DiGA in Primary Care and the Influence of Patient-Related Factors - Results of a Survey of Family Doctors.

BACKGROUND: In 2019, the Digital Healthcare Act created the legal basis for prescribable mobile health applications, referred to as DiGA (in German: Digitale Gesundheitsanwendungen), as a novel healthcare delivery option in Germany [1, 2]. OBJECTIVES: The aim of this study is to analyze the use of DiGA in primary care, focusing on the influence of socio-demographic characteristics of family doctors (FDs) and patient-related factors. METHODS: Pen-and-paper survey among 97 FDs in the district of Giessen, Hesse, Germany. RESULTS: 59.4% of surveyed FDs have already prescribed DiGA. The age and digital affinity of FDs as well as the location of their practice are significantly correlated with the level of information and willingness to use DiGA. Male und younger FDs rate their digital affinity higher. When deciding whether to prescribe DiGA, 72.9% of surveyed physicians take patient-related factors such as digital affinity, motivation, age and health literacy into consideration. CONCLUSION: Socio-demographic characteristics of FDs and patient-related factors have an influence on the use of DiGA.

Genome Comparisons between Botrytis fabae and the Closely Related Gray Mold Fungus Botrytis cinerea Reveal Possible Explanations for Their Contrasting Host Ranges.

While Botrytis cinerea causes gray mold on many plants, its close relative, Botrytis fabae, is host-specifically infecting predominantly faba bean plants. To explore the basis for its narrow host range, a gapless genome sequence of B. fabae strain G12 (BfabG12) was generated. The BfabG12 genome encompasses 45.0 Mb, with 16 chromosomal telomere-to-telomere contigs that show high synteny and sequence similarity to the corresponding B. cinerea B05.10 (BcB0510) chromosomes. Compared to BcB0510, it is 6% larger, due to many AT-rich regions containing remnants of transposable elements, but encodes fewer genes (11,420 vs. 11,707), due to losses of chromosomal segments with up to 20 genes. The coding capacity of BfabG12 is further reduced by nearly 400 genes that had been inactivated by mutations leading to truncations compared to their BcB0510 orthologues. Several species-specific gene clusters for secondary metabolite biosynthesis with stage-specific expression were identified. Comparison of the proteins secreted during infection revealed high similarities, including 17 phytotoxic proteins that were detected in both species. Our data indicate that evolution of the host-specific B. fabae occurred from an ancestral pathogen with wide host range similar to B. cinerea and was accompanied by losses and degeneration of genes, thereby reducing its pathogenic flexibility.

Intraspecific variation in realized dispersal probability and host quality shape nectar microbiomes.

Epiphytic microbes frequently affect plant phenotype and fitness, but their effects depend on microbe abundance and community composition. Filtering by plant traits and deterministic dispersal-mediated processes can affect microbiome assembly, yet their relative contribution to predictable variation in microbiome is poorly understood. We compared the effects of host-plant filtering and dispersal on nectar microbiome presence, abundance, and composition. We inoculated representative bacteria and yeast into 30 plants across four phenotypically distinct cultivars of Epilobium canum. We compared the growth of inoculated communities to openly visited flowers from a subset of the same plants. There was clear evidence of host selection when we inoculated flowers with synthetic communities. However, plants with the highest microbial densities when inoculated did not have the highest microbial densities when openly visited. Instead, plants predictably varied in the presence of bacteria, which was correlated with pollen receipt and floral traits, suggesting a role for deterministic dispersal. These findings suggest that host filtering could drive plant microbiome assembly in tissues where species pools are large and dispersal is high. However, deterministic differences in microbial dispersal to hosts may be equally or more important when microbes rely on an animal vector, dispersal is low, or arrival order is important.

Prescribing Behavior and Reasonable Price for Mental Health DiGAs - Results of a Pilot Study.

