Background: Necrotizing fasciitis (NF) is a life-threatening infection of the skin and soft tissue that spreads quickly and requires immediate surgery and medical treatment. Amputation or radical debridement of necrotic tissue is generally always required. The risks and benefits of both the surgical options are weighed before deciding whether to amputate or debride. This study set forth to create an easy-to-use risk scoring system for predicting the risk scoring system for amputation in patients with NF (ANF).Methods: This retrospective study included 1,506 patients diagnosed with surgically confirmed NF at three general hospitals in Thailand from January 2009 to December 2012. All diagnoses were made by surgeons who strictly observed the guidelines for skin and soft tissue infections produced by the Infectious Diseases Society of America. Patients were randomly allocated to either the derivation  or validation (n = 313) cohort. Clinical risk factors assessed at the time of recruitment were used to create the risk score, which was then developed using logistic regression. The regression coefficients were converted into item scores, and the total score was calculated.Results: The following four clinical predictors were used to create the model: female gender, diabetes mellitus, wound appearance stage 3 (skin necrosis and gangrene), and creatinine ≥1.6 mg/dL. Using the area under the receiver operating characteristic curve (AuROC), the ANF system showed moderate power (78.68%) to predict amputation in patients with NF with excellent calibration . The positive likelihood ratio of amputation in low-risk (score ≤ 4) and high-risk (score ≥ 7) patients was 2.17 (95%CI: 1.66–2.82) and 6.18 (95%CI: 4.08–9.36), respectively. The ANF system showed good performance (AuROC 76.82%) when applied in the validation cohort.Conclusion: The developed ANF risk scoring system, which includes four easy to obtain predictors, provides physicians with prediction indices for amputation in patients with NF. This model will assist clinicians with surgical decision-making in this time-sensitive clinical setting. Necrotizing fasciitis (NF) is a dangerous infection that causes widespread inflammation and necrosis of the soft tissues, and that most often affects the fascia and subcutaneous layers . The recThe microbes, risk factors, and causes associated with NF have been established, and classification systems have been developed to identify and score patients at high risk for NF –17. In 2Accordingly, the aim of this study was to use the epidemiology of NF disease in Thailand to create an easy-to-use risk scoring system for predicting the risk scoring system for amputation in patients with NF (ANF). That score could be used in a routine clinical practice, and it will help physicians and medical team to use it for making decisions on patient care. In addition, our ultimate goal is to help a patient avoid amputation by early prediction and managing the factors related to disease progression.This was a retrospective cohort study. A prognostic prediction analysis and clinical score development study was conducted in accordance with the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) statement . Ten outFrom January 2009 to December 2012, the medical records of patients with surgically-confirmed NF were obtained from three general hospitals in Northern Thailand. The hospitals were Chiangrai Prachanukroh Hospital , Kamphaeng Phet Hospital , and Phayao Hospital .insample.” The derivation cohort  is a sample to develop ANF scoring system, and a validation cohort (n = 313) is to confirm accuracy and appropriateness of this scoring system. In our study, an NF with amputation was found in 127 patients (8.4%). This detail is shown in In total, 1,506 patients with NF were enrolled. They were divided into two groups using random sampling by computer generation (4:1), Stata command “Necrotizing fasciitis was defined by the presence of extensive necrosis affecting at least the fascia and subcutaneous tissue. Patients diagnosed with NF according to the standard definition were eligible for inclusion. Diagnoses were made by surgeons who strictly observed the guidelines for skin and soft tissue infections produced by the Infectious Diseases Society of America .The stages of wound appearance were defined as a clinical stage of NF. Cutaneous manifestations of NF present when the disease progresses through stages 1, 2, and 3 . Wound appearance stage 1 (early): the disease was clinically presenting with swelling and erythema; stage 2 (intermediate): belb formation is an important diagnostic clue of NF. When present, it signals the onset of critical skin ischemia; stage 3 (late): indicates the development of tissue necrosis and skin gangrene, which are severe signs of NF infection , 22.Severe pain was defined based on the patient complaint by use of a pain-assessment tool  according to the pain management guideline 2017 , 24.The protocol for this study was approved by the Ethics Committee of Chiangrai Prachanukroh Hospital and the Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand .t-test, and those results are shown as mean ± standard deviation (SD). Categorical data were compared using chi-square test or Fisher's exact test, and those results are given as number and percentage. All p-values are two-tailed and were considered statistically significant at a p-value < 0.05.Descriptive statistics were used to summarize patient demographic and clinical characteristics. Continuous data were compared using Student's P-values < 0.05 were considered statistically significant to include in running the model. Amputation and no amputation variables were evaluated using univariable logistic regression, and those results are summarized as odds ratio (OR) and 95% confidence interval (CI). Variables found to be statistically significant and other variables of interest were then entered into a multivariable logistic regression model to identify factors independently associated with amputation in NF. Item scores were calculated using the weighted coefficients of the significant variables from multivariable analysis. By dividing each regression coefficient by the smallest coefficient of the model and rounding to the nearest integer, the score was determined  was used to verify the scoring system. The efficiency and accuracy of the model were assessed using a ROC