Parasitic dinoflagellate Hematodinium perezi prevalence in larval and juvenile blue crabs Callinectes sapidus from coastal bays of Virginia.

The parasitic dinoflagellate Hematodinium perezi infects the American blue crab Callinectes sapidus and other decapods along the Eastern seaboard and Gulf of Mexico coast of the USA. Large juvenile and adult blue crabs experience high mortality during seasonal outbreaks of H. perezi, but less is known about its presence in the early life history stages of this host. We determined the prevalence of H. perezi in megalopae and early benthic juvenile crabs from multiple locations along the Virginia portion of the Delmarva Peninsula. The DNA of H. perezi was not detected in any megalopae collected from several locations within the oceanic coastal bay complex in which H. perezi is found at high prevalence levels. However, prevalence levels were high in early benthic juveniles from 2 oceanic coastal embayments: South Bay and Cobb Bay. Prevalence levels were lower at locations within Chesapeake Bay, including Cherrystone Creek, Hungars Creek, and Pungoteague Creek. Sampling over different seasons and several consecutive years indicates that disease transmission occurs rapidly after megalopae settle in high-salinity bays along the Delmarva Peninsula during the late summer and fall. Infected juvenile crabs can overwinter with the parasite and, when subjected to increasing water temperatures in spring, infections progress rapidly, culminating in transmission to other crabs in late spring and early summer. In high-salinity embayments, H. perezi can reach high prevalence levels and may significantly affect recruitment of juvenile blue crabs into the adult fishery.

Characterization of microsporidian Ameson herrnkindi sp. nov. infecting Caribbean spiny lobsters Panulirus argus.

The Caribbean spiny lobster Panulirus argus supports a large and valuable fishery in the Caribbean Sea. In 2007-2008, a rare microsporidian parasite with spore characteristics typical of the Ameson genus was detected in 2 spiny lobsters from southeast Florida (FL). However, the parasite species was not confirmed by molecular analyses. To address this deficiency, reported here are structural and molecular data on single lobsters displaying comparable 'cotton-like' abdominal muscle containing ovoid microsporidian spores found at different locations in FL in 2014 and 2018 and in Saint Kitts and Nevis Islands in 2017. In the lobster from 2014, multiple life stages consistent with an Ameson-like monokaryotic microsporidian were detected by transmission electron microscopy. A partial (1228 bp) small subunit (SSU) rRNA gene sequence showed each microsporidia to be identical and positioned it closest phylogenetically to Ameson pulvis in a highly supported clade also containing A. michaelis, A. metacarcini, A. portunus, and Nadelspora canceri. Using ecological, pathological, ultrastructural, and molecular data, the P. argus microsporidian has been assigned to a distinct species: Ameson herrnkindi.

Developing and implementing national health identifiers in resource limited countries: why, what, who, when and how?

Many resource-limited countries are scaling up health services and health-information systems (HISs). The HIV Cascade framework aims to link treatment services and programs to improve outcomes and impact. It has been adapted to HIV prevention services, other infectious and non-communicable diseases, and programs for specific populations. Where successful, it links the use of health services by individuals across different disease categories, time and space. This allows for the development of longitudinal health records for individuals and de-identified individual level information is used to monitor and evaluate the use, cost, outcome and impact of health services. Contemporary digital technology enables countries to develop and implement integrated HIS to support person centred services, a major aim of the Sustainable Development Goals. The key to link the diverse sources of information together is a national health identifier (NHID). In a country with robust civil protections, this should be given at birth, be unique to the individual, linked to vital registration services and recorded every time that an individual uses health services anywhere in the country: it is more than just a number as it is part of a wider system. Many countries would benefit from practical guidance on developing and implementing NHIDs. Organizations such as ASTM and ISO, describe the technical requirements for the NHID system, but few countries have received little practical guidance. A WHO/UNAIDS stake-holders workshop was held in Geneva, Switzerland in July 2016, to provide a 'road map' for countries and included policy-makers, information and healthcare professionals, and members of civil society. As part of any NHID system, countries need to strengthen and secure the protection of personal health information. While often the technology is available, the solution is not just technical. It requires political will and collaboration among all stakeholders to be successful.

Evaluation of solid particle number and black carbon for very low particulate matter emissions standards in light-duty vehicles.

