of arthritis.A 14-year-old Sri Lankan girl presented to our medical unit with right-sided buttock pain and hip pain of 3 weeks’ duration. She had been in good health before she developed fever, arthralgia, myalgia, and headache approximately 5 weeks earlier. A nonstructural protein 1 (NS1) antigen test for dengue fever had been positive and hematological and biochemical investigations were compatible with dengue fever. She was treated at a local hospital where she had an uneventful recovery and was discharged after 6 days. Ten days after the onset of fever (4 days after the discharge) she developed right-sided buttock and hip pain with difficulty in walking. She was readmitted to the local hospital and was managed as post-viral arthritis. She was treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids. Her symptoms improved and she was discharged home. However, her symptoms recurred after a few days and had persisted with worsening pain.She did not have other small or large joint pain or swelling and there was no history suggestive of inflammation of enthesitis. She did not have fever during this episode. She did not have red eyes, dysuria, or skin eruptions. There was no preceding history of a diarrheal illness, sore throat, or any illness other than dengue fever. There was no past history of joint pains, recurrent oral ulceration, or photosensitive rashes. There was no history of altered bowel habits or bloody diarrhea suggestive of inflammatory bowel disease. There was no family history of arthritis or autoimmune diseases. There was no past history or contact history of tuberculosis.On examination she was mildly pale. There was no uveitis, oral ulceration, or skin lesions. Her cardiovascular system, respiratory system, and abdominal examination were normal. There was tenderness over her sacroiliac joint and sacroiliac stretch maneuvers were positive suggestive of right-sided sacroiliitis. Her left-side sacroiliac examination was normal. There was no tenderness over her spine and the straight leg raising sign was negative. A neurological examination of her lower limbs was normal. The rest of the joint examination was normal as well.An X-ray of her sacroiliac joint revealed features of right-sided sacroiliitis with joint space widening and reactive bony changes surrounding the joint Fig. . MagnetiHer complete blood count showed neutrophil leukocytosis and a microcytic hypochromic anemia Table . Blood pALT alanine aminotransferase, AST aspartate aminotransferase, T4 thyroxin, TIBC total iron-binding capacity, TSH thyroid-stimulating hormone, WBC white blood cell.Iron studies revealed iron deficiency status Table  and she Dengue fever usually manifests with significant musculoskeletal symptoms including arthralgia and myalgia. However, dengue virus as a cause of arthritis is not reported so far. Our patient was a previously healthy girl who developed serologically proven uncomplicated dengue fever and later on developed imaging-proven right sacroiliitis 10 days after the onset of dengue. Whether the dengue was the cause or the triggering factor for the sacroiliitis or whether it was an entirely different pathology that merely coincided with the dengue is a dilemma. However, the fact that there was no preceding history of spondyloarthropathy and most of the known causes of sacroiliitis were excluded raises the possibility that sacroiliitis may be linked with dengue.Sacroiliitis can occur in isolation due to infectious causes or as part of an inflammatory arthropathy, mainly seronegative spondyloarthropathy. The most common bacterial infections that have a predilection for sacroiliac joints are brucellosis and tuberculosis, which usually cause unilateral disease , 9. Non-Several viruses are also implied as the causes of arthritides. Viruses can cause infection or act as cofactors in the development of rheumatic diseases. The viruses that usually cause arthritis include rubella, mumps, parvovirus B19, hepatitis B and C, EBV, CMV, and the group of arthritogenic alphaviruses such as chikungunya, Ross River virus (RRV), Barmah Forest virus, Sindbis virus, o'nyong-nyong virus, and Mayaro virus , 13. HowDirect invasion of the synovium and the joint tissue due to tropism of these viruses for the synovial tissue, for example rubella virus and vaccine, parvovirus.By means of immune complex formation and deposition in the joint tissue as the viral particles act as antigenic components, for example alphaviruses, hepatitis B and C, and parvovirus.Latent viruses, immune dysregulation, and virus-induced autoimmunity: where the viruses remain in the host cells expressing viral antigens on the cellular surface inducing a chronic inflammatory status or viruses directly invade the components of the immune system and cause immune dysregulation resulting in autoimmune diseases  –17. MoleChen and colleagues showed that primary human osteoblasts (HObs) could be productively infected by RRV and the RRV-infected HObs produce high levels of inflammatory cytokine including interleukin-6 (IL-6) resulting in increased receptor activator of nuclear factor kappa-B ligand (RANKL) but decreased osteoprotegerin (OPG) . This elThere are several hypothesized mechanisms of the pathogenesis of arthritis following viral infection. These postulated mechanisms are:Therefore, there is a possibility that the dengue virus too can affect the joint tissues by the means of the above mechanisms, particularly the first two, and it is an area that needs to be explored. These viral arthritides are usually mild and self-limiting, lasting no longer than a few weeks. There is no specific treatment and simple symptomatic measures with analgesics are sufficient .Even though dengue infection causes significant musculoskeletal symptoms it was not reported to cause arthritis. Here we presented a case of a previously healthy young girl who presented with unilateral sacroiliitis following dengue virus infection. After excluding other possible causes for sacroiliitis, we postulated that sacroiliitis could have been caused or triggered by dengue fever in this patient but there is a possibility that the sacroiliitis merely coincided with the dengue fever. This case illustrates the possibility that dengue virus could have a link with development of arthritis in the same manner as other arthritogenic viruses; possible mechanisms for this include direct invasion of the synovium and the joint tissue by the virus, immune complex formation and deposition in the joint tissue, and immune dysregulation. Further studies are needed in this field to gain more knowledge, as dengue infection is highly prevalent in Sri Lanka.


Studies assessing the costs of alcoholic liver disease are lacking. We aimed to calculate the costs of hospitalisations before and after diagnosis compared to population controls matched by age, sex and socio-economic deprivation. We aimed to use population level data to identify a cohort of individuals hospitalised for the first time with alcoholic liver disease in Scotland between 1991 and 2011.Incident cases were classified by disease severity, sex, age group, socio-economic deprivation and year of index admission. 5 matched controls for every incident case were identified from the Scottish population level primary care database. Hospital costs were calculated for both cases and controls using length of stay from morbidity records and hospital-specific daily rates by specialty. Remaining lifetime costs were estimated using parametric survival models and predicted annual costs. 35,208 incident alcoholic liver disease hospitalisations were identified. Mean annual hospital costs for cases were 2.3 times that of controls pre diagnosis (£804 higher) and 10.2 times  post diagnosis. Mean incident admission cost was £6,663. Remaining lifetime cost for a male, 50–59 years old, living in the most deprived area diagnosed with acoholic liver disease was estimated to be £65,999 higher than the matched controls . In Scotland, alcoholic liver disease diagnosis is associated with significant increases in admissions to hospital both before and after diagnosis. Our results provide robust population level estimates of costs of alcoholic liver disease for the purposes of health-care delivery, planning and future cost-effectiveness analyses. Alcoholic Liver Disease (ALD) accounts for significant morbidity, mortality and economic burden worldwide. The UK In this study, costs and survival data were modelled to allow annual costs per incident case and remaining lifetime costs to be estimated. In addition we estimated costs of incident admission according to disease severity. Use of population level data and the comparison with matched controls enabled us to produce a robust estimate of the additional hospital costs of an incident ALD case in Scotland. High quality cost of illness studies are not only valuable for health-care policy makers and planners, but also provide valuable information for future cost-effectiveness studies of interventions that aim to prevent incident cases or improve individual prognosis.This SCottish Alcoholic Liver disease Evaluation (SCALE) study aimed to identify hospital admissions and associated costs before and after diagnosis and outcomes for all individuals hospitalised for the first time with ALD in Scotland between 1991–2011 compared to population controls matched by age, sex and socio-economic deprivation.Admissions data were drawn from the Scottish Morbidity Records (SMR01 and SMR04), which are national data schemes that record comprehensive information relating to all inpatient and day cases admitted to acute and psychiatric National Health Service (NHS) hospitals in Scotland . SeveralWe obtained anonymised individual level data on all hospital admissions for patients who were admitted with ALD in a principal or secondary diagnostic position on at least one occasion between 1981 and 2011, including sex, age group and Scottish Index of Multiple Deprivation (SIMD) quintiles from Information Services Division (ISD), NHS National Services Scotland (NSS). SIMD measures deprivation using a combination of income, employment, health, education, skills and training, housing, geographic access and crime indicators. ALD admissions were classified using the International Classification of Diseases (ICD9/ICD-10) codes set used by ISD who are responsible for publishing national statistics on alcohol-related hospital admissions in Scotland see . DefinitTable 2An incident ALD hospitalisation was defined as ALD in any diagnostic position and no ALD diagnosis was found in hospitalisations for that patient in the preceding 10 years. This length of ‘look back’ period kept the double-counting of cases low (0.7%) while still retaining over 20 years of study period (1991–2011).The control group was identified from the Community Health Index  ,13 and cDate of death, if applicable, was obtained for all cases and controls who died during the period under review from NRS.Dates of admission and discharge from the Scottish Morbidity Records were used to calculate length of stay. This was multiplied by a daily (per diem) cost based on specialty and hospital codes taken from the Scottish Costs Book 2013 . These cIncident ALD hospitalisations were classified into 3 severity groups as set out in We categorised incident admissions by sex, age group, socio-economic deprivation category and co-morbidities for each severity grouping. For analysis of hospital admissions the incident admission date for a case was used to attach a pseudo-date of first ALD event for each of the 5 matched controls. In each 180 day interval for a maximum of 