curve. The same diagnostic performance parameters that were calculated and assessed in the derivation cohort were calculated and assessed in the validation cohort.The validation cohort  ≥18.50, and 25.70% had diabetes mellitus. A swelling wound (wound appearance stage 1) was presented in 94.82% of patients, and the most common wound site was the lower limbs (77.04%). An amputation with NF found 127 patients (8.4%) and non-amputation with NF found 1,379 patients (91.6%). Sites of amputation were finger/toes (44.1%), above knee (22.8%), below knee (20.5%), forefoot (8.7%), hand and forearm (3.9%). Clinical and demographic characteristics of patients with NF among all patients and comparison between the derivation cohort and the validation cohort are shown in The overall amputation rate in this study was 8.43% . Univariable analysis for risk factors significantly associated with amputation in patients with NF in the derivation cohort is shown in The variables identified in univariable analysis were entered into subsequent multivariable analysis to develop the scoring system for amputation in patients with NF. Using backward stepwise logistic regression, the multivariable model included four variables. The weighted coefficient was used to calculate the point value for each factor, which was then rounded to the nearest whole number . The tot2 = 2.59; p = 0.8586).To categorize patients into three risk categories, cut-off scores of 4 and 7 were selected. Patients with a total score of ≥7 were considered to be at high risk. Amputation among those patients was found to be predicted with moderate accuracy . Patients with a total score of ≤4 were considered to be at low risk. No amputation was correctly predicted in 95.99% of cases (863/899) in this group. No amputation group could be excluded with moderate accuracy (NPV 21.43%). The corrected prediction of absence or presence of amputation was (863 + 28)/(899 + 78) = 91.19%, whereas the incorrect prediction rate was (36 + 50)/(899 + 78) = 8.80% . With thThe ROC curves for the derivation and validation cohorts showed similar results  that can be used as a screening tool to identify NF patients at risk for amputation. The ANF risk scoring system grades NF patients as being at low risk, moderate risk, or high risk for amputation, and this information will help clinicians with treatment decision-making. Amputation is an intensive treatment that can cause significant morbidity and organ failure; however, patients with high mortality risk are often indicated for primary amputation to prevent death. The ANF tool may be useful in decision-making for the clinical management of patients with NF who have been admitted to the hospital.We divided the patients in the NF patients in the derivation group into the amputation and no amputation groups. We then analyzed for factors that were significantly different between those two groups. Significant factors from univariable analysis were then entered into a multivariable logistic regression model to identify predictors independently associated with amputation. The ANF risk scoring system includes predictors related to a patient demography , patient comorbidity (diabetes mellitus), clinical sign , and laboratory result (creatinine ≥1.6 mg/dL). These predictors are similar to the important risk factors for amputation identified by many other studies .The patients with NF in this study were classified into three groups according to their likelihood of amputation . The ANF risk scoring system was internally validated, and it showed high discriminative power when evaluated in this study's validation cohort. The cut-off points used in this study were determined from evaluations of sensitivity, specificity, and positive and negative predictive values. The cut-off point for high risk for amputation was determined to be an ANF score of ≥7. Using this system, patients scoring ≤4 are classified as low-risk, and patients scoring 5–6 are classified as being at moderate risk for amputation. The ANF score of a patient can then be combined with other factors and the judgment of the physician. Patients with an ANF score ≥7 should be closely monitored and managed to avoid limb loss or death, if possible.P = 0.002) (p = 0.19) had no significant association with the amputation rate  . In contion rate . The LRIion rate . In contWomen have more subcutaneous fat than men, which makes them more vulnerable to infection. Previous studies have shown that female gender, diabetes, cutaneous gangrene on admission, symptoms of an underlying condition, clostridial infection, heart disease, and shock (systolic blood pressure <90 mmHg) at hospital admission are all independent predictors of limb loss in patients with NF , 35.Diabetes was previously reported to be a clinical predictor of limb amputation in patients with NF. In our study, the prevalence of diabetes was 25.70%. Our finding that diabetes is independently associated with limb loss is similar to the reported findings of several previous studies , 36, 37.p < 0.001) (p = 0.005)  . Similar= 0.005) , 7, 38. = 0.005) . In most= 0.005) , 39.A higher risk of limb failure was found in our sample when the serum creatinine level was >1.6 mg/dL. Renal dysfunction, which is thought to be linked with septic shock, is reflected by a higher serum creatinine level. Several previous studies reported shock (systolic blood pressure <90 mmHg) at admission to be an independent predictor of limb loss, elevated creatinine level, and higher mortality .The strengths of this study should be emphasized. First, this study included a large sample size of patients with NF to evaluate amputation outcome. We also included patients from three large hospitals in Thailand, which suggests that our results can be generalized to other regions of Thailand, and to other low to middle income Asian countries. Second, the ANF risk scoring system was developed in accordance with the stringent criteria set forth in the TRIPOD statement . Third, The most notable limitation of this study is it retrospective design, which rendered it vulnerable to missing or incomplete data. For example, the LRINEC scoring system could not be used in this study because some important laboratory investigations, such as CRP level, were not performed in all patients.p < 0.001. However, there was no difference in mortality between amputations and no amputations . The