To reliably measure at the low particulate matter (PM) levels needed to meet California's Low Emission Vehicle (LEV III) 3- and 1-mg/mile particulate matter (PM) standards, various approaches other than gravimetric measurement have been suggested for testing purposes. In this work, a feasibility study of solid particle number (SPN, d50 = 23 nm) and black carbon (BC) as alternatives to gravimetric PM mass was conducted, based on the relationship of these two metrics to gravimetric PM mass, as well as the variability of each of these metrics. More than 150 Federal Test Procedure (FTP-75) or Supplemental Federal Test Procedure (US06) tests were conducted on 46 light-duty vehicles, including port-fuel-injected and direct-injected gasoline vehicles, as well as several light-duty diesel vehicles equipped with diesel particle filters (LDD/DPF). For FTP tests, emission variability of gravimetric PM mass was found to be slightly less than that of either SPN or BC, whereas the opposite was observed for US06 tests. Emission variability of PM mass for LDD/DPF was higher than that of both SPN and BC, primarily because of higher PM mass measurement uncertainties (background and precision) near or below 0.1 mg/mile. While strong correlations were observed from both SPN and BC to PM mass, the slopes are dependent on engine technologies and driving cycles, and the proportionality between the metrics can vary over the course of the test. Replacement of the LEV III PM mass emission standard with one other measurement metric may imperil the effectiveness of emission reduction, as a correlation-based relationship may evolve over future technologies for meeting stringent greenhouse standards. IMPLICATIONS: Solid particle number and black carbon were suggested in place of PM mass for the California LEV III 1-mg/mile FTP standard. Their equivalence, proportionality, and emission variability in comparison to PM mass, based on a large light-duty vehicle fleet examined, are dependent on engine technologies and driving cycles. Such empirical derived correlations exhibit the limitation of using these metrics for enforcement and certification standards as vehicle combustion and after-treatment technologies advance.

Smoldering and Flame Resistant Textiles via Conformal Barrier Formation.

A durable and flexible silicone-based backcoating (halogen free) is applied to the backside of an otherwise smoldering-prone and flammable fabric. When exposed to fire, cyclic siloxanes (produced by thermal decomposition of the backcoating) diffuse through the fabric in the gas phase. The following oxidation of the cyclic siloxanes forms a highly conformal and thermally stable coating that fully embeds all individual fibers and shields them from heat and oxidation. As a result, the combustion of the fabric is prevented. This is a novel fire retardant mechanism that discloses a powerful approach towards textiles and multifunctional flexible materials with combined smoldering/flaming ignition resistance and fire-barrier properties.

Prognosis of uveal melanoma based on race in 8100 patients: The 2015 Doyne Lecture.

A retrospective, nonrandomized, interventional case series of 8100 patients with uveal melanoma were evaluated for melanoma-related metastasis based on patient race. The patient race was Caucasian (n=7918, 98%), Hispanic (n=105, 1%), Asian (n=44, <1%), or African American (n=33, <1%). On the basis of race (Caucasian, Hispanic, Asian, and African American), significant differences were noted in mean age at presentation (58, 48, 44, and 52 years; P<0.001), distance of posterior tumor margin to foveola (5, 5, 6, and 4 mm; P<0.001), distance of posterior tumor margin to optic disc (5, 5, 6, and 4 mm) (P<0.001), tumor base (11, 12, 12, and 13 mm; P<0.001), tumor thickness (5.4, 7.1, 6.5, and 7.5 mm; P<0.001), intraocular hemorrhage (10, 14, 11, and 24%; P=0.02), and rupture of Bruch's membrane (20, 27, 39, and 36%; P=0.001). On the basis of multivariate analysis, the rate of metastasis increased with increasing age (P<0.001), ciliary body location (P<0.001), increasing tumor base (P<0.001), increasing tumor thickness (P<0.001), pigmented tumor (P=0.001), subretinal fluid (P=0.001), intraocular hemorrhage (P=0.045), and extraocular extension (P=0.036). Kaplan-Meier estimates of metastasis at 3, 5, and 10 were 8, 15, and 25% in Caucasians; 13, 13, and 13% in Hispanics; 4, 4, and 36% in Asians; and 8, 8, and 8% in African Americans. Compared with Caucasians, despite relative risk for metastasis of 0.31 for African Americans, 0.73 for Hispanics, and 1.42 for Asians, there was no statistical difference in metastasis, or death from uveal melanoma based on race. In summary, uveal melanoma showed similar prognosis for all races.