BACKGROUND: Since the Digital Health Care Act came into force in 2020, mHealth services can be prescribed and reimbursed as DiGAs in Germany. The most reimbursable DiGAs can be found in the area of psychiatric diseases. Little is known about the prescribing behavior of medical and psychological psychotherapists and the price they considered reasonable. OBJECTIVES: To gather more detailed knowledge about the prescription behavior, appropriate diagnosis, reasonable price and importance of relevant characteristics. METHODS: Online survey of 38 medical and psychological psychotherapists working in central Hesse. RESULTS: Just under a third have prescribed DiGAs to date; suitable diagnoses include somatoform disorders, anxiety disorders and addictive disorders. Medical quality, user- friendliness and data protection are considered important. the reasonable price is below the current average market price. CONCLUSION: The DiGAs do not seem to be prescribed by psychotherapists on a broad scale yet, the suitable indications are in line with the market offer, although the prices seem to be too high from the prescribers' point of view.

Nectar compounds impact bacterial and fungal growth and shift community dynamics in a nectar analog.

Floral nectar is frequently colonised by microbes. However, nectar microbial communities are typically species-poor and dominated by few cosmopolitan genera. One hypothesis is that nectar constituents may act as environmental filters. We tested how five non-sugar nectar compounds as well as elevated sugar impacted the growth of 12 fungal and bacterial species isolated from nectar, pollinators, and the environment. We hypothesised that nectar isolated microbes would have the least growth suppression. Additionally, to test if nectar compounds could affect the outcome of competition between microbes, we grew a subset of microbes in co-culture across a subset of treatments. We found that some compounds such as H2 O2 suppressed microbial growth across many but not all microbes tested. Other compounds were more specialised in the microbes they impacted. As hypothesised, the nectar specialist yeast Metschnikowia reukaufii was unaffected by most nectar compounds assayed. However, many non-nectar specialist microbes remained unaffected by nectar compounds thought to reduce microbial growth. Our results show that nectar chemistry can influence microbial communities but that microbe-specific responses to nectar compounds are common. Nectar chemistry also affected the outcome of species interactions among microbial taxa, suggesting that non-sugar compounds can affect microbial community assembly in flowers.

Soluble Urokinase Plasminogen Activator Receptor Levels Are Associated with Severity of Fibrosis in Patients with Primary Sclerosing Cholangitis.

The soluble urokinase-type plasminogen activator receptor (suPAR) has evolved as a useful biomarker for different entities of chronic liver disease. However, its role in patients with primary sclerosing cholangitis (PSC) is obscure. We analyzed plasma levels of suPAR in 84 patients with PSC and compared them to 68 patients with inflammatory bowel disease (IBD) without PSC and to 40 healthy controls. Results are correlated with clinical records. suPAR concentrations were elevated in patients with PSC compared to patients with IBD only and to healthy controls (p < 0.001). Elevated suPAR levels were associated with the presence of liver cirrhosis (p < 0.001) and signs of portal hypertension (p < 0.001). suPAR revealed a high accuracy for the discrimination of the presence of liver cirrhosis comparable to previously validated noninvasive fibrosis markers (area under the curve (AUC) 0.802 (95%CI: 0.702−0.902)). Further, we demonstrated that suPAR levels may indicate the presence of acute cholangitis episodes (p < 0.001). Finally, despite the high proportion of PSC patients with IBD, presence of IBD and its disease activity did not influence circulating suPAR levels. suPAR represents a previously unrecognized biomarker for diagnosis and liver cirrhosis detection in patients with PSC. However, it does not appear to be confounded by intestinal inflammation in the context of IBD.

Herbivory by European Earwigs (Forficula auricularia; Dermaptera: Forficulidae) on Citrus Species Commonly Cultivated in California.