14 years before and after the incident date the percentage of cases and controls hospitalised at least once in that period and the mean cost per person hospitalised were calculated.Incident hospitalisation rates for 1991–2011 by sex, age group, year of admission and socio-economic deprivation were modelled using negative binomial regression. Mortality during the incident ALD hospitalisation  was modelled using logistic regression to determine adjusted effects on mortality of the same covariates as used for incident rates as well as the patient’s co-morbidities. For patients discharged alive, time to all-cause death after incident hospitalisation was modelled using Cox regression again with the same set of covariates including co-morbidities and with year of discharge replacing year of admission. The number of readmissions per year was calculated, accounting for different exposure lengths caused by death and the end of follow-up period, and these rates were modelled using negative binomial regression with the same set of covariates as for modelling in-hospital mortality. Costs were analysed using generalised linear models (GLMs) with gamma distribution and a log link with the covariates time period, sex, age group, socio-economic deprivation category and year of admission. Despite matching on sex, age group and socio-economic deprivation category we adjusted for these variables in our analysis as ignoring them may have introduced bias .We estimated remaining lifetime by extrapolating beyond the observed follow-up period using parametric survival models. We explored different distributions  and assessed goodness of fit by comparing observed cumulative incidence curves/survival probabilities to different model predictions. Although extrapolation is the subject of continuing debate our period of extrapolation was relatively short and the methodology is now well established .We identified 35,208 incident ALD admissions in the period between 1991 and 2011. Overall incident ALD hospitalisation rates are shown in Overall, 6,137 patients died during their incident ALD hospitalisation , comprising 4,113 men  and 2,024 women  patients were discharged alive from their incident ALD hospitalisation. The results of modelling all-cause mortality after discharge are shown in The following figures are not adjusted as in the statistical analysis. They are for illustration only.The results of modelling daily pre-incident and post-incident hospital costs per person are shown in Appendices 6 and 7 (SM1). These costs are calculated by adding the costs of all the admissions in the observation period (excluding incident costs) and dividing by the number of days of observation. In the pre-incident period the mean daily cost for cases was 2.4 times that for controls  and 10.2 times in the post-incident period . There was a strong socio-economic gradient in both periods—costs for patients from the most deprived areas were 51% higher in the pre-incident period  than those from the least deprived areas and 57% in the post-incident period . Costs showed a strong age gradient and daily costs for the 70+ age category were 2.8 times those of the under 40s in the pre-incident period  and 8.7 times in the post-incident period .The results of modelling overall incident admission costs (ie cost of the CIS when ALD was first diagnosed) are shown in There is strong evidence that both overall incident admission and daily post admission costs have reduced over the study period. Incident costs show a 43% reduction  and post incident costs a 28% reduction  between 1991 and 2011. Descriptive analysis suggests that these reductions have mainly been driven by a reduction in length of stay which has reduced from a median of 10 to 5 days for incident admissions. The mean length of stay for all admissions has reduced from 9.4 days to 4.6 days for cases and from 6.2 days to 3.8 days for controls .This study aimed to identify hospital admissions and associated costs before and after diagnosis and outcomes for all individuals hospitalised for the first time with ALD in Scotland between 1991–2011 compared to population controls matched by age, sex and socio-economic deprivation.Our results were broadly consistent with previously published statistics and studies of ALD. Incidence rates identified in the study matched previously published data for Scotland , 20. TheThis study found substantial additional costs associated with every incident ALD admission compared to matched controls. In addition to a mean cost of incident admission of £6,663, cases were 2.1 times more likely to have been in hospital in the pre-incident period costing an average of £804 per annum more than matched controls over the 14 years preceding the incident admission. In the period following the incident admission annual costs associated with cases were over 10 times those of their matched controls. Even with shorter life expectancies remaining lifetime costs were substantially higher for cases than controls with strong age and socio-economic gradients. The study found strong evidence that the cost of both incident and individual post-discharge admissions has reduced over the study period. This reduction seems to have been driven mainly by reduced length of stay with median incident length of stay reducing from 10 to 5 days over the study period and substantial reductions in all lengths of stay for cases and controls.This was a population-wide study using data at an individual level which permitted analysis taking age, sex and socio-economic factors into account. We had the benefit of a large sample size and detailed follow-up over a long period was possible through data linkage of high quality records. As Scotland benefits from a universal healthcare system free at the point of delivery, selection bias was minimised. The matched cohort design of the study together with the inclusion of the matched variables in the statistical analyses  provided assurance that unmeasured confounding was minimised. The categorisation of admissions undertaken in this study allowed analysis of outcomes and costs by disease severity.A limitation to our study is that incident cases were identified from hospital records only and that cases of diagnosed ALD which did not lead to hospitalisation were not included in our analysis. We obtained data on ALD deaths without a hospital admission. There were 5,320 over the full study period . However, these were not included in our analysis as they did not incur hospital costs. Our analysis did not include emergency hospital attendances where those did not lead to a hospital admission as these are excluded from the data sources used (SMR01 and SMR04). A further limitation of the study is that only hospital costs were included and not costs incurred in primary or social care. The majority of care for ALD occurs in hospital  and the A limitation of our study design is that controls were only matched on sex, age and socio-economic status. We did not match on comorbidity and we did not adjust for it in the cost analyses as we wished to capture the full difference in costs between cases and controls although we hypothesised that much of the additional co-morbidity would have resulted from excess alcohol consumption and therefore should not have been adjusted for. We were unable to adjust for tobacco consumption despite the likelihood that smoking was more prevalent among cases. We are therefore unable to attribute the full additional cost of ALD cases to the ALD diagnosis.Our method for calculating lifetime costs is based on a modelled daily cost which is then multiplied by an estimated remaining lifetime. It is possible that high costs for severe cases who died quickly may have resulted in higher average costs particularly when extrapolated over a long period (as for the younger age categories). However this possible overestimation might be partially offset by expected increasing inpatient care as people age and are nearing the end of life. Future research should examine in more detail the treatment pathways for ALD post diagnosis in order to better understand the main drivers of costs.Our findings on incident rates were generally consistent with and have been superceded by the most recent national data released for Scotland ,20. The The high rate of in-hospital mortality for incident ALD hospitalisations reflects a number of current issues reported in the literature. Difficulties in the early detection of ALD mean that many patients present late to hospital and their disease is already at an advanced stage . A revieOur 5/10 year post-discharge survival rates for patients with ALD decompensation at index admission (40%/25%) were broadly comparable with mortality rates reported in recent studies –32. In cThis study found substantially higher costs associated with incident ALD cases compared to matched controls, driven mainly by the number of days in hospital rather than differences in daily rates. We are not aware of any other studies that look at costs per incident case of ALD. Two US studies estimated costs per hospital admission for alcoholic hepatitis ,10 reporCosts for both cases and controls reduced over the study period driven primarily by reductions in lengths of stay, reflecting national policy in this area , S9 Appe. The numIncident ALD hospitalisation rates are high by international standards and although they had reduced at the end of our study period they are now increasing again. Policy makers need to ensure that efforts to reduce population level harms related to alcohol are maintained. ALD disproportionately affects those who live in more deprived areas so effective policies have the potential to reduce health inequalities.ALD is associated with high in-hospital mortality although this has reduced over time. Further research would be useful to determine why in-hospital mortality is so high, what factors have led to improvements in mortality and the impact of the reducing length of incident stay. Our study used a novel definition of severity in ALD, which has informed our results. These groupings may prove useful in future studies.Post-discharge survival is poor and has not improved over time. The National Confidential Enquiry into Patient Outcome and Death  found a This study established that patients diagnosed with ALD have had an increased number of hospital admissions for a long period of time before their diagnosis and many of those admissions were for alcohol-related conditions. This would suggest that there is opportunity for early assessment of risk of developing ALD and early clinical intervention which should be investigated further. The high cost of hospital care for each incident case of ALD suggests that effective preventive measures or early treatment options are highly likely to be cost-effective. Alternative treatment pathways post index admission such as assertive outreach or improved palliative care  should aThe new information on costs provided in this paper can be used in future cost-effectiveness analyses. However, a more detailed exercise examining treatment pathways for ALD post diagnosis and associated costs would be beneficial.S1 Appendix(XLSX)Click here for additional data file.S2 Appendix(XLSX)Click here for additional data file.S3 Appendix(XLSX)Click here for additional data file.S4 Appendix(XLSX)Click here for additional data file.S5 Appendix(XLSX)Click here for additional data file.S6 Appendix(XLSX)Click here for additional data file.S7 Appendix(XLSX)Click here for additional data file.S8 Appendix(XLSX)Click here for additional data file.S9 Appendix(XLSX)Click here for additional data file.