data on the amputations index date, time, and duration of index operations were not collected. However, we have the data of length of stay in a hospital of non-amputated, which was 11 days (SD = 11.59) and in amputated it was 16 days (SD = 10.79), with a P-value < 0.001. Amputation was performed to control the infection. However, there was no difference in mortality between amputations and no amputations. Our data showed that the mortality of amputated was 20.20% and non-amputated was 19.12% . This was similar to previous studies  or mortality rate, we found that LOS in a hospital of non-amputated is significantly lower  than those in amputated groups ,  studies  which reDespite this limitation, the ANF risk scoring system can be used in all clinical settings because of its low-cost and because it is simple to implement and use. The advantage of the ANF score is that it can help to detect early the amputation risk in patients with NF. Using this system, disease progression can be stopped or reduced, potential complications of NF can be monitored, and the risk of amputation can be greatly reduced or eliminated.The developed ANF risk scoring system, which includes four easy to obtain predictors, provides physicians with prediction indices for amputation in patients with NF. This model will assist clinicians with surgical decision-making in this time-sensitive clinical setting.coco_a105@hotmail.com.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the Ethics Committee of Chiangrai Prachanukroh Hospital and the Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand . Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.NCha, PK, and SS: study concept and design, statistical analysis, and interpretation of data. PK, NChu, and SS: acquisition of data. NCha, SS, and PP: drafting of the manuscript. NCha, PK, NChu, AD, SS, and PP: critical revision of the manuscript. All authors contributed to the article and approved the submitted version.via the Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN).This study was supported by a grant from the University of Phayao The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Duvalius cave beetles have a wide distribution in the Palearctic region. They have distinct adaptations to life in soil and subterranean habitats. Our present study intends to extend the knowledge on the morphology of cave Carabidae by describing two larvae belonging to different species of Duvalius and the ultrastructural details with possible implications in taxonomy and ecology. These two species are endemic for limited areas in the northern and north-western Romanian Carpathians. Our study provides knowledge on the biology and ecology of the narrow endemic cave beetles and their larvae are important in conservation and to establish management measures. Endemic species are vulnerable to extinction and, at the same time, an important target of global conservation efforts.The Duvalius (Hungarotrechus) subterraneus  and Duvalius (Biharotrechus) paroecus —are presented in this paper. The interest in studying these larvae lays in their rarity and the limited distribution of the Duvalius species. The larvae were collected from caves in the Romanian Carpathians and were examined under a stereomicroscope and scanning electron microscopy. New important taxonomical and fine morphological characteristics are discussed together with conclusions on the larvae microhabitat as part of the measures to be taken by a proper management of caves.The morphological and ultrastructural descriptions of the larvae of two cave species of Trechini— Duvalius  species have distinct adaptations to life in soil and subterranean habitats, as do many species of the subtribe [Duvalius has a wide distribution in the Palearctic region. Representatives of this genus were mentioned from Maghreb (Algeria), the western part of Europe in Spain  and France, central and southern Europe, Italy  but also Sicily and Sardinia, the Balkan Peninsula and the Carpathian Mountains. Towards the east, Duvalius is present from the Caucasus and the Middle East (Iran) to East China (Tien Shan Mountains) [untains) ,3. Duvalius consists of a complex [ complex  of trogl complex , which w complex ,5, along complex , and in  complex . Duvalius representatives is difficult due to their hidden life, with the larvae even less studied than the adults [The study of the biology of e adults . Severale adults ,9 and one adults , Giachine adults ,12, Luffe adults , Makarove adults , Casale e adults , Ortuño e adults  and Giace adults . The clae adults ,17, togee adults , contribe adults .However, there is little information about the larvae of subterranean Trechini species. The reproduction of cave adults and their larvae in the laboratory has been successful only in a few cases, due to the difficulty of recreating the cave’s relatively stable environmental conditions . The genDuvalius and the ultrastructural details, with possible implications in taxonomy and ecology. The larvae described here belong to Duvalius (Hungarotrechus) subterraneus  and D. (Biharotrechus) paroecus . These two species are endemic for limited areas, in the northern part of the Eastern Carpathians, respectively, and are vulnerable due to deforestation on the surface and non-organized tourism in caves. We will also discuss the habitats of the described larvae with remarks on the need for conservation measures in the caves.Our present study intends to extend the knowledge on the morphology of cave Carabidae by describing two larvae belonging to different species of Duvalius was collected on 21 March 2019  in the entrance zone of the Izvorul Tăușoarelor Cave  subterraneus  were also found and identified. The cave is protected under the Romanian legislation (O.U.G. nr. 57/2007) and considered as a scientific reservation with limited access.A larva of D. (Biharotrechus) paroecus , on the muddy cave floor, covered with humid degraded wood pieces. In a passage of Varnița Leșului Cave  and for details under an OLYMPUS BX51  microscope. All drawings were prepared using camera lucida mounted on both microscopes. Measurements were made using a micrometer. The nomenclature and the location of pores and setae used here are according to those proposed by Bousquet and Goulet , MakarowThe two larvae were also prepared for scanning electron microscopy (SEM) using the turbomolecular pumped coater