Agricultural plant species differ in susceptibility to herbivores; therefore, identifying natural resistances or tolerances to pests can be leveraged to develop preventative, integrated pest management approaches. While many Citrus species are grown in California, most pest management guidelines are based upon research conducted on navel oranges [Citrus sinensis (L.) Osbeck; Sapindales: Rutaceae]. A recent study has established European earwigs (Forficula auricularia L.; Dermaptera: Forficulidae) as herbivores of young navel orange fruit, causing damage ranging from small bite marks to large chewed holes. It is unknown whether earwigs damage fruit of other citrus species. We conducted field experiments in which we caged earwigs to branch terminals bearing young fruit to explore potential differences in susceptibility of Citrus species to European earwigs. Specifically, we tested whether three species, navel oranges, clementines (C. clementina hort. ex Tanaka), and true mandarins (C. reticulata Blanco) exhibit differences in: 1) feeding deterrence to earwigs; 2) suitability as food for earwigs; 3) preferential abscission of damaged fruit; and 4) healing of damaged fruit. Earwigs caused heavy damage on navel orange and clementine fruit, whereas heavy damage was rare on true mandarin fruit. There was little evidence of preferential abscission of damaged fruit or healing of seriously damaged fruit. Consequently, several heavily damaged navel orange and one clementine fruit were retained to harvest and developed large scars. Overall, we found that Citrus fruit vary in their susceptibility to earwigs, and pest management strategies for earwigs should be refined to consider their varying effects on different Citrus species.

Safety of Triage Self-assessment Using a Symptom Assessment App for Walk-in Patients in the Emergency Care Setting: Observational Prospective Cross-sectional Study.

BACKGROUND: Increasing use of emergency departments (EDs) by patients with low urgency, combined with limited availability of medical staff, results in extended waiting times and delayed care. Technological approaches could possibly increase efficiency by providing urgency advice and symptom assessments. OBJECTIVE: The purpose of this study is to evaluate the safety of urgency advice provided by a symptom assessment app, Ada, in an ED. METHODS: The study was conducted at the interdisciplinary ED of Marburg University Hospital, with data collection performed between August 2019 and March 2020. This study had a single-center cross-sectional prospective observational design and included 378 patients. The app's urgency recommendation was compared with an established triage concept (Manchester Triage System [MTS]), including patients from the lower 3 MTS categories only. For all patients who were undertriaged, an expert physician panel assessed the case to detect potential avoidable hazardous situations (AHSs). RESULTS: Of 378 participants, 344 (91%) were triaged the same or more conservatively and 34 (8.9%) were undertriaged by the app. Of the 378 patients, 14 (3.7%) had received safe advice determined by the expert panel and 20 (5.3%) were considered to be potential AHS. Therefore, the assessment could be considered safe in 94.7% (358/378) of the patients when compared with the MTS assessment. From the 3 lowest MTS categories, 43.4% (164/378) of patients were not considered as emergency cases by the app, but could have been safely treated by a general practitioner or would not have required a physician consultation at all. CONCLUSIONS: The app provided urgency advice after patient self-triage that has a high rate of safety, a rate of undertriage, and a rate of triage with potential to be an AHS, equivalent to telephone triage by health care professionals while still being more conservative than direct ED triage. A large proportion of patients in the ED were not considered as emergency cases, which could possibly relieve ED burden if used at home. Further research should be conducted in the at-home setting to evaluate this hypothesis. TRIAL REGISTRATION: German Clinical Trial Registration DRKS00024909; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00024909.

Severe portal and systemic acidosis during CO2-laparoscopy compared to helium or gasless laparoscopy and laparotomy in a rodent model: an experimental study.

BACKGROUND AND AIMS: This experimental study assesses the influence of different gases and insufflation pressures on the portal, central-venous and peripheral-arterial pH during experimental laparoscopy. METHODS: Firstly, 36 male WAG/Rij rats were randomized into six groups (n = 6) spontaneously breathing during anaesthesia: laparoscopy using carbon dioxide or helium at 6 and 12 mmHg, gasless laparoscopy and laparotomy. 45 and 90 min after setup, blood was sampled from the portal vein, vena cava and the common femoral artery with immediate blood gas analysis. Secondly, 12 animals were mechanically ventilated at physiological arterial pH during 90 min of laparotomy (n = 6) or carbon dioxide laparoscopy at 12 mmHg (n = 6) with respective blood gas analyses. RESULTS: Over time, in spontaneously breathing rats, carbon dioxide laparoscopy caused significant insufflation pressure-dependent portal acidosis (pH at 6 mmHg, 6.99 [6.95-7.04] at 45 min and 6.95 [6.94-6.96] at 90 min, pH at 12 mmHg, 6.89 [6.82-6.90] at 45 min and 6.84 [6.81-6.87] at 90 min; p < 0.05) compared to laparotomy (portal pH 7.29 [7.23-7.30] at 45 min and 7.29 [7.20-7.30] at 90 min; p > 0.05). Central-venous and peripheral-arterial acidosis was significant but less severely reduced during carbon dioxide laparoscopy. Laparotomy, helium laparoscopy and gasless laparoscopy showed no comparable acidosis in all vessels. Portal and central-venous acidosis during carbon dioxide laparoscopy at 12 mmHg was not reversible by mechanical hyperventilation maintaining a physiological arterial pH (pH portal 6.85 [6.84-6.90] (p = 0.004), central-venous 6.93 [6.90-6.99] (p = 0.004), peripheral-arterial 7.29 [7.29-7.31] (p = 0.220) at 90 min; Wilcoxon-Mann-Whitney test). CONCLUSION: Carbon dioxide laparoscopy led to insufflation pressure-dependent severe portal and less severe central-venous acidosis not reversible by mechanical hyperventilation.