Previous research on the costs of treatment for ASBO is outdated and often based on reimbursements, rather than true healthcare provider costs of the admission and related interventions. An accurate estimate of the true costs of treatment is necessary to understand the healthcare burden and to model cost-efficacy of adhesion strategies. The aim of this study was to provide an accurate cost estimate of the in-hospital costs for treatment of adhesive small bowel obstruction (ASBO) using micro-costing methods.Consecutive patients admitted for ASBO to the Radboud University Medical Center from November 2013 to November 2015 were included. An episode of ASBO was defined as an admission for SBO with operative confirmation of adhesions or after radiological exclusion of other causes for SBO. For the purpose of generalization we used the costs of medication and interventions as provided by the Dutch Healthcare Authority and only if these were not available local hospital costs. We evaluated costs separately for operative and non-operative treatment for ASBO.P = 0.003). A total of 12 patients developed complications, 2 in the non-operative group (10 %) and 10 in the operative group . Overall costs for an admission for ASBO with operative treatment were €16 305 (SD €2 513), and for non-operative treatment € 2 277 (SD € 265) (p = <0.001). The highest expenditure with operative treatment for ASBO was made for ward stay , OR time , ICU stay  and  feeding costs . A table with correction coefficient to correct for differences in price levels for goods and services between different countries has been added.During the study period 39 admissions for ASBO were eligible for analysis. An operative treatment was required in 19 patients (48.7 %). Mean hospital stay for ASBO with operative treatment was 16.0 ± 11 days versus 4.0 ± 2.0 days for non-operative treatment (The in-hospital costs of an admission for ASBO are higher than previously thought. These costs can be used to guide hospital reimbursement policy and for the development of a cost-effective model for the use of adhesion barriers. Adhesive small bowel obstruction (ASBO) is the most common pathology of the small bowel, and frequently results in surgical emergencies . In a naPost-operative adhesions are the cause of small bowel obstruction in 60 % of cases . In a meRemarkably, there is little data on the financial implications of adhesion-related complication such as ASBO that can guide policymakers in developing guidance for reimbursement, management, and prevention of this condition. The studies that modelled cost-effectiveness of adhesion barriers have used incomplete estimates or the negotiated reimbursement prices for treatment of ASBO, rather than true healthcare provider costs , 8, 10. In a recent study, the hospital costs of patients undergoing an emergency laparotomy in general were estimated at €15 500 per patient, which is on average €7 000 more than its reimbursement . The estIn the present study we modelled the costs of an admission for ASBO based on accurate data that in addition to the operating room times, ICU and ward stay comprised full detailed information on all relevant interventions made during the admission, including medication, parenteral feeding, imaging studies, and laboratory studies.All consecutive patients admitted with ASBO to the Radboudumc between November 2013 and November 2015 were eligible for inclusion. A waiver for ethical approval was obtained by local institutional review board after review of the protocol. To identify cases, the hospitals’ discharge registry was searched for patients with a reimbursement code for small bowel obstruction. The Radboudumc is a university teaching hospital in Nijmegen, the Netherlands, with complete electronic patient files. Electronic patient files of the identified records were reviewed for an admission for ASBO during the study period. ASBO was defined as an episode with operative confirmation of adhesions, or in the non-operative group as an episode of postoperative SBO in which other potential causes of bowel obstruction were excluded by appropriate means. Patients who were treated non-operatively received tube decompression and no oral feeding. Operative treatment of ASBO consisted of an explorative laparotomy with cleaving of adhesions and if necessary partial resection of small bowel. None of the patients had laparoscopic cleaving of adhesions. Complications were defined according to the criteria of the International Classification of Diseases, Tenth Revision, the National Nosocomial Infections Surveillance System, the Center for Disease Control and Prevention, or according to the decision of the senior medical staff of the department. Complications were categorized according to the Clavien-Dindo classification . All comThe total costs of the admission were divided in nine categories: operation , medication, radiology, laboratory, microbiology, ward stay, ICU days, feeding, and blood products administered during admission. All data needed for an accurate estimate of admission costs were derived from the electronic patients file. A standardized price list from the Dutch Healthcare Authority was used for the calculation of costs for occupancy of operating room, medication, radiology, laboratory, microbiology, ward stay, ICU stay, feeding and blood products . No stanThe price for occupancy of the operating room was based on the total anaesthesia time, and a standardized price of €16,70 per minute. Medication costs comprised the costs of all medications prescribed during the admission. The costs of medication were updated per April 2016 . Costs fThe average costs of operation materials were €155 if no bowel resection was performed and €436 if bowel resection was performed. The difference in price of materials was mainly attributable to the use of stapling devices.A table of correction coefficients was added to allow for quick comparison of costs between different countries . These ct-test or Mann-Whitney U test where appropriate. Continuous variables are presented as means with standard deviation, or medians with interquartile range (25–75) if non-normal distribution. Dichotomous or categorical variables are presented as absolute numbers and percentages. P < 0.05 was considered significant. All analyses were performed using SPSS version 23°0 .Baseline data consisted of patients age, sex, Charlson comorbidty index, ASA classification and the number of previous abdominal operations. Comparison was made between patients undergoing operative treatment and non- operative treatment using a Chi-square, Fisher’s exact test, independent From the hospital registry we identified 185 cases with a code of SBO. We excluded 49 patients because they were not admitted but only seen on the outpatient clinic. A total of 97 admitted patients were excluded, 29 patients were diagnosed with Hirschprung’s disease, 16 patients had a tumor, 23 had other specified cause for bowel obstruction, and in 21 patients an adhesive aetiology was unsure. Thirty-nine patients had a total of 46 admissions for ASBO during the study period. We excluded 7 admissions because patients were transferred to other hospitals for further treatment of ABSO. A total of 39 admissions of ASBO during the study period were included in the analysis . A total of 12 patients developed complications, two in the non- operative group (10.0 %) and 10 in the operatively treated group . Complications in the non- operative group were pneumonia (n = 1), and de novo atrial fibrillation (n = 1). One patient in the operative group developed a staphylococcal sepsis, for which prolonged ICU admission was indicated. Other complications in the operative group comprised pneumonia (n = 2), wound infection (n = 2), intra-abdominal abscess formation (n = 1), de novo atrial fibrillation (n = 1), urinary tract infection (n = 1), bacteremia (n = 1), and delirium (n = 1). Two operative patients had a second-look laparotomy. In the first patient almost the entire small bowel was entrapped in the adhesions and appeared ischemic at the initial explorative laparotomy. Because there was doubt about the reversibility of this bowel ischemia a second look laparotomy was performed the next day, at which the bowel had normal appearance and peristalsis. The second patient underwent a second look laparotomy to inspect the anastomosis made following bowel resection at initial laparotomy. The indication for this second look was made after the patients became septic on the ICU and an anastomotic leakage was expected based on clinical evaluation. At second look on day 3 a sufficient anastomosis without signs of leakage was found. Origin of sepsis remained unsure, but a pulmonary origin was suspected after negative second look. The patient fully recovered with intravenous antibiotic treatment.Operative treatment of ASBO led to a mean hospital stay of 16.0 days (SD 11.0 days) while non- operative treatment of ASBO led to a mean hospital stay of 4.0 days (SD 2.0 days P = 0.003), resulting in a mean overall costs of €16 305 (SD €2 513) and 2 277 (SD €265) respectively. Mean costs were significantly different between both groups (P < 0.005). Costs of the different components are shown in Table Mean hospital stay for ASBO with operative treatment was 16.0 ± 11 days versus 4.0 ± 2.0 days for non-operative treatment (An overview of correction coefficients is presented in Table Adhesive small bowel is associated with high morbidity and costs. The average costs for a non- operative episode were over €2 000 and for a surgical episode over €16 000. The majority of costs were related to ward and ICU stay.The costs for operative treatment of ASBO determined in this study were comparable to the €15 500 Shapter et al. reported in their estimation of the costs for an unspecified emergency laparotomy . In theiCorrection coefficients can be used to calculate a quick estimate of the costs in a different country. However, a more precise estimate would require to recalculate the prices from the different components as listed in Table The cost estimates in our study are useful to guide reimbursement policies and model cost-effectiveness