Quorum Q150T ES , from the Integrated Electron Microscopy Laboratory (LIME) of the National Institute for Research and Development of Isotopic and Molecular Technologies (INCDTIM), Cluj-Napoca, Romania, and examined with an SEM Hitachi SU8230  . The preparation was carried out by Dr. Lucian Barbu.We assumed that this individual was a third instar larva based on the comparison with the data from the literature and with the larva described after.Body slightly sclerotized, with setation. Body has an elongated shape; color brown-whitish. Body length  8.3 mm A,B.Longer than wide; flat; (length (HL): 1 mm; width (HW): 0.83 mm; ratio HL/HW: 1.20) anophthalmos; parallelized without the very slight constriction in the middle of the posterior lateral region as in other Trechinae; without postocular and epicranial grooves, any other structures (egg-bursters and teeth-like) are absent. Short epicranial suture, as long as one-fourth of the head width. Frontal sutures clearly visible, deeply curved and sinuous. Antennal ring strongly separated D,E. MicrIs tri-lobed and almost symmetrical; with one median tooth and another seven teeth on each side; median lobe largest and medially protruding, projecting forwards I. With fDorsally, on each side of frontal FR , 10 smalLong, slender and with four segments; every segment longer than wide; first segment with three pores  not evident. Stipes with six setae (MX2–MX7) and a variable number of short setae (gMX). Lacinia absent. Galea with two segments A,B; secoLabial palps with two segments, as in other representatives of the Trechini, the second one subdivided into three apparent segments A,E,G. PrWith one claw A: trochaIn dorsal view with eight long setae (UR1–UR8) on each side A,B; on tWith conical shape, 24 setae D,E and tWe assumed that this individual was a second instar larva based on the comparison with the data from the literature and with the larva described previously.Body lightly sclerotized, with setation. Body has an elongated shape; color brown-whitish. Body length  7.3 mm A.It is as long as it is wide; flat;  anophthalmos; parallelized without a very slight constriction in the middle of the posterior lateral region as in other Trechinae; without postocular and epicranial grooves, any other structures (egg-bursters and teeth-like) are absent B. Short Is tri-lobed and almost symmetrical; median lobe largest and medially protruding, strongly projecting forwards, with two median teeth and another 11 teeth on each side; the teeth are arranged in layers G,I. The Dorsal A—on eachLong, slender and four segments; every segment longer than wide; first segment with three pores ANa–ANc; F,G; secoNarrow, regularly and moderately curved, without additional teeth, only with a small excision in front of retinaculum A; with tCardo very small with seta (MX1) not evident A. StipesLabial palps with two segments, as in other representatives of the tribe Trechini. The second segments subdivided into three apparent segments A,D. PremWith one claw A,B, simiIs similar to that of the previous species C. In dorIs similar to that of the previous species C. With cThe larvae of these specialized troglobiotic (cave-adapted) carabid are difficult to find, even in the caves where adult individuals are abundant ,30 . Each lobe has several small lobes at a fine structural level. These small lobes differ in number and shape between the two species. The central lobe of the two species is a formation consisting of two layers. The D. subterraneus first layer has four small lobes on each side. In the anterior part, between the two NA7 setae, the nasale has a slightly more prominent small lobe. The small lobes have a rounded apical part. The D. paroecus first layer has three small lobes on each side. The small lobes have a sharp apical part. The anterior small lobe (between the two NA8) is rounded and slightly contoured. The D. subterraneus second layer is an irregular formation in the anterior part. Laterally, there are three small, slightly contoured lobes on each side. The D. paroecus second layer is well contoured with five small sharp lobes on each side. In the anterior part, the second layer has six small sharp lobes.The nasale  of the two species presents structural differences. The nasale of D. subterraneus (D. paroecus (Duvalius species, but was not observed under classical microscopes. The arrangement of the pairs of chaetic sensilla, both on the inner and on the outer curvature, highlights the possible mechanoreceptor role of these sensilla. Thus, in addition to the role in food intake, the mandibles provide information on the mandibles’ position relative to their food sources, and possible obstacles in the vicinity of the larva. Several authors have investigated the sensilla equipment of the larval head in Carabids: Altner and Bauer [Mandibles of the two larvae have a different number of setae (three for erraneus A–C and tparoecus A–C. We nparoecus A–C. Untind Bauer , Bauer and Bauer , Moore and Bauer , Li et and Bauer  and Giglnd Bauer .Duvalius larvae described here, the hyaline vesicles and grooved peg sensillum were well represented, which indicated sensitivity to substances dissolved in the humid cave air or water. Attention was given especially to the ultrastructure and function of a sense organ located on the second segment. In carabid beetles, this structure is called the hyaline vesicle, and it was described by van Emden  and JeanDuvalius larvae at an ultrastructural level highlights the presence of particular sensory ultrastructures with a fundamental role in the reception and transmission of information from the environment [2 reception [The description of ironment . As withironment . The disironment . Sensilleception . Althougeception , their neception . Trichoieception . Bland eeception  suggesteDuvalius. It will, thus, provide valuable information on the specificity of vulnerable cave microhabitats, knowledge needed to establish proper management of caves. Knowledge on the biology and ecology of the narrowly endemic cave beetles and their larvae are important in conservation and to establish management measures. Endemic species are vulnerable to extinction and, at the same time, an important target of global conservation efforts [Duvalius or other cave species is absolutely obligatory, to avoid the microhabitats of their adults and larvae. On the surface, conservation measures must aim at conserving the forest habitats above the caves, ensuring a humid and cooler environment for the more superficial possible habitats of cave beetles and other cave species. Our study should be completed by comprehensive phylogenetic analysis on  efforts ,54 becau efforts ,57,58,59 efforts . For the efforts . Therefo