Culturable bacteria are more common than fungi in floral nectar and are more easily dispersed by thrips, a ubiquitous flower visitor.

Variation in dispersal ability among taxa affects community assembly and biodiversity maintenance within metacommunities. Although fungi and bacteria frequently coexist, their relative dispersal abilities are poorly understood. Nectar-inhabiting microbial communities affect plant reproduction and pollinator behavior, and are excellent models for studying dispersal of bacteria and fungi in a metacommunity framework. Here, we assay dispersal ability of common nectar bacteria and fungi in an insect-based dispersal experiment. We then compare these results with the incidence and abundance of culturable flower-inhabiting bacteria and fungi within naturally occurring flowers across two coflowering communities in California across two flowering seasons. Our microbial dispersal experiment demonstrates that bacteria disperse via thrips among artificial habitat patches more readily than fungi. In the field, incidence and abundance of culturable bacteria and fungi were positively correlated, but bacteria were much more widespread. These patterns suggest shared dispersal routes or habitat requirements among culturable bacteria and fungi, but differences in dispersal or colonization frequency by thrips, common flower visitors. The finding that culturable bacteria are more common among nectar sampled here, in part due to superior thrips-mediated dispersal, may have relevance for microbial life history, community assembly of microbes, and plant-pollinator interactions.

Unexpected plasticity in the life cycle of Trypanosoma brucei.

African trypanosomes cause sleeping sickness in humans and nagana in cattle. These unicellular parasites are transmitted by the bloodsucking tsetse fly. In the mammalian host's circulation, proliferating slender stage cells differentiate into cell cycle-arrested stumpy stage cells when they reach high population densities. This stage transition is thought to fulfil two main functions: first, it auto-regulates the parasite load in the host; second, the stumpy stage is regarded as the only stage capable of successful vector transmission. Here, we show that proliferating slender stage trypanosomes express the mRNA and protein of a known stumpy stage marker, complete the complex life cycle in the fly as successfully as the stumpy stage, and require only a single parasite for productive infection. These findings suggest a reassessment of the traditional view of the trypanosome life cycle. They may also provide a solution to a long-lasting paradox, namely the successful transmission of parasites in chronic infections, despite low parasitemia.

Granulocyte-colony stimulating factor (G-CSF) to treat acute-on-chronic liver failure: A multicenter randomized trial (GRAFT study).