of adhesion barriers, Because the study had high adherence to the international guidelines and the morbidity found was comparable to that reported in literature , 19, 11.The relative small sample size is explained by the methodology used in this study. We included only recently admitted patients from our own institution with high ascertainment of adhesive etiology to enable the micro-costing method. Micro-costing is the gold standard for accurately defining healthcare provider costs, but seldom applied because of the large quantity of data that needs to be collected from each patient . In our We also excluded a larger number of paediatric patients with Hirschsprung’s disease. Our Institution is also a referall central for paediatric surgery. Because Hirschsprung’s disease has no separate reimbursement code in the Dutch reimbursement system, it often received the same code as used for bowel obstruction .Our results show that the largest part of the expenditures in treatment of ASBO are related to the duration of hospital stay. Several studies have reported a reduced length of stay and lower incidence of postoperative ileus when adhesiolysis is performed through laparoscopy instead of laparotomy –25. HoweThe results of our study have important implications for policies regarding reimbursements. Reimbursement for operative cases of ASBO is generally too low . The cosThe costs of an admission for ASBO are higher than what is reported in the previous literature. Our results can be used to guide reimbursement policy and the development of a cost-effectiveness model for the use of adhesion barriers.


Medical care of cancer patients at the end-of-life is costly. This study aims to describe the monthly trends of EOL medical care, drug therapy, and chemotherapy costs per patient with cancer in the last year of life in the inpatients vs. outpatient setting for the 13 most prevalent cancers in Korea.Using the Health Insurance Review and Assessment Service (HIRA) database, we identified the patients who had been treated for the primary diagnoses of one of the 13 most prevalent cancers in Korea and died between January 1, 2013 and December 31, 2015. We calculated the mean monthly costs of medical care, drug therapy, and chemotherapy per patient in the last year of life by cancer site and patient setting (inpatient vs. outpatient).For most cancers, the monthly inpatient costs per patient remain stable or increased gradually from 12 months to 3 months prior to death and then increased steeply from 2 months prior to death. The mean monthly inpatient costs per patient were highest for acute myeloid leukemia (AML) throughout the last year of life; all solid tumors had similar trends of monthly inpatient costs. The mean monthly inpatient costs for AML increased from $5,465  in 12 months prior to death to $15,033  in the last month. The monthly outpatient costs per patient showed similar, gradually decreasing trends for most cancers. The mean outpatient costs were highest for kidney cancer; the costs sharply decreased from $954  in 12 months prior to death to $424  in the last month. The proportion of inpatients receiving chemotherapy in the last month of life was highest for AML (77%), followed by liver cancer (67%) and breast cancer (56%).The monthly inpatient medical care costs per patient with cancer increased as the patient approached death, while the monthly outpatient costs decreased. A considerable proportion of inpatient received chemotherapy in the last month of life. Efforts are needed to optimize EOL care for cancer patients. Cancer is a leading cause of death in Korea; in 2016, 27.8% of all deaths in Korea were from cancer . ConsequStudies in other countries show that the amount of health care resources used increases as the patient approaches death ,10. For Examining the trends of monthly EOL care costs among cancer decedents can illuminate the increasingly high economic burden of cancer even within the last year of life. A study in Korea estimated that the costs of cancer care steadily increased until 2 months prior to death and that 69.5% of total medical care costs for cancer in the last year of life were spent in the last six months . AnotherTerminal cancer patients were treated with multiple drugs for the management of the symptoms of cancer and comorbid conditions; some even received chemotherapy near the end of life ,17. A U.th revision (ICD-10). The 13 cancers were stomach cancer , liver cancer (C22), lung cancer (C34), breast cancer (C50), colorectal cancer , kidney cancer , prostate cancer (C61), acute myeloid leukemia , non-Hodgkin’s lymphoma (C85), cervical cancer (C53), ovarian cancer (C56), pancreatic cancer (C25), and thyroid cancer (C73).We used the Health Insurance Review and Assessment Service (HIRA) database, which contains national health insurance claims data in Korea. The HIRA database includes cost information on all medical services and prescription drugs that are reimbursed by the health insurance authority. We identified the patients who had been treated for the primary diagnoses of one of the 13 most prevalent cancers in Korea and died between January 1, 2013 and December 31, 2015 by linking HIRA claims data with the mortality dates derived from the Statistic Korea. Personal identification numbers in the HIRA database were anonymized before providing to researchers. Diagnoses were coded according to the International Classification of Disease-10We extracted claims data for the identified decedents for 360 days before death. We calculated the mean number of inpatient and outpatient days as well as the monthly medical care costs per patient by cancer site and patient setting (inpatient vs. outpatient). Monthly costs were calculated on the basis of 30 days per month by equally dividing 360 days into 12 months. Outpatient costs were determined by summing claimed amounts on all services provided for the decedents in the outpatient setting each month. Inpatient costs were assumed to be equally spread over the duration of hospitalization. In other words, total costs incurred during a period of hospitalization that lasted more than a day were divided by the number of inpatient days based on the assumption that costs per inpatient day were the same throughout the period. The resulting inpatient costs per day were multiplied by the number of inpatient days in a given month to produce the monthly inpatient costs. For example, if a patient was hospitalized on day 28 of month 11 and then discharged on day 2 of month 12, we counted 2 days in month 11 and 2 days in month 12. Costs in Korean won were converted to US$ using the conversion rate of 1,100 won/US$.We calculated drug therapy costs as a proportion of total medical care costs, the proportion of patients receiving chemotherapy, and the ratio of mean drug therapy costs to mean chemotherapy costs in the last month of life by cancer site and patient setting. We also calculated the monthly costs of drug therapy and chemotherapy per patient in the last year of life. The mean drug therapy costs were defined as the mean of drug therapy costs per patient in all patients who were treated with prescription drugs each month. Only a portion of all cancer patients who were on drug therapy received chemotherapy. The mean chemotherapy costs were defined as the mean of chemotherapy costs per patient in all patients who were treated with chemotherapy each month. As a result, the mean chemotherapy costs per patient may be greater than the mean drug therapy costs per patient.The mean and standard deviation (SD) were calculated for all continuous variables. All analyses were performed by using SAS-EG version 4.3 . The approval of the Institutional Review Board for this study with the general population was waived under Article 16 of the Rule of the Bioethics and Safety Act in Korea .We included a total of 134,633 males and 75,039 females in the analysis . The mosFor most cancers, the monthly inpatient costs per patient remain stable or increased gradually from 12 months to 3 months prior to death and then increased steeply from 2 months prior to death . The meaAmong the patients who incurred inpatient costs in the last month of life, approximately 20% of the inpatient medical costs were spent on drug therapy for most cancers; however, the proportion was 30% for AML . The proFor inpatients, the mean drug therapy costs increased but the mean chemotherapy costs decreased as the patient approached death . For exaThis population-based study examined the monthly costs of EOL care per patient including drug therapy and chemotherapy for inpatient vs. outpatient care in the last year of life among decedents from one of the 13 most prevalent cancers in Korea based on national health insurance claims data. We showed that the monthly inpatient costs per patient increased as the patient approached death for all cancers while the monthly outpatient costs per patient decreased during the same period. Similarly, in the United States, inpatient costs per cancer decedent increased from $1,785 in 6 months before death to $20,559 in the last month, while outpatient costs decreased from $6,021 to $2,238, respectively [Our data showed that the mean inpatient costs per patient increased steeply in the last few months of life for most cancers while the number of inpatients simultaneously increased. In addition, a substantial proportion of patients received chemotherapy in the inpatient setting in the last month of life, suggesting that a high proportion of EOL care costs incurred for inpatient care. This is consistent with the finding of another study in Korea; approximately 80% of spending per cancer decedent in Korea were associated with inpatient care . These fWhile the proportion of outpatients receiving chemotherapy in the last month of life tended to be low, the ratio of the mean chemotherapy costs to the mean drug therapy costs was considerably high in these patients. This is probably because chemotherapy costs comprise most of drug therapy costs and not many other costs are incurred in the outpatient setting. On the contrary, the proportion of inpatients receiving chemotherapy tended to be high, but