Alpelisib is a PIK3a inhibitor approved for the treatment of metastatic ER+ breast cancer in combination with fulvestrant. Although rash is a common side effect of this medication, we present the first case of drug reaction with eosinophilia and systemic symptoms (DRESS) upon initial exposure to alpelisib. Here we describe the clinical-pathological findings and management of our patient with alpelisib-induced life-threatening DRESS syndrome. The goal of this case report is to highlight association of alpelisib with DRESS syndrome, in clinical practice, so that alpelisib can be immediately stopped and treatment for this serious condition promptly initiated. Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe adverse drug reaction characterized by an extensive skin rash in association with visceral organ involvement, lymphadenopathy, eosinophilia, and atypical lymphocytosis. It is most commonly associated with antiepileptic medications . MetastaA 52-year-old female with metastatic HR positive (ER+ and PR+), HER2 negative breast cancer involving liver, bone, and pleural cavity presented to the hospital with fever of 102°F, chills, and non-pruritic generalized body rash of 1 day duration. She had initiated treatment with alpelisib  plus fulvestrant (500 mg intramuscular injection) and cetirizine prophylaxis 12 days prior to presentation. Patient did not receive any CYP3A4 inhibitors. Rash started on her trunk  with elevated absolute eosinophil count of 1,310 and new onset thrombocytopenia of 72,000. Her AST, ALT, and bilirubin were elevated to 74 U/L, 46 U/L, and 1.7 mg/dl, respectively, from a normal baseline 4 days earlier. Left lower abdomen skin punch biopsy showed spongiotic dermatitis with focal interface dermatitis and high epidermal cytoids characteristic of morbilliform drug eruption seen in the setting of DRESS syndrome  for the publication of any potentially identifiable images or data included in this article.UM and PA wrote the manuscript. TP, JS, GR, MA, AM-A, and KB reviewed and edited the manuscript. JS also helped with pathology slide and explanation. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Borrelia exposure. To test our hypothesis, a case-control study was carried out during 2019 in Serbia to determine the seroprevalence of anti-Borrelia antibodies in two case groups  and a control group . Individuals vaccinated against rabies following either “pre-exposure protocol”  or “post-exposure protocol”  were considered as rabies risk groups and healthy blood donors (n = 30) as the control group. The results showed higher Borrelia seroprevalence in PrEP  and PEP  groups compared with the control group . Furthermore, odds ratio (OR) analysis showed that risk of rabies (in either the PrEP (OR = 2.91) or PEP (OR = 3.29) groups) is associated with increased odds of being seropositive to Borrelia. However, the difference in Borrelia seroprevalence between groups was not statistically significant (Chi-square (χ²) test p > 0.05). The shared odds of LB and rabies exposure found in this study suggest that, in countries where both diseases occur, the common citizen can be at risk of both diseases when in a risky habitat. These findings are important to guide physicians in targeting high-risk groups, and diagnose LB, and to guide decision-makers in targeting control and prevention measures for both infections in risk areas.Lyme borreliosis (LB) is the most common tick-borne disease in Serbia and other European countries. Rabies is a fatal zoonosis distributed worldwide and is caused by the rabies virus. Professionals at risk of rabies—including veterinarians, hunters, communal service workers, and forestry workers—overlap with some professions at a higher risk of exposure to tick bites and tick-borne pathogen infections. We hypothesized that individuals identified by the public health system as at risk of rabies virus infection, and consequently vaccinated against rabies virus, also share a higher likelihood of  Ixodes ricinus , the most important tick vector of human diseases in Europe, is a generalist tick that can feed on several animal species, including humans—who are considered accidental hosts [Ixodes ricinus is mostly found in deciduous forests where small mammals and deer serve as its main hosts. However, this tick species can also be found in swamps and meadows during periods of high rainfalls [I. ricinus include tick-borne encephalitis, human granulocytic anaplasmosis and other rickettsial diseases, babesiosis and Lyme borreliosis (LB) [Borrelia infection in Europe is caused by the members of the Borrelia burgdorferi sensu lato (s.l.) complex, including Borrelia burgdorferi sensu stricto (s.s.), Borrelia afzelii, and Borrelia garinii, and the estimated incidence of LB in the region ranges from 85,000 to more than 200,000 cases per year [Borrelia spielmanii and some pathogenic strains of Borrelia lusitaniae, Borrelia valaisiana, and Borrelia bissettii [I. ricinus is responsible for the transmission of several tick-borne diseases (TBDs) including LB, tick-borne encephalitis, and rickettsioses [Borrelia DNA have been detected in I. ricinus collected from several regions [B. burgdorferi s.l. complex [Ecological perturbations due to land use by humans, growing human population, globalization, and climate change are associated with an increased incidence and prevalence of vector-borne diseases. Higher average temperatures associated with climate change are suitable for most arthropod vectors, which may explain the territorial expansion and increased abundance of different vectors. Ticks are the main vectors for animal and human diseases in Europe, and their geographic ranges have expanded in recent years ,2,3. Ixoal hosts ,5. Ixodeainfalls ,7. Diseasis (LB) ,9. Borreper year ,11. Althissettii . The spittsioses ,14,15,16ttsioses ,17, wher regions ,19, and  complex . Due to Lyssavirus, Family: Rhabdoviridae), which affects the central nervous system of mammals and leads to signs of encephalomyelitis with almost 100% fatality rate [Rabies is a lethal zoonosis