BACKGROUND & AIMS: Based on positive results from small single center studies, granulocyte-colony stimulating factor (G-CSF) is being widely used for the treatment of patients with acute-on-chronic liver failure (ACLF). Herein, we aimed to evaluate the safety and efficacy of G-CSF in patients with ACLF. METHODS: In this multicenter, prospective, controlled, open-label phase II study, 176 patients with ACLF (EASL-CLIF criteria) were randomized to receive G-CSF (5 µg/kg daily for the first 5 days and every third day thereafter until day 26) plus standard medical therapy (SMT) (n = 88) or SMT alone. The primary efficacy endpoint was 90-day transplant-free survival analyzed by Cox regression modeling. The key secondary endpoints were overall and transplant-free survival after 360 days, the development of ACLF-related complications, and the course of liver function scores during the entire observation period. RESULTS: Patients treated with G-CSF had a 90-day transplant-free survival rate of 34.1% compared to 37.5% in the SMT group (hazard ratio [HR] 1.05; 95% CI 0.711-1.551; p = 0.805). Transplant-free and overall survival at 360 days did not differ between the 2 arms (HR 0.998; 95% CI 0.697-1.430; p = 0.992 and HR 1.058; 95% CI 0.727-1.548; p = 0.768, respectively). G-CSF did not improve liver function scores, the occurrence of infections, or survival in subgroups of patients without infections, with alcohol-related ACLF, or with ACLF defined by the APASL criteria. Sixty-one serious adverse events were reported in the G-CSF+SMT group and 57 were reported in the SMT group. In total, 7 drug-related serious adverse reactions occurred in the G-CSF group. The study was prematurely terminated due to futility after conditional power calculation. CONCLUSIONS: In contrast to previous findings, G-CSF had no significant beneficial effect on patients with ACLF in this multicenter controlled trial, which suggests that it should not be used as a standard treatment for ACLF. CLINICALTRIALS. GOV NUMBER: NCT02669680 LAY SUMMARY: Granulocyte-colony stimulating factor was considered as a novel treatment for acute-on-chronic liver failure (ACLF). We performed the first randomized, multicenter, controlled phase II trial, which showed that G-CSF did not improve survival or other clinical endpoints in patients with ACLF. Therefore, G-CSF should not be used to treat liver disease outside clinical studies.

A pilot study of patient satisfaction with a self-completed tablet-based digital questionnaire for collecting the patient's medical history in an emergency department.

BACKGROUND: The increasing popularity and availability of tablet computers raises questions regarding clinical scenarios. This pilot study examined the patient's satisfaction when using a tablet-based digital questionnaire as a tool for obtaining medical history in an emergency department and to what extent gender, age, technical competence and mother tongue influence the user satisfaction. Patients were asked to complete three consecutive questionnaires: The first questionnaire collected basic epidemiological data to measure past digital usage behaviour, the second questionnaire collected the patient's medical history, and the third questionnaire assessed the overall perceived user satisfaction when using the tablet-based survey application for medical anamnesis. RESULTS: Of 111 consenting patients, 86 completed all three questionnaires. In summary, the user evaluation was positive with 97.7% (n = 84) of the patients stating that they had no major difficulties using the digital questionnaire. Only 8.1% (n = 7) of patients reported a preference to fill out a paper-and-pen version on the next visit instead, while 98.8% (n = 85) stated that they would feel confident filling out a digital questionnaire on the next visit. The variables gender, age, mother tongue and/or technical competence did not exert a statistically significant influence towards the defined scales usability, content and overall impression. CONCLUSION: In conclusion, self-administered tablet-based questionnaires are widely accepted tools for collecting medical information in the emergency room across all ages and genders, regardless of technical competence.

Characterizing Herbivory by European Earwigs (Dermaptera: Forficulidae) on Navel Orange Fruit with Comparison to Forktailed Bush Katydid (Orthoptera: Tettigoniidae) Herbivory.

In establishing Integrated Pest Management (IPM) plans for understudied pests, it is crucial to understand the nature of their herbivory and resulting damage. European earwig (Forficula auricularia L.; Dermaptera: Forficulidae) densities are increasing in citrus orchards in Central California. Field observations suggest that earwigs feed on young, developing citrus fruit, but this hypothesis had not been examined with formal experimentation. Forktailed bush katydid nymphs (Scudderia furcata Brunner von Wattenwyl; Orthoptera: Tettigoniidae) are well-known citrus herbivores that feed on young citrus fruit, and it is possible that earwig damage may be misdiagnosed as katydid damage. Here we report findings from two field experiments in navel oranges (Citrus sinensis (L.) Osbeck; Sapindales: Rutaceae) that together tested: (1) whether earwigs damage young citrus fruit; (2) whether the amount of damage earwigs generate differs across developmental stage or sex of adult earwigs; (3) the window of time during which fruit are most sensitive to earwig damage; (4) whether damaged fruit are retained to harvest; and (5) the resulting damage morphology caused by earwigs relative to katydids. Earwigs, particularly nymphs, chewed deep holes in young citrus fruit from 0 to 3 wk after petal fall. Fruit damaged by earwigs were retained and exhibited scars at harvest. The morphology and distribution of scars on mature fruit only subtly differed between earwigs and katydids. This study establishes that earwigs can be direct pests in mature navel orange trees by generating scars on fruit and likely contribute to fruit quality downgrades.