the ratio of the mean chemotherapy costs to the mean drug therapy costs was low among these patients. This is probably due to higher costs of non-pharmacological treatments used in the inpatient setting. These findings suggest the aggressiveness of cancer treatments even in the last months of life. Another study in Korea also documented a substantial proportion of cancer decedents receiving aggressive medical care near the end of life; 50.3% and 5.7% received chemotherapy in the last 2 months and 2 weeks of life, respectively . SimilarWe showed that the mean inpatient medical care costs of cancer per patient in the last year of life in Korea varied by cancer site with AML incurring the highest costs, which is consistent with the findings of a 2005 study . We furtWe showed that the mean outpatient chemotherapy costs for kidney cancer were very high initially and then gradually declined until the rate of decrease becomes steeper in the 3 months before death. It is plausible that recently introduced, orally administered, pricy targeted drugs might have been used for patients with kidney cancer in the last year of life until these therapies were discontinued when the patients approach the end of life ,24. AlthThe ratio of the mean chemotherapy costs to the mean drug therapy costs in the last month was highest for outpatients with thyroid cancer (1.98). This is probably because no other drugs than pricy chemotherapy were used to treat these patients . Our finUsing national health insurance data, this study provides recent evidence on extraordinarily high costs of EOL cancer care in the inpatient setting that continue to increase until the last month of life. This analysis of population-based data presents system-wide costs of cancer care without a bias that can occur in an analysis of data from a limited number of patients or medical care institutions. Moreover, this is the first study to examine monthly cost trajectories for drug therapy and chemotherapy by cancer site and patient setting among end-stage cancer patients in Korea. We showed that the mean monthly inpatient care costs per cancer patient increased steeply very close to death for most cancers and that chemotherapy was used for a substantial proportion of patients even in the last month of life. These findings suggest the likelihood of unnecessary medical spending for terminal cancer care and highlight the importance of optimizing EOL care for cancer patients. Furthermore, our findings present policy implications for cancer care in Korea where hospice and home care services are not commonly used to care for terminal cancer patients . While hAlthough this analysis of real world data provides a basis for developing evidence-based policy interventions for cancer care, this study has the following limitations. First, the HIRA database used in this study includes only medical care services that are reimbursed by the national health insurance system. Thus, non-reimbursable services such as caretaker services that were paid for by the patients out of pocket were not included in the analysis. Future studies should include costs of these services to estimate the entire economic burden of cancer care. Second, while being hospitalized for cancer, patients can receive inpatient care for unrelated conditions, suggesting the possibility of overestimation of cancer care costs. Conversely, if patients were primarily hospitalized for conditions other than cancer, cancer treatment costs may have been excluded from the analysis, thus underestimating cancer care costs. Third, our findings are descriptive only and do not account for differences in patient demographics or clinical profiles. The objective of this study was to describe cancer care costs in all cancer decedents in the last year of life by cancer site but not to investigate factors influencing the costs. The claim data used in our analysis were collected for the primary purpose of reimbursement. As a result, aside from patient sociodemographic information, the data include limited clinical information. An investigation of factors influencing cancer care costs would best be conducted by using claims data merged with an external data source with rich clinical information, such as electronic medical records, which should be left for future research.In conclusion, medical care costs for cancer in the last year of life showed different trends depending on patient setting. The mean monthly inpatient medical care costs per patient increased and the mean monthly outpatient costs per patient decreased for all cancers as the patient approached death. The mean monthly inpatient medical care costs were highest for AML and increased steeply in parallel with drug therapy over the last year of life. The mean monthly outpatient medical care, drug therapy, and chemotherapy costs were highest for kidney cancer and decreased sharply over the last year of life. A considerable proportion of patients received chemotherapy in the inpatient setting in the last month of life. Our findings highlight the need to examine the appropriateness of aggressive treatments including chemotherapy among patients with terminal cancer to reduce the undue financial burden on the patient, the family, and the insurance system.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.


Fabavirus genus (Secoviridae family). The comparison of CVF and PrVF RNA2 genomic sequences suggests that the two viruses may significantly differ in their expression strategy. Indeed, similar to comoviruses, the smaller genomic segment of PrVF, RNA2, may be translated in two collinear proteins while CVF likely expresses only the shorter of these two proteins. Linked with the observation that identity levels between the coat proteins of these two viruses are significantly below the family species demarcation cut-off, these findings support the idea that CVF and PrVF represent two separate Fabavirus species.During their lifetime, perennial woody plants are expected to face multiple infection events. Furthermore, multiple genotypes of individual virus species may co-infect the same host. This may eventually lead to a situation where plants harbor complex communities of viral species/strains. Using high-throughput sequencing, we describe co-infection of sweet and sour cherry trees with diverse genomic variants of two closely related viruses, namely prunus virus F (PrVF) and cherry virus F (CVF). Both viruses are most homologous to members of the  Prunus, several new viral species were described in recent years with the aid of high-throughput sequencing (HTS) [Prunus species [Prunus sp., and cherry species in particular, are frequent and thus hamper the determination of pathogen-symptoms correlation [Prunus infecting virus species might be highly heterogeneous, consisting of distant genetic variants [Fruit trees are known to be hosts to a high number of viruses, mainly as a result of their vegetative mode of propagation and long-term cultivation in orchards. Especially in ng (HTS) ,2. In 20ng (HTS) . This nu species ,5. It warelation . Moreovevariants  with yetExisting HTS methodologies already have satisfactory sequencing capacity for the study of such heterogeneous viral populations. For instance, when artificial mixtures of five human immunodeficiency virus 1 genotypes were subjected to HTS, comparable results were produced with different sequencing platforms . In such a situation, the existence of low complexity regions may represent an obvious obstruction for the assembly step of genetically close genotypes .Fabavirus, family Secoviridae, which were found by HTS to infect cherry trees as mixtures of genotypes. Fabaviruses are single-stranded positive sense RNA viruses with two genomic segments (RNA1 and RNA2). Each RNA encodes a polyprotein which is proteolytically cleaved into the functional proteins. RNA1 contains the nucleoside triphosphate (NTP)-binding, genome-linked protein (VPg), proteinase and polymerase motifs, whereas RNA2 has the movement (MP) and capsid (CP) proteins motifs [In the present study, we molecularly characterized two closely related viruses of the genus s motifs . During s motifs . Neverths motifs  and has s motifs . The secThe majority of samples from cherry trees were collected during 2014–2016 from four locations. Six samples were taken from the germplasm at the Research and Breeding Institute of Pomology, Holovousy, Czech Republic . Two samples, SwC–H and SwC–H6, were collected in South Bohemia region , approximately 10 km each from the other and 160 km away from the Holovousy village. One sample was collected in 2009, from a sweet cherry orchard in Aridaia, Pella in Greece .Selected specimens were subjected to (a) enrichment of double-stranded RNA (dsRNA) species as described previously , (b) isoTM chip .Enriched dsRNA was extracted following cellulose-based protocol with slight modifications, which included optional S1 nuclease (Thermo Scientific) and TURBO DNase  treatments. Quantification and quality controls were done with Nanodrop spectrophotometer and/or Qubit fluorometr and native agarose electrophoresis, respectively. Library preparations were done either externally with TrueSeq Illumina kit or internally with MuSeek Library preparation kit (Thermo Scientific) and subjected to HiSeq2500 sequencing . Small RNAs library construction and sequencing were performed by Life Sequencing S.L.  on an Ion Torrent platform using the Ion 318The obtained sequence reads were quality trimmed and de novo assembled using CLC Genomic Workbench 8.5.1 . Verification of assembly consistency was done by back-mapping of trimmed reads onto reference sequences with following parameters—coverage fraction minimum 0.5, identity 0.95. Continuity of the assemblies was visually verified for covering inconsistencies. Total RNA was extracted from 50 mg of fresh leaf material using a MagJET Plant RNA Kit (Thermo Scientific) and transcribed into complementary DNA (cDNA) with random hexamers and Maxima H Minus First Strand cDNA Synthesis Kit (Thermo Scientific) according to the manufacturer’s recommendations. The obtained cDNA was amplified with SapphireAmp Fast PCR Master Mix  and the