with worldwide distribution and is caused by rabies virus , we designed a case-control study to compare the seroprevalence of anti-Borrelia antibodies in individuals immunized against rabies (two case groups) and healthy blood donors with no profession-associated accesses to risk areas (control group) in Serbia and Bosnia and Herzegovina. Such valuable information would be highly useful for the planning of prevention and control measures, particularly for personnel at high risk of LB.Considering the above evidence, we hypothesized that individuals identified by the public health system as at risk of rabies virus infection also share a high likelihood of being bitten by This study was approved by the Novi Sad Ethical Committee at the Faculty of Medicine, the University of Novi Sad , and was conducted according to the Declaration of Helsinki and The Patient Rights Law of the Republic of Serbia. Written informed consents were obtained from blood donors to allow the use of their blood samples for this study.Borrelia IgG among individuals at risk, or not, of rabies virus exposure. Accordingly, two groups of individuals were considered at risk of rabies virus exposure. The first group included individuals who live, or spend time, in rural areas or forests and after being bitten by rabid or rabies-suspected animals, were vaccinated against rabies and treated with anti-rabies sera . The second group included professionals  who had received preventive rabies immunization  due to profession-associated increased risk of rabies virus exposure. Sera from clinically healthy blood donors without an identified profession-associated risk of rabies virus exposure were selected as the control group. Anti-Borrelia antibodies were tested in all sera samples by indirect immunofluorescent test (IFAT). The association between the seroprevalence of Borrelia spp. and rabies virus exposure was explored in potential risk groups, including age , gender , residence ) and the anti-rabies immunization protocol (PEP and PrEP). Socio-demographic data were obtained through medical documentation available at the Pasteur Institute Novi Sad (PEP and PrEP groups) and Blood Transfusion Institute of Vojvodina (control group).An observational, case-control study was conducted during the year 2019 in Serbia and Bosnia and Herzegovina to compare the seroprevalence of anti-n = 42, n = 58, ® . In the case of PEP, along with the first vaccine dose, human rabies immune globulin (HRIG)  was administered to each patient as passive immunization. Accordingly, all the sera samples in the PEP and PrEP groups contained neutralizing anti-rabies antibodies in titer 0.5 ≤ IU detected with the golden standard assay i.e., rapid fluorescent foci inhibition test (RFFIT). Sera were stored at −80 °C for at least one year after the detection of rabies-neutralizing antibodies titer.For this study, sera samples of PEP n = 42,  and PrEPn = 30, Treponema pallidum and antigen, as well as for antibodies and the DNA of the human immunodeficiency and hepatitis C viruses.Healthy blood donor sera samples n = 30,  used as Borrelia spirochetes were grown in complete BSK-H medium  at 33 °C [Borrelia culture was adjusted to approximately 3 × 107 organisms/mL. We used the whole spirochetes as antigen and 0.2 mL of the suspension of Borrelia afzelii in PBS was added to microscopic slide coated with poly-L-lysine  and left to dry at room temperature. Antigenic fields were then encircled with hydrophobic PAP pen . The B. afzelii strain, part of a Borrelia spp. collection, was kindly donated by the Group of Medical Entomology, Institute for Medical Research, University of Belgrade.at 33 °C . The culBorrelia IgG were detected by an in-house IFAT using B. afzelii antigens on microscopic slides. Previous to the analysis of the samples of the study, the in-house IFAT assay was validated using Euroimmun commercial IFAT assay  as a reference and according to the guidelines and methodology for validation of diagnostic tests described in the Manual of Diagnostic Tests and Vaccines for Terrestrial Animals of the World Organization for Animal Health (OIE) [B. afzelii antigens on the slides was confirmed by adding to each slide a positive control  . The absence of non-specific reactions of the secondary antibody was confirmed by adding a negative control  on each slide.Anti-th (OIE) . OptimalrecomBlot test , based on recombinant Borrelia spp. antigens. Inconclusive results in the second-tier test were considered negative. Fluorescence reactions were visualized on a Leica DM 3000 microscope  with an excitation wavelength of 515–560 nm. Results were considered positive when an intense fluorescence reaction was detected at 1:100 or higher sera dilution. In case of weak fluorescence at 1:100 dilution, the sample was declared as borderline and additionally tested using the second-tier Borrelia IgG and the exposure to rabies virus between groups of cases (PEP and PrEP) and control , and further between demographic groups , was explored on a series of contingency tables , assessed using two-tailed Chi-square (χ²) test; Yates’s correction was used to prevent overestimation of statistical significance because of the small sample size (n) in the study. The test was implemented in the statistical software package IBM SPSS Statistics 25 . The association between Borrelia spp. seropositivity and rabies virus risk exposure in the case groups  and control group  were calculated by the odds ratio (OR) (CI 95%). Statistical significance was considered for p-values < 0.05. Data analysis was performed using GraphPad Prism v.8.0.1 .The association between the seroprevalence of anti-Borrelia IgG were detected in 20 of the 130 analyzed samples . In a second-tier test, three samples (2 PEP and 1 PrEP) were borderline and considered as negative. The highest Borrelia spp. seroprevalence  was found among individuals at risk of rabies virus exposure . Specifically, anti-Borrelia IgG were detected in 19.0% (8/42) and 17.2% (10/58) samples of the PEP and PrEP groups, respectively. In contrast, only 6.67% (2/30) samples were seropositive for Borrelia spp. in the healthy donors group , composed by individuals without risk of rabies virus exposure  and PrEP  case groups was not statistically significant compared with the healthy donors control group. In addition, no significant difference  was found in the Borrelia spp. seroprevalence