Profile of Fork-Tailed Bush Katydid (Orthoptera: Tettigoniidae) Feeding on Fruit of Clementine Mandarins.

Sweet oranges (Citrus sinensis (L.) Osbeck Sapindales: Rutaceae) dominated commercial citrus production in California until recently when there has been a shift to mandarins, mostly Citrus reticulata (Blanco) mandarins and Citrus clementina (hort. ex Tanaka) clementines. Past analyses of commercial field scouting and harvest data indicated that fork-tailed bush katydids (Scudderia furcata Brunner von Wattenwyl), a major pest in oranges, are present in clementine groves, but that fruit scarring attributed to katydids is rare. Conversely, jagged or web-like scarring attributed to caterpillars was more prevalent than expected. We used two field experiments in four representative cultivars of clementines to test four explanatory hypotheses for this observation: 1) katydids do not feed on clementine fruit, 2) damaged clementine fruit recover, 3) damaged clementine fruit preferentially abscise, and 4) katydid scars on clementine fruit have a different, undocumented morphology, not recognized as katydid damage. We find support for the latter two hypotheses. Katydids fed readily on the clementine fruit of all cultivars tested, chewing irregular holes that developed into jagged or web-like scars of a range of shapes and often led to splitting and abscission of maturing fruit. The katydid scars often more closely resembled chewing caterpillar damage than the round katydid scars in oranges, suggesting that katydid damage is being misclassified in clementines. The resistance documented in some other mandarins was not observed. Katydids are clearly a frugivorous pest causing previously unrecognized scarring in clementines.

Arthropod Infestation Levels on Mandarins in California.

Integrated pest management (IPM) guidelines for horticulture are typically established from years of experimental research and experience for a crop species. Ecoinformatics methods can help to quickly adapt these guidelines following major changes in growing practices. Citrus production in California is facing several major challenges, one of which is a shift away from sweet oranges [Citrus sinensis (L.) Osbeck Sapindales: Rutaceae] toward mandarins (including mostly cultivars of C. reticulata Blanco and C. clementina hort. ex Tanaka). In the absence of IPM guidelines for mandarins, growers are relying on pest information developed from oranges. We mined a database of management records from commercial growers and consultants to determine densities for four arthropod pests: cottony cushion scale (Icerya purchasi Maskell Hemiptera: Monophlebidae), citricola scale (Coccus pseudomagnoliarum Kuwana Hemiptera: Coccidae), European earwig (Forficula auricularia Linnaeus Dermaptera: Forficulidae), citrus red mite (Panonychus citri McGregor Acari: Tetranychidae), and a natural enemy, predatory mites in the genus Euseius (Congdon Acarina: Phytoseiidae). Densities of cottony cushion scale were approximately 10-40 times higher in the two most commonly grown mandarin species than in sweet oranges, suggesting this pest is reaching outbreak levels more often on mandarins. Densities of the other pests and predatory mites did not differ significantly across citrus species. This is a first step toward establishing IPM guidelines for mandarins for these pests; more research is needed to determine how arthropod densities relate to crop performance in mandarins.

The Status Quo of Rare Diseases Centres for the Development of a Clinical Decision Support System - A Cross-Sectional Study.