virus-specific primers . The proGeneral sequence analyses were done in Geneious 9.1.8 . Pairwise comparisons were calculated from CLUSTALW multiple alignments using the matrix percentage tool from the Geneious’s alignment tool. The same approach was applied for comparison of codon positions, which were at first separately extracted using Molecular Evolutionary Genetics Analysis (MEGA) 6.06 software  and thenLuteoviridae, and other two to the family Secoviridae.High-throughput sequencing analysis of nine sweet or sour cherry samples originating from the Czech Republic and Greece revealed the presence of several viruses , three oIn the present study, we investigated the later two, both verified by Sanger sequencing with appropriate primers . DetaileThe inter-sample molecular similarities of PrVF genotypes allowed their clustering (names of clusters for RNA1 and RNA2 were chosen arbitrary) into several groups of molecular identity  supported as well by phylogenetic analyses. It is not clear at this stage if preferential associations exist between the genomic RNAs 1 and 2 of PrVF belonging to different clusters. In the majority of PrVF-positive samples RNA1 B and RNA2 B were present. All samples contained more than one variant of RNA1, whereas three of them contained a single variant of RNA2. Samples SwC–H and SwC–H6, hosted two variants of RNA1 from the same molecular group .Fabavirus genus and, particularly, to that of PrVF. The sequences of two variants of the RNA1 segment, 6169 nucleotides (nt) and 6188 nt long, respectively, and of one 3857 nt long RNA2 segment were obtained. Further, each 3′ terminus had polyA tail of undefined length. The lengths of both RNAs are comparable with those of PrVF and other fabaviruses. RNA1 of CVF is among the longest species, with an exception of RNA1 of peach leaf pitting-associated virus that is 6357 nt long [CGCUUUC-3′ at the 5′ untranslated region (UTR), a sequence similar to the one reported for other fabaviruses  [As for other fabaviruses, the genome of CVF–H is divided between two genomic segments . The orgerlined) ,14. A noerlined) , when coNo AUG codon was found upstream of the CVF MP, however, there are AUA or AUC codons, in frame with the following polyprotein and approximately in the same alignment position as the first start codon of PrVF . This coThe putative cleavage sites of CVF polyproteins were compared with those predicted for PrVF and were found to be identical, with the exception of the cleavage site between the large and small CPs .Secoviridae family . Further analyses with RDP4 (Recombination detection program) [Genetic algorithm recombination detection (GARD) and single breakpoint (SBP) recombination analyses found several potential recombination breakpoints in the RNA1 of PrVF but none of them was characterized by significant topological incongruence (program)  revealedSecoviridae family, isolates of distinct species share less than 80% and 75% of aa identities in the Pro–Pol and CP regions, respectively [ectively ,18. The n = 3) and RNA2 (n = 2) of CVF, respectively. The obtained values for PrVF were similar: 0.012  and 0.047 . Substitution rates at the three codon positions  are in the order r3 > r1 > r2  [Prunus for a long time.Cherry virus F, together with prunus virus F and the recently described peach leaf pitting-associated virus  form a d Europe) ,4,8 and Secoviridae family, for example in the case of Tomato black ring virus (TBRV) and Beet ringspot virus (BRSV) in the Nepovirus genus [CVF likely represents a new virus species, close to PrVF. These viruses exhibit low identity levels with the other fabaviruses and form a separate phylogenetic cluster . The useus genus . In thisus genus . Besidesus genus .Comovirus, family Secoviridae) it has been shown that the upstream AUG is in a suboptimal context and that it may be bypassed during ribosomes scanning so that translation is also initiated from a downstream start codon in an optimal context [Comovirus, family Secoviridae) is translated in a similar fashion producing two proteins differing in their C’ part: P58 and MP [In the case of CVF, a distinct difference with PrVF seems to be the presence of an exceptionally long RNA2 5′ UTR and the inability to encode the long version of the polyprotein that can be produced by PrVF. The existence of two in-frame initiation codons is a feature known in related comoviruses. For cowpea mosaic virus  or processes them with equal efficiency as the original RNA template.With the broader application of HTS in plant pathology, a deeper insight into intra-host variability of phytoviruses will be obtained in the near future. Understanding mechanisms of establishment and successful maintenance of intra-host heterogeneous genotypes may lead to discovery of novel virus–virus interactions and subsequent impact on disease phenotype. Given the high number of viral agents detected in the analyzed samples in this study it is not possible to evaluate the contribution of distinct species and/or their combinations to the observed symptoms, especially when there were also cases of no apparent manifestations . Single


The recent observation of interviral recombination between members of two distinct classes of DNA viruses has opened the gates to a new field of human disease development. In all cases studied thus far interviral recombination is a rare event that requires special circumstances for intracellular interaction of participating viral genomes. The rarity and special requirements do not detract from the potential clinical significance of resulting recombinants, as exemplified by recombination between JC viral and Epstein-Barr viral genomes. This significance depends largely upon the mechanisms of recombination that would generate specific forms of recombinant viral genomes. At this time little is known regarding mechanisms of interviral recombination. DNA break-induced replication seems presently to be a highly plausible means of initiating formation of different, potentially active recombination products. Generalizing interviral recombination to a variety of viruses will open a fertile field for discovery as multiple diseases of mysterious etiology are investigated. At first consideration the observation that the distinct human viruses, JC virus (JCV) and Epstein-Barr virus (EBV) can undergo interviral recombination  may seemAssessment of important aspects of the clinical significance of interviral recombination requires understanding of the mechanisms underlying this process. Elucidating such recombination mechanisms will address three major questions concerning significance. First, when two DNA viruses recombine, can one virus incorporate the complete genome of the second virus? This is of particular importance regarding circular viruses, and can be illustrated using the example of JCV and EBV. JCV is a small polyomavirus, with double-stranded DNA of approximately 5 kb, that replicates in circular form initiated from a single origin of replication located in its control region (NCCR). EBV is a very large gamma-herpes virus of about 180 kb that can replicate as circular episomes initiated from its latent ori P. A speculative model describing the structural interaction of these two viral genomes is presented in A plausible mechanism that would explain all aspects of the type of JCV-EBV recombination thus far observed has yet to be proposed or tested. There are three sequences in the JCV NCCR that bear significant homology to any sequences in the entire EBV genome. These homologies are all at sites in the NCCR that are rearranged in the forms of JCV found in the demyelinating disease, PML . These hAs one considers interviral recombination in general, certain of the clinical implications described for JCV-EBV recombination are further clarified. One can use JCV-EBV interviral recombination as an example to generalize such recombination between different human viruses. As discussed, JCV-EBV recombination requires special circumstances, and it is likely that recombination among different viruses will require special circumstances as well. It is likely, therefore, that all or nearly all interviral recombination events are rare. Can such rare events be of great significance? They may be so. The JCV-EBV recombination described above involves latent EBV in which genes necessary for productive activation have been disabled . We haveThere are several diseases, the etiology of which may now be assessed in terms of interviral recombination. Recombination between HIV-1 and HIV-2 has been demonstrated after coinfection with genetically modified viruses and has not thus far been shown in an infected population. Although its consequences cannot be assessed, they are potentially intriguing because each virus may influence cell entry of the other and because these viruses differ in propensities for pathology in AIDS. JCV-EBV recombination has been shown in immunosuppressed individuals . JCV mus