of the case groups. Although the differences did not reach statistical significance, odds ratio (OR) analysis showed that Borrelia spp. seroprevalence was positively correlated (OR > 1) with risk of rabies virus exposure in the PEP  and PrEP  case groups compared with the healthy donors control group. In contrast, comparison of Borrelia spp. seroprevalence in PEP and PrEP case groups revealed an OR very close to 1 , suggesting that the outcome  is independent of the vaccination protocol .Borrelia spp. seroprevalence across the Serbian territory. Anti-Borrelia IgG were detected in sera from North , Central , and South  Serbia, as well as the Belgrade area , while anti-Borrelia IgG were not detected in sera samples from Sarajevo in Bosnia and Herzegovina . Excluding the results from the Belgrade area , Borrelia spp. seroprevalence was higher in Northern Serbia. The local administrative unit level analysis showed that most seropositive patients in Northern Serbia were concentrated in the municipalities Šid, Bački Petrovac, Srbobran, Temerin, Plandište, and Inđija  were found in seroprevalence between the North , Central  and South  regions of Serbia. As all healthy donor samples were from Northern Serbia, we compared the Borrelia spp. seroprevalence among the two case and control groups in Northern Serbia. The difference in Borrelia spp. seroprevalence between PEP  and PrEP  case groups in the North region was not statistically significant compared with that of the healthy donors control group. However, the OR analysis revealed greater odds of association of Borrelia spp. seroprevalence with the rabies virus exposure in PEP  and PrEP  compared with the healthy donors control group.When considering Borrelia spp. seroprevalence between PEP and PrEP case groups in this age category was not possible in the present study. There was no significant difference  in the Borrelia spp. seroprevalence of PEP  and PrEP  case groups. No significant differences (Chi-square test p = 1) in Borrelia spp. seroprevalence were detected in seniors when PEP  and PrEP (0/3) case groups were compared between them. In the healthy donors control group, we found anti-Borrelia IgG only in two individuals from the adult age group , while no seropositive individuals were found in seniors (0/1) or children and teenagers (0/2) age groups. In the adults, Borrelia spp. seroprevalence was associated with rabies virus exposure risk in the PEP  and PrEP  case groups, compared with the healthy donors control group  or seniors (Chi-square test p = 1), regardless of immunization protocol.Individuals at risk of rabies virus exposure were unequally distributed in the age groups, and the highest seroprevalence was detected in children and teenagers , followed by seniors , and adults . Due to the fact that PrEP requires the existence of a profession-associated risk of rabies virus exposure, no children or teenagers could undergo this type of vaccination protocol; therefore, comparison of ol group a. In addBorrelia IgG antibodies were women and men, respectively. No significant difference was found in the Borrelia spp. seroprevalence between women and men . For the healthy donor group, all seropositive samples were from women . The comparison of the relative odds showed that male individuals of the PEP group had more chance of being seropositive to Borrelia spp. compared with the healthy donors  (p = 0.07). No significant association was found between Borrelia spp. seropositivity and the exposure to rabies virus risk in females from PEP  and PrEP  case groups  and 20%  of seropositive samples to anti- = 0.03) b. No sige groups b.Borrelia infection. The present study revealed an 18% of Borrelia spp. seroprevalence in individuals immunized against rabies, which is higher than any value previously reported by other authors in the healthy population from Serbia [Borrelia spp. seroprevalence with rabies virus exposure risk in the PEP and PrEP case groups, which could be due to activities shared by individuals at risk of rabies and LB, including extensive contact with animals and exposure to tick bites, as reported by most of the study individuals. The lack of statistically significant differences in the comparisons of Borrelia spp. seroprevalence between groups may be associated with one of the main limitations of our study . This finding is in agreement with previous studies conducted in Europe that have described high exposure risk to B. burgdorferi s.l. complex in many occupational groups, including forestry workers, farmers, veterinarians, military recruits, and outdoor workers [Borrelia antibodies are not necessarily associated with clinical symptoms of LB and that it is currently unknown for how long these antibodies last in the bloodstream [Lyme borreliosis (LB) is the most common TBD in Europe and is the cause of major concern for both public and veterinary health due to its considerable impact on animal health and human life quality. To the best of our knowledge, this is the first study to consider that individuals at risk of rabies virus exposure also have high odds of m Serbia ,27. In a workers ,29,30. Iodstream . Therefoodstream . The ideBorrelia spp. seroprevalence and increased likelihood of exposure to ticks and tick-borne pathogens, compared with all previously tested groups from Serbia [In the present study, subjects immunized against rabies showed higher m Serbia ,33. Whenm Serbia . This fim Serbia . On the m Serbia . The ream Serbia . If we cBorrelia IgG antibodies in forest workers, park maintenance workers, and soldiers was 11.76%, 23.5%, and 17.14%, respectively [Borrelia spp. Although this is an interesting result, the small sample size makes it impossible to make a meaningful comparison with previous seroprevalence studies in Belgrade. Observed seroprevalence in a population immunized against rabies suggests possible overlap of Borrelia exposure risk that was previously linked only to specific professions. Since the majority of seropositive persons are living in northern parts of Serbia, it should be further investigated whether the shared odds of Borrelia and rabies virus exposure are present only to specific regions of the country. In regions where shared odds of Borrelia and rabies virus exposure are confirmed, a series of preventive measures related to TBDs can be implemented simultaneously with rabies prophylaxis, including