Two Unusual but Treatable Causes of Refractory Ascites After Liver Transplantation.

Refractory ascites (RA) is thought to complicate the postoperative course of 5-7% (Nishida et al. in Am J Transplant. 6: 140-149, 2006; Gotthardt et al. in Ann Transplant. 18: 378-383, 2013) of liver transplant recipients. RA after liver transplantation is often a frustrating diagnostic dilemma with few good management options unless an obvious mechanical factor is identified. Supportive therapies often fail until a treatable precipitating cause is identified and removed. We describe two patients who developed RA following liver transplantation for primary sclerosing cholangitis, and hepatitis C and alcoholic liver disease, respectively. The cause for RA was hyperkinetic portal hypertension secondary to splenomegaly in the first case and a pancreatic AVM in the 2nd case. After failure of other interventions, surgical splenectomy resulted in immediate and durable resolution of the previously intractable ascites.

Rescue intra-arterial chemotherapy following retinoblastoma recurrence after initial intra-arterial chemotherapy.

PURPOSE: To determine the efficacy of rescue intra-arterial chemotherapy (IAC) for retinoblastoma recurrence following failed initial IAC. METHODS: Retrospective, non-comparative, interventional case series of 12 eyes in 12 patients. INTERVENTION: Rescue IAC employed chemotherapy agents of melphalan (5mg, 7.5mg) alone or with additional topotecan (1mg). MAIN OUTCOME MEASURE: Tumor control and globe salvage. RESULTS: The median patient age at initial presentation was 16 months. At initial examination, the International Classification of Retinoblastoma grouping was group B (n=1), group D (n=7), or group E (n=4). The initial IAC was primary in 5 cases (42%) and secondary following failure of intravenous chemotherapy in 7 (58%). In all cases, initial IAC was delivered using melphalan 3mg (n=3), melphalan 5mg (n=7), or combination melphalan 5mg/topotecan 1mg (n=2) for a median of 3 cycles. The mean interval from initial IAC to recurrence necessitating rescue IAC was 5 months (median 4, range 2-10 months). Of the 12 patients, 3 (25%) had undergone previous enucleation of the opposite eye and the rescue IAC was planned for the only remaining eye. Rescue IAC was delivered for recurrent solid tumor (n=1), recurrent subretinal seeds (n=7), recurrent vitreous seeds (n=1), or combination recurrent subretinal/vitreous seeds (n=3). IAC was technically successful through the ophthalmic artery in 9 cases (75%) or the middle meningeal artery in 3 (25%). Rescue IAC involved median 3 cycles (mean 3, range 2-4 cycles) of higher dose melphalan in 4 cases (33%) or combination melphalan/topotecan in 8 (67%). At mean follow-up of 20 months (median 14 months, range 7-36 months), complete tumor control was achieved in 9 eyes (75%) and globe salvage in 8 eyes (67%). Of the 3 failure eyes, all were initially groups D or E, previously treated with initial IAC, and 2 had previous intravenous chemotherapy. There were 4 eyes that came to enucleation for persistent subretinal/vitreous seeds (n=3) or neovascular glaucoma without viable tumor (n=1). There was no case of cerebrovascular stroke, systemic metastasis, or death. CONCLUSION: Rescue IAC following retinoblastoma recurrence after initial IAC provided tumor control in 75% of cases and globe salvage in 67%. Rescue IAC can be considered in children who fail initial IAC, especially if the opposite eye has been enucleated.

High-throughput screening identifies compounds that enhance lentiviral transduction.