Optimizing the Response of Prevention: HIV Efficiency in Africa’ (ORPHEA) project, we collected retrospective data from government and non-governmental health facilities for 2011–12. We used multi-stage sampling to determine a sample of health facilities by type, ownership, size and interventions offered totalling 144 sites in 78 health facilities in 33 districts across Kenya. Data sources included key informants, registers and time-motion observation methods. Total costs of production were computed using both quantity and unit price of each input. Average cost was estimated by dividing total cost per intervention by number of clients accessing the intervention. Multivariate regression methods were used to analyse predictors of log-transformed average costs. Average costs were $7 and $79 per HTC and PMTCT client tested, respectively; and $66 per VMMC procedure. Results show evidence of economies of scale for PMTCT and VMMC: increasing the number of clients per year by 100% was associated with cost reductions of 50% for PMTCT, and 45% for VMMC. Task shifting was associated with reduced costs for both PMTCT (59%) and VMMC (54%). Costs in hospitals were higher for PMTCT (56%) in comparison to non-hospitals. Facilities that performed testing based on risk factors as opposed to universal screening had higher HTC average costs (79%). Lower VMMC costs were associated with availability of male reproductive health services (59%) and presence of community advisory board (52%). Aside from increasing production scale, HIV prevention costs may be contained by using task shifting, non-hospital sites, service integration and community supervision.We estimate costs and their predictors for three HIV prevention interventions in Kenya: HIV testing and counselling (HTC), prevention of mother-to-child transmission (PMTCT) and voluntary medical male circumcision (VMMC). As part of the ‘ Key MessagesIn Kenya, during 2011–12, the costs per client in HIV testing and counselling (HTC) was $7, for prevention of mother-to-child transmission (PMTCT) client tested was $59 and per voluntary medical male circumcision (VMMC) procedure was $66.Economies of scale were observed for the production of HIV prevention services particularly for PMTCT and for VMMC.Task shifting was associated with lower costs for PMTCT and for VMMC, but not for HTC.Incentives for good performance for staff members were not associated with higher costs.The availability of male reproductive health services and the presence of a community advisory board were associated with lower VMMC costs.HIV is a serious public health problem in Kenya with 1.6 million people including 191 000 children infected  . In 2013UNAIDS Getting to Zero 2011–2015 Strategy (Kenya was a signatory country of the 2011 United Nations (UN) Political Declaration on HIV and AIDS  , adopted in June 2011 at the UN General Assembly High‐Level Meeting on AIDS, and the country has now moved towards implementing the Sustainable Development Goals (SDGs) . The newStrategy , the couStrategy . SimilarStrategy . FurtherStrategy . The latStrategy . OverallStrategy  due in pStrategy . A revieStrategy . Hence, Like other high prevalence countries in sub-Saharan Africa, achieving an AIDS-free generation in Kenya requires aggressive programming in stopping transmission by preventing new infections . In KenyGiven the continued need for expanded services, while resources are diminishing, the main objectives of this paper are to document the costs of HIV prevention interventions, explore the predictors of economic efficiency, and quantify the potential economies of scale in the production of HIV prevention services. We estimate average costs at each step of the service cascade for each intervention, and then quantify the relationship between average unit cost and scale of production (i.e. the number of clients) as well as quality indicators for each type of facility. We define economic  efficiency as delivering a given level of HIV services output at the lowest feasible cost . Lastly, the methods to measure cost and scale have developed slowly in the HIV field over the past decade with innovations still necessary to optimize program scale and economic efficiency  in the world  research project (2011–14) that was carried out in Kenya, Zambia, South Africa, Rwanda and Nigeria. The general multi-country methods are presented elsewhere (This study was part of the large multi-country ‘The study sampled Government of Kenya (GOK) health service delivery points at all levels and private providers  at each level within the health system . We used multistage sampling techniques to select 56 sites for HTC, 57 sites for PMTCT and 31 sites for VMMC, for a total of 144 sites in 78 health facilities, with most facilities offering more than one intervention. Ten out of 47 counties in Kenya were purposively selected for inclusion in the study to ensure national representation. Data were collected at the district level and at each of the 144 sites. The study collected information through several avenues: interviews with facility in-charges and other relevant health staff; record verification; payslip checking; direct observation; client exit interviews; and provider vignettes. In addition, we gathered: district- and site-level characteristics, inputs to HIV service production, amount of services produced by each site, quality of services provided, service coverage, sources of funding, accountability-related characteristics and the potential demand of relevant HIV services in the same area. Cost data were collected retrospectively for the most recent year available: 2011 or 2012  approach to estimate total variable costs as the product of the annual number of clients for each intervention times the price for each component of the HIV prevention service. Variable costs included specific items such as rapid tests, antiretrovirals for PMTCT prophylaxis, surgical circumcision kits, etc. Fixed costs included items such as utilities, capital, equipment, training and supervision, etc. We then calculated average costs by dividing the total costs incurred in the facility for each HIV prevention intervention by the total number of clients served for each particular service in that facility . A combiThe costs were collected in current Kenyan shillings, and transformed into US dollars at the constant exchange rate of 88.9 shillings per USD for the year 2011 . The depIn addition, we included the following measures relevant to evaluating costs and efficiency determinants . In addiFor the log-transformed linear regression models, we first analysed the number of clients per year  as the main predictor; and then we analysed the full model adjusting for other types of variables such as those related to the service delivery model as well as the management of HIV prevention services at the facility level. We adopted an accounting identity approach to characterize the relationship between cost and its determinants , assuminP < 0.10) as well as their overall contribution for the model’s explanatory power as measured by the overall model significance (F test) and the R-squared. We used the term predictor instead of independent variable to emphasize that we did not have an experimental design, so the model measured only associations given by the direction and magnitude of the coefficients from linear regression. The main component of unit costs were staff salaries which we measured using allocations based on full time equivalents (FTE) devoted to specific HIV prevention services . There were differences by type of facility: hospitals had a greater number of HTC clients than non-hospital facilities (5244 vs 3071); and hospital’s HTC staff were also more likely to receive rewards for good performance in comparison to staff in non-hospital facilities (40 vs 19%). Among the 57 facilities selected for PMTCT services, an average of 864 clients were tested annually in each facility; and hospitals were also more likely to have PMTCT staff who can receive rewards for good performance in comparison to non-hospital facilities (47 vs 20%). In the 33 facilities providing VMMC, an average of 869 VMMC procedures per year were conducted in each facility. Hospitals were also more likely to have VMMC staff who can receive rewards for good performance in comparison to non-hospital facilities (50 vs 17%).R-square coefficients. We now present graphical results. β = 0.79; CI 95% 0.24–1.34). The HTC costs model including scale explained about a fifth of the variation in the average costs (R-squared = 0.22). For PMTCT, costs decreased if the facility performed task shifting  and also if the facility performed audits at least once per year . On the other hand, PMTCT costs increased if the facility was a hospital . The final PMTCT model including scale explained over a third of the variation in the average costs (R-squared = 0.35). For VMMC, costs decreased if the facility promoted the procedure through the male reproductive services (β = −0.59 95% CI −1.06 to −0.13); if the facility performed task shifting ; and if the facility had a community advisory council . On the other hand, VMMC costs increased if some of the activities were performed outside the facility , and for the facilities that had the highest performance . Further, there was an interaction effect whereby facilities that were both the best in terms of competence and performance for VMMC had substantially lower costs . The final VMMC costs model including scale explained most of the variation in the average costs (R-squared = 0.59).This is, to our knowledge, the first article examining predictors of HIV prevention costs at the national level in sub-Saharan Africa. Several points merit discussion. First, most studies in the past have been based on smaller samples, localized interventions and non-standard data collection methods , as wellFifth, the costs of PMTCT, HTC and VMMC are largely consistent with the previous literature. The cost per HTC client of $7.4 in Kenya suggests that costs have decreased over time as scale has increased when compared to a previous estimation of $16 per client a decade earlier  as related to VMMC facilities, while the latter result may be related to overall facility supervision and oversight (Our results suggest that there is a potential to increase efficiency within the current constraints of the health system in Kenya, both financial and structural. Specifically, we found that scale is important even across facility types, and not just comparing hospitals with clinics. In light of these results, it is important to think about scale not only as a given factor, which in many circumstances it is, but also to give importance to demand creation activities at the facility level. Our results suggest that this type of investment will probably be very productive. It may also be important to consider economies of scale when determining the size or capacity of health facilities and when selecting their location and size. The results also suggest the importance of evaluating excess supply, such as the extent to which current levels of structure and staffing are not being used to their optimum potential. This may become increasingly important to consider at the policy level as devolution of health deepens (R-squared for the intervention models, given that we have cross-sectional data, were only modestly high and therefore conclusions