Clinical decision support systems (CDSS) help to improve the diagnostics and treatment of rare diseases (RD). As one of four funded consortia of the Medical Informatics Initiative supported by the Federal Ministry of Education and Research (BMBF, Germany), MIRACUM develops a clinical decision support system (CDSS) for RD based on distributed data of ten university hospitals. The CDSS will be developed at the Rare Diseases Centres (RDC) of the MIRACUM consortium. Since it is essential to deliver decision support at the right time and place in the clinician's workflow, this study aimed to capture relevant information of the RDCs regarding patient admission and diagnostic process. Additionally, we investigated how patient documentation and digitalisation is performed at the centres. Therefore, we conducted a cross-sectional survey involving experts in the RDs domain to capture relevant information for the further development of a CDSS in RD. For each centre, one expert on RDs participated in the study (n=8). The survey identified several challenges regarding the reuse of patient data, e.g. the paper-based documentation of a patientâAZs medical history and coding of diagnoses using ICD-10. However, we noticed a relevant use of current software diagnosis support and a similarly performed diagnostic process in all RDC. Further studies are needed to get more detailed insights and to define specific requirements.

Rituximab-Containing Treatment Regimens May Imply a Long-Term Risk for Difficult-To-Treat Chronic Hepatitis E.

Hepatitis E virus (HEV) infection is an emerging disease in industrialized countries which is usually characterized by a self-limited course. However, there is an increased risk of HEV persistence in immunocompromised risk populations, comprising patients following solid organ transplantation or hematological malignancies. Recently, chronic HEV infection following rituximab-containing treatment regimens has been described. Here we report five patients with chronic hepatitis E after prior rituximab therapy for various indications. We determined the immunological characteristics of these patients and analyzed the development of ribavirin (RBV) treatment failure-associated mutations in the HEV genome. One patient became chronically HEV-infected 110 months after administration of rituximab (RTX). Immunological characterization revealed that all patients exhibited significant hypogammaglobulinemia and CD4+ T cell lymphopenia. One patient permanently cleared HEV following weight-based ribavirin treatment while three patients failed to reach a sustained virological response. In depth mutational analysis confirmed the presence of specific mutations associated with RBV treatment failure in these patients. Our cases indicate that rituximab-containing treatment regimens might imply a relevant risk for persistent HEV infection even years after the last rituximab application. Moreover, we provide further evidence to prior observations suggesting that chronically HEV infected patients following RTX-containing treatment regimens might be difficult to treat.

Basilar artery thrombosis during sexual intercourse.

An ischemic stroke during sexual intercourse is very rare. A basilar artery thrombosis during sexual intercourse has not been described previously. We report a young woman with a life-threatening basilar artery thrombosis during sexual intercourse, with a resulting locked-in syndrome. The positive high intensity transient signals (HITS) diagnosis showed a right-to-left shunt and is in line with paradoxic embolism. The molecular genetics revealed a homozygosity 4G/4G in the region PAI1, -675 (promoter polymorphism) as a risk factor for ischemic stroke. Sexual intercourse is a possible, albeit unusual stroke cause, especially in young people.

Differential Impacts of Citrus Thrips Across Sweet Orange and Mandarin Species.

Several domesticated Citrus species are grown as major commercial crops in California. Despite this, farmers currently use a single set of management practices, originally created for sweet oranges (Citrus sinensis (L.) Osbeck [Sapindales: Rutaceae]), for both sweet oranges and all mandarin species. Mandarins, primarily Citrus reticulata Blanco, Citrus clementina hort. ex Tanaka, and Citrus unshiu Marcovitch, comprise almost 25% of California citrus acreage, and little work has been done to assess host-pest interactions for these species. Citrus thrips (Scirtothripscitri Moulton [Thysanoptera: Thripidae]) are one of the main pests in California citrus and are major targets for early spring, "petal fall" insecticide applications. We used mixed species citrus blocks to test the influence of Citrus species, including C. sinensis, C. reticulata, C. clementina, and C. unshiu, on 1) citrus thrips densities following petal fall; 2) citrus thrips-induced scarring on both the calyx and stylar ends of fruit; and 3) fruit deformation. Citrus sinensis and C. unshiu had relatively high citrus thrips densities and scarring levels, whereas C. reticulata had lower densities of citrus thrips and scarring levels. The age structure of citrus thrips populations also varied across Citrus species. Fruit deformity associated with citrus thrips scarring was found on all Citrus species examined. Scarring on the stylar-end of fruit, a previously largely ignored location of citrus thrips scarring, was found to be common in C. reticulata. It is clear from our work that species-specific management guidelines for citrus thrips are needed in sweet oranges and mandarins.