A difficulty in the field of gene therapy is the need to increase the susceptibility of hematopoietic stem cells (HSCs) to ex vivo genetic manipulation. To overcome this obstacle a high-throughput screen was performed to identify compounds that could enhance the transduction of target cells by lentiviral vectors. Of the 1280 compounds initially screened using the myeloid-erythroid-leukemic K562 cell line, 30 were identified as possible enhancers of viral transduction. Among the positive hits were known enhancers of transduction (camptothecin, etoposide and taxol), as well as the previously unidentified phorbol 12-myristate 13-acetate (PMA). The percentage of green fluorescent protein (GFP)-positive-expressing K562 cells was increased more than fourfold in the presence of PMA. In addition, the transduction of K562 cells with a lentiviral vector encoding fVIII was four times greater in the presence of PMA as determined by an increase in the levels of provirus in genetically modified cells. PMA did not enhance viral transduction of all cell types (for example, sca-1(+) mouse hematopoietic cells) but did enhance viral transduction of human bone marrow-derived CD34(+) cells. Notably, the percentage of GFP-positive CD34(+) cells was increased from 7% in the absence of PMA to greater than 22% in the presence of 1 nM PMA. PMA did not affect colony formation of CD34(+) cells or the expression of the hematopoietic markers CD34 and CD45. These data demonstrate that high-throughput screening can be used to identify compounds that increase the transduction efficiency of lentiviral vectors, identifying PMA as a potential enhancer of lentiviral HSC transduction.

Discovery of an opportunistic starfish pathogen, Orchitophrya stellarum, in captive blue crabs, Callinectes sapidus.

Histophagous scuticociliate infections were discovered in blue crabs, Callinectes sapidus, held in research facilities at the Virginia Institute of Marine Science. Ciliates were observed infecting every tissue examined including the gills, heart, muscle, hepatopancreas, and epidermis. Hemolymph smears and histological tissue sections indicated a morphological similarity to Mesanophrys chesapeakensis, the only recorded histophagous ciliate infecting blue crabs. However, subsequent analysis of the ribosomal ITS region (ITS1-5.8S-ITS2) of the ciliate indicated the parasite was Orchitophrya stellarum, a parasitic ciliate previously reported infecting sea stars from Europe, Australia, and North America. A simple Polymerase Chain Reaction (PCR-RFLP) assay was developed to detect and differentiate between O. stellarum and M. chesapeakensis. Its application confirmed the presence of O. stellarum infecting blue crabs held in an additional research facility in Maryland. For growth studies, cultures of O. stellarum grew optimally on 10% blue crab serum in crustacean saline held at 10-20°C. A field survey of blue crabs collected during the winters of 2011-2012 and sea stars (Asterias forbesi) during the winter of 2010 from the Chesapeake Bay and eastern shore of Virginia did not identify additional infected individuals.

GADD34 induces cell death through inactivation of Akt following traumatic brain injury.

Neuronal cell death contributes significantly to the pathology of traumatic brain injury (TBI) irrespective of the mode or severity of the injury. Activation of a pro-survival protein, Akt, is known to be regulated by an E3 ligase TRAF6 through a process of ubiquitination-coupled phosphorylation at its T308 residue. Here we show that upregulation of a pro-apototic protein, GADD34, attenuates TRAF6-mediated Akt activation in a controlled cortical impact model of TBI in mice. TBI induces the expression of GADD34 by stimulating binding of a stress inducible transcription factor, ATF4, to the GADD34 promoter. GADD34 then binds with TRAF6 and prevents its interaction with Akt. This event leads to retention of Akt in the cytosol and prevents phosphorylation at the T308 position. Finally, in vivo depletion of GADD34 using a lentiviral knockdown approach leads to a rescue of Akt activation and markedly attenuates TBI-induced cell death.

Retinoblastoma frontiers with intravenous, intra-arterial, periocular, and intravitreal chemotherapy.

In this report, we explore retinoblastoma diagnostic accuracy and review chemotherapy alternatives for retinoblastoma using intravenous, intra-arterial, periocular, and intravitreal routes. A review of 2775 patients referred for management of retinoblastoma, disclosed 78% with confirmed retinoblastoma and 22% with simulating lesions, termed pseudoretinoblastomas. Children ≤2 years old showed leading pseudoretinoblastomas of persistent fetal vasculature, Coats disease, and vitreous haemorrhage, whereas those >5 years showed simulators of Coats, toxocariasis, and familial exudative vitreoretinopathy. The diagnosis of retinoblastoma should be established before planning therapeutic strategy. Chemotherapy strategy depends on tumour laterality and stage of disease. If bilateral retinoblastoma, intravenous chemotherapy (IVC) is important as first-line therapy for control of intraocular disease, prevention of metastasis, and reduction in prevalence of pinealoblastoma and long-term second malignant neoplasms. Bilateral groups D and E retinoblastoma receive additional subtenon's carboplatin boost for improved local control. If unilateral disease is present, then intra-arterial chemotherapy (IAC) is often considered. IAC can be salvage therapy following chemoreduction failure. Unilateral retinoblastoma of groups D and E are managed with enucleation or globe-conserving IVC and/or IAC. Intravitreal chemotherapy is cautiously reserved for recurrent vitreous seeds following other therapies. In conclusion, the strategy for retinoblastoma management with chemotherapy depends on tumour laterality and stage of disease. Bilateral retinoblastoma is most often managed with IVC and unilateral retinoblastoma with IAC, but if advanced stage, combination IVC plus IAC or enucleation.