need to be made with caution.In terms of strengths, this article contributes a specific example of applying a micro-costing approach to HIV prevention services and modelling a unit cost function in terms of its main predictors. The main weakness may be that we can only observe associations given the cross-sectional nature of the data. Thus, more rigorous research is needed to attempt to measure causal relationships in the future. In addition, there are other limitations. First, our modelling choice of a cost accounting identity imposes arithmetical consistency, which is useful for short-run budgeting discussions and enables us to make projections of incremental policies such as scale-up in coverage. However, our models are agnostic with respect to technology, as opposed to flexible cost functions. Thus, other policy concerns such as substitution between health inputs or the impact of economies of scope would necessitate other econometric approaches, which would require more degrees of freedom than those available in our data. A second concern is that the study did not account for all of the potential variables that can affect unit cost variations; other constraints, different from technology and competence, may also explain inefficiency. Finding the right balance in key management aspects such as supervision, accountability, monitoring, incentives and governance remains a challenge, especially in the fully devolved county health functions. Additional exploration of facility-level and county-level management practices and standards that explain variability in efficiency is needed. Third, our study provides evidence—and identifies gaps—on the efficiency and costs of HIV prevention services for a specific cross-section at a particular time point. Ideally, this type of information should be provided on a continued basis and even in real-time to decision makers and managers at all levels in the health system; thus, more regular evaluations are recommended. Although the results may be applicable to other settings and times with similar set of circumstances these findings are specific to Kenya. Finally, the The analysis has established that volume of service or scale of output explains considerable variation in unit costs for HIV prevention activities, but not all. This implies that an increase in the number of clients in all facilities and particularly in the lower level facilities can lead to declines in costs. Expanding the volume of services can improve levels of efficiency in the HIV prevention response particularly for PMTCT and VMMC. Other factors associated with decreased costs were: task-shifting, community oversight and service integration. Factors associated with increased costs were: hospital-based services; and outreach efforts. Aside from increasing production scale, HIV prevention costs may be further contained by using task shifting for PMTCT and VMMC. In contrast, targeted testing for HTC may require more resources. ORPHEA provides the first national-level evidence base for HIV prevention costs and their determinants for an African country, Kenya.Supplementary MaterialClick here for additional data file.


Yeast published by John Wiley & Sons, Ltd.Hybridization between different species can result in the emergence of new lineages and adaptive phenotypes. Occasionally, hybridization in fungal organisms can drive the appearance of opportunistic lifestyles or shifts to new hosts, resulting in the emergence of novel pathogens. In recent years, an increasing number of studies have documented the existence of hybrids in diverse yeast clades, including some comprising human pathogens. Comparative and population genomics studies performed on these clades are enabling us to understand what roles hybridization may play in the evolution and emergence of a virulence potential towards humans. Here we survey recent genomic studies on several yeast pathogenic clades where hybrids have been identified, and discuss the broader implications of hybridization in the evolution and emergence of pathogenic lineages. © 2017 The Authors.  Saccharomyces cerevisiae  and trans (elsewhere in the genome) elements, and in hybrid genomes it is possible that the cis component of one parent is regulated by the trans component of the other, which can alter gene regulation. As shown by Tirosh and colleagues, alterations in either cis or trans regulatory elements are important to obtain genomic stability, and therefore the reprogramming of gene expression should also be considered as an important factor in the stabilization of hybrid genomes , C. neoformans var. grubii (serotype A) and C. neoformans var. gattii (serotypes B and C). However, in 2001, the analysis of molecular markers indicated the existence of two separated species: C. neoformans var. neoformans and var. grubii and Cryptococcus gattii  and C. deneoformans (previous var. neoformans), and C. gattii was divided into five different species, namely, C. gattii, C. bacillisporus, C. deuterogattii, C. tetragattii and C. decagattii  are the most studied . All of these species are facultative commensals of human skin or mucosae, and all have the ability to form biofilms in catheters and other medical devices, being associated with opportunistic nosocomial infections . Owing to these differences, Pryszcz and colleagues proposed the existence of two possible scenarios: C. metapsilosis hybridization occurred more recently, or for some reason C. orthopsilosis genome is evolving faster (Pryszcz et al., C. orthopsilosis, presenting one of the lowest heterozygosity values among the hybrid strains (Schroder, C. orthopsilosis it is possible to find strains with almost quadruple the heterozygous variants found in MCO456 (Schroder, Although not as high as in Candida or Cryptococcus clades. Gene exchange through hybridization was already reported in other species. Coccidioidomycosis is a pulmonary infection caused by the inhalation of Coccidioides immitis or Coccidioides posadasii spores, which are present in the soil and air. Although not being a dangerous disease in immunocompetent patients, it is estimated that 150 000 new cases of coccidioidomycosis occur annually in the USA, of which one‐third are fatal, being a special concern for immunocompromised persons (Odio et al., C. immitis population may have been recently introgressed from C. posadasii, presenting an enrichment in genes associated with immune evasion and cell walls (Neafsey et al., The relevance of hybridization to human health is not exclusive to Fusarium keratoplasticum, the main causative agent of nosocomial infections associated with plumbing systems. Fusarium is responsible for skin lesions, pneumonia and disseminated infections in immunocompromised patients (Nucci & Anaissie, Malassezia furfur, a commensal fungus of the human skin, sometimes responsible for skin disorders, such as eczema or atopic dermatitis (Theelen et al., M. furfur (Wu et al., M. furfur lineages, if we consider M. furfur as a species complex, they could be considered as inter‐species hybrids (Wu et al., The same concern is appearing in relation to the filamentous fungi Candida and Cryptococcus hybrids have only superficially approached the mechanisms underlying hybrid genome evolution, and how they relate to phenotypic change, in particular with respect to their pathogenic behaviour.Altogether, these findings show that hybridization is a transversal phenomenon in fungal pathogens, occurring in different clades Figure . MoreoveHybridization is a biological process responsible for the origin of new lineages or species with adaptation to new environments. The increasing identification of hybrid species with medical or economical importance shows that this evolutionary process has to be regarded as an important driver of evolution, especially in the fungal clade. Advances in medical procedures allowing the survival of immunocompromised patients, globalization and climate change are all factors probably underlying the increase in the number of hybrid opportunistic fungal pathogens. The trend is also likely to increase even further. Considering this, there is a need for investment in the development of new diagnostic tests in order to apply the optimal therapeutics. For this reason, it is important to understand the mechanisms underlying the hybridization events in fungi, especially those leading to the harmonious coexistence of two different genomes in one unique organism.C. metapsilosis, both parent lineages are unknown (Pryszcz et al., In this regard, the fields of genomics and bioinformatics are set to play a crucial role in future studies. In order to achieve this, the future will need to witness further developments of new programmes and tools especially directed to the assembly and analysis of fungal genomes, with a particular focus on highly heterozygous genomes. This should be regarded as an urgent task since good genomic sequences are the essential basis of achieving better knowledge on these pathogens. Short‐read paired‐end technologies are widely used for genome sequencing. However, difficulties in solving complex genome assemblies are leading to an integrated use of multiple technologies (Goodwin et al., Genomic analyses can certainly increase our understanding of the evolution of hybrid pathogens, yet they need to be complemented with experimental functional analyses. Only a few studies have compared pathogenesis‐relevant phenotypes such as drug resistance, adherence or virulence among different hybrid strains and their homozygous parents. Only the comprehensive and carefully planned phenotyping of a large number of hybrid and non‐hybrid strains from which the genomes have been sequenced will help us to understand the genetic mechanisms underlying virulent traits in hybrids. Finally, transcriptome analysis performed with technologies such as RNAseq has the potential to reveal how transgressive phenotypes may be achieved in yeast hybrids and how hybridization can rewire transcriptional networks.In conclusion, hybridization is a process suggested to be at the origin of new emerging pathogens (Hagen et al., The authors declare that there is no conflict of interest.