Disease will limit future food supply from the global crustacean fishery and aquaculture sectors.

Seafood is a highly traded food commodity. Farmed and captured crustaceans contribute a significant proportion with annual production exceeding 10 M metric tonnes with first sale value of $40bn. The sector is dominated by farmed tropical marine shrimp, the fastest growing sector of the global aquaculture industry. It is significant in supporting rural livelihoods and alleviating poverty in producing nations within Asia and Latin America while forming an increasing contribution to aquatic food supply in more developed countries. Nations with marine borders often also support important marine fisheries for crustaceans that are regionally traded as live animals and commodity products. A general separation of net producing and net consuming nations for crustacean seafood has created a truly globalised food industry. Projections for increasing global demand for seafood in the face of level or declining fisheries requires continued expansion and intensification of aquaculture while ensuring best utilisation of captured stocks. Furthermore, continued pressure from consuming nations to ensure safe products for human consumption are being augmented by additional legislative requirements for animals (and their products) to be of low disease status. As a consequence, increasing emphasis is being placed on enforcement of regulations and better governance of the sector; currently this is a challenge in light of a fragmented industry and less stringent regulations associated with animal disease within producer nations. Current estimates predict that up to 40% of tropical shrimp production (>$3bn) is lost annually, mainly due to viral pathogens for which standard preventative measures (e.g. such as vaccination) are not feasible. In light of this problem, new approaches are urgently required to enhance yield by improving broodstock and larval sourcing, promoting best management practices by farmer outreach and supporting cutting-edge research that aims to harness the natural abilities of invertebrates to mitigate assault from pathogens (e.g. the use of RNA interference therapeutics). In terms of fisheries losses associated with disease, key issues are centred on mortality and quality degradation in the post-capture phase, largely due to poor grading and handling by fishers and the industry chain. Occurrence of disease in wild crustaceans is also widely reported, with some indications that climatic changes may be increasing susceptibility to important pathogens (e.g. the parasite Hematodinium). However, despite improvements in field and laboratory diagnostics, defining population-level effects of disease in these fisheries remains elusive. Coordination of disease specialists with fisheries scientists will be required to understand current and future impacts of existing and emergent diseases on wild stocks. Overall, the increasing demand for crustacean seafood in light of these issues signals a clear warning for the future sustainability of this global industry. The linking together of global experts in the culture, capture and trading of crustaceans with pathologists, epidemiologists, ecologists, therapeutics specialists and policy makers in the field of food security will allow these issues to be better identified and addressed.

Current trends in hospital mergers and acquisitions.

Healthcare reform will impact hospital consolidation in three key areas: Payment rates will decrease, indirectly encouraging consolidation by forcing hospitals to find new ways to reduce costs and increase negotiating clout with suppliers and payers. The cost of doing business will increase as hospitals spend more on compliance, technology, and physician employment. The ACO model will encourage hospital network formation by rewarding integrated healthcare systems that can reduce costs and improve quality.

High prevalent and incident HIV-1 and herpes simplex virus 2 infection among male migrant and non-migrant sugar farm workers in Zambia.

BACKGROUND: More insight is needed regarding risk factors for prevalent and incident HIV-1 infection among male farm workers in Sub-Saharan Africa to control the HIV-1 epidemic. METHODS: Male farm workers were recruited from a sugar estate in Zambia to participate in a prospective cohort study. Questionnaire data were collected via interview, and testing was conducted for HIV-1, herpes simplex virus type 2 (HSV-2), and syphilis infection at baseline and follow-up between May 2006 and September 2007. RESULTS: Among 1062 workers enrolled, HIV-1 prevalence at baseline was 20.7%. Testing HSV-2 seropositive (adjusted odds ratio (AOR) 5.4, 95% CI 3.6 to 8.1), self-reported genital ulcers in the past year (AOR 2.8, 95% CI 1.9 to 4.2), and being widowed (AOR 3.7, 95% CI 2.0 to 6.9) were significantly associated with prevalent HIV-1 infection. The HIV-1 incidence among 731 initially negative participants with at least one follow-up visit was 4.1 per 1000 person-months (95% CI 2.6 to 5.7); seroconversion was independently associated with prevalent HSV-2 infection (adjusted hazard ratio (AHR) 2.4, 95% CI 1.0 to 5.8) and incident HSV-2 infection (AHR 18.0, 95% CI 4.2 to 76.3). HIV-1 prevalence and incidence rates were similar among migrant and non-migrant workers. CONCLUSIONS: HIV-1 prevalence and incidence were high, and HSV-2 infection was a risk factor for HIV-1 acquisition. There is an urgent need to expand HIV-1 prevention programmes tailored to farm workers and their communities.

Diseases of spiny lobsters: a review.

Spiny lobsters have few reported pathogens, parasites and symbionts. However, they do have a diverse fauna comprised of a pathogenic virus, several bacteria, protozoans, helminths and even symbiotic crustaceans. A few idiopathic syndromes have also been reported, but these appear correlated with lobsters held in poor conditions. Fungal and bacterial pathogens present significant threats for rearing spiny lobsters in aquaculture settings, but only one pathogen, Panulirus argus virus 1, is thought to have damaged a fishery for a spiny lobster. No doubt others will emerge as lobsters are brought into aquaculture setting and as fishing pressure intensifies with stocks become more susceptible to anthropogenic stressors.

Myospora metanephrops (n. g., n. sp.) from marine lobsters and a proposal for erection of a new order and family (Crustaceacida; Myosporidae) in the Class Marinosporidia (Phylum Microsporidia).

In this study we describe, the first microsporidian parasite from nephropid lobsters. Metanephrops challengeri were captured from an important marine fishery situated off the south coast of New Zealand. Infected lobsters displayed an unusual external appearance and were lethargic. Histology was used to demonstrate replacement of skeletal and other muscles by merogonic and sporogonic stages of the parasite, while transmission electron microscopy revealed the presence of diplokaryotic meronts, sporonts, sporoblasts and spore stages, all in direct contact with the host sarcoplasm. Analysis of the ssrDNA gene sequence from the lobster microsporidian suggested a close affinity with Thelohania butleri, a morphologically dissimilar microsporidian from marine shrimps. Whilst morphological features of the lobster parasite are consistent with members of the family Nosematidae, molecular data place the parasite closer to members of the family Thelohanidae. Due to the contradiction between morphological and molecular taxonomic data, we propose the erection of a new genus in which the lobster parasite is the type species (Myospora metanephrops). Furthermore, we recommend the erection of a new family (Myosporidae) and a new order (Crustaceacida) to contain this genus. The taxonomic framework presented could be further applied to the re-classification of existing members of the Phylum Microsporidia.

Polypoidal choroidal vasculopathy following photodynamic therapy for choroidal hemangioma.

PURPOSE: To report a case of circumscribed choroidal hemangioma (CCH) that responded to photodynamic therapy (PDT) but 3 years later developed polypoidal choroidal vasculopathy (PCV) with exudative retinopathy. METHODS: Case report. RESULTS: A 59-year-old woman with a juxtapapillary CCH in her left eye was treated with a single 83-second, 7.5 mm PDT laser spot at 689 nm (50 J/cm2) 15 minutes after the injection of intravenous verteporfin (6 mg/m2). Three years later, the patient presented with photopsia in her left eye. Fundus examination of the left eye showed CCH regressed completely to a flat atrophic scar. There was diffuse macular edema and exudative retinopathy along the inferotemporal vascular arcade. On indocyanine green angiography, there were hyperfluorescent dilated choroidal vessels inferior to the foveola with late staining and leakage consistent with PCV. Hypofluorescence superior and nasal to the optic disc at the site of the treated hemangioma, consistent with choroidal ischemia, was observed. She was treated with 1.25 mg (0.05 cc) intravitreal bevacizumab. After 21 months of follow-up, the exudative retinopathy and macular edema completely regressed. CONCLUSIONS: PDT is an effective treatment for CCH. Side effects of PDT for CCH are rare but include PCV.