educational and screening programs, as well as recommendation of preventive immunizations against ticks or most common TBDs for which vaccines are available. Unfortunately, there are no data about seroprevalence in the general population from Central and South Serbia, which makes it impossible to compare with subjects immunized against rabies from these regions. In addition, seroprevalence found in this study group from Northern Serbia was similar to seroprevalence in professionals at increased risk of LB in Slovenia (21.73% vs. 23.8%) . PreviouBorrelia spp. and have achieved the seroconversion, IgG remain detectable for longer periods and have greater specificity for binding to epitopes compared with IgM. For this reason, we only tested exposure to Borrelia spp. by screening anti-Borrelia IgG. It is considered that Borrelia seroprevalence in a region is dependent upon LB endemicity. Except for few studies, there are no published data on Borrelia seroprevalence in the human population from other countries bordering Serbia, including Bulgaria, Bosnia and Herzegovina, Montenegro, North Macedonia, and Albania. Countries neighboring Serbia on the north and west with LB endemic regions are Hungary, Slovenia, and Croatia [Borrelia IgG in healthy persons were between 9.7% and 44% [Borrelia spp. (2.7–4.7%) [Borrelia IgG antibodies in a healthy population of voluntary blood donors from Romania, which is bordering Serbia on the east [Borrelia IgG has been previously determined in a healthy population from South Bačka District (3.22%) in Northern Serbia and in Belgrade city (2.9–8.57%) [Borrelia spp. seroprevalence rates in Belgrade could be likely attributed to several factors, including the demography of the sampled population , the extent of tick infestations, and the sensitivity of diagnostic assays employed [Borrelia spp. seroprevalence in the Slovenian general population [In persons who have been infected with  Croatia ,36,37,38 and 44% ,34,36. O.7–4.7%) . Similar9–8.57%) ,33,39. Temployed . Other spulation  and in bpulation . Borrelia infection in Serbia. Although the small sample size and unequal distribution of individuals in both case and control groups are a main limitation of our study, the obtained results suggest that Borrelia spp. infection could be a newly recognized occupational hazard in Serbia for professionals working in rabies-risky areas. Individuals following either the PrEP or PEP prophylaxis protocols are good cohorts when considering shared odds of rabies virus and Borrelia exposure. The higher distribution of Borrelia seroprevalence in several municipalities from Northern Serbia suggests that risk of rabies virus exposure is highly associated with Borrelia infection in Northern Serbia. The data obtained in this study indicate that further research is needed to increase the sample size and extend the observations of this study to other TBDs and regions of Serbia. These findings should be considered by physicians and policy-makers to guide risk assessment and public health policies for TBDs at the population level.The results of the present study strongly suggest that individuals at risk of rabies virus exposure also have a high likelihood of exposure to tick bites and


Current treatments of obesity often fail to consider gender and psychological aspects, which are essential for weight loss and weight maintenance. The aim of our study was to analyze subjective illness representations (SIRs) of adults with obesity according to the Common-Sense Self-Regulation Model (CSM) by assessing their associations with weight-related variables and gender.M = 42.2 years, SD = 10.9; 82% female) with obesity . Student's t-tests and multiple hierarchical regression analyses were conducted with the control variables (age and BMI) and subjective illness representations and gender as independent variables.Data was collected via online self-assessment between April 2017 and March 2018. SIRs were operationalized by the revised Illness Perception Questionnaire (IPQ-R) and illness outcomes according to the CSM were defined as BMI, eating behaviour, physical wellbeing, bodyweight satisfaction, and shape concerns. The sample consisted of 427 adults  = 4.19, p < 0.001] and females had unfavourable values of the weight-related variables as well as a more cyclic , and more emotional representation  of their obesity.The explanation of outcome variances was moderate to high (21-43%) except for restraint eating behaviour (10%). Subjective illness representations showed several significant associations with weight-related variables, especially timeline and emotional representations. Female gender was significantly associated with more restraint eating behaviour [The results of this study indicate that gender and subjective illness representations, especially the emotional representation, play an important role for weight-related variables. Therefore, the assessment of SIRs may constitute an economic tool to identify specific individual deficits of self-regulation. The mal7% with aroup (2) . Study rroup (2) , 7. Gendroup (2) , diet haroup (2) , body diroup (2) , 11. Theroup (2) , 12. Femroup (2) , 14. Theroup (2) –17. Anderoup (2)  suggesteWomen and men have been shown to differ in other self-regulation strategies such as rumination or goal-setting , 20. RumA number of existing treatment methods are offered, with the basic program usually focusing on three key elements: exercise, nutrition, and psychological therapy . In combPatients with obesity in the maintenance phase need to maintain behavioural changes, even though they have already reached their desired weight . ConsequSIRs include several cognitive representations and one emotional representation, which relates primarily to depressive moods and anxieties . The cogThe CSM is applied in research and in practise, for example, to examine the self-management of patients, to develop individual intervention goals, to understand health behaviour , 47, to 2). The latter are partly unaware that they have obesity and perceive more personal control over the change in lifestyle to lose weight. Improving self-management and self-regulation has been shown to support adherence and weight maintenance, although the underlying cognitive mechanisms remain to be identified  a more chronic and emotional representation as well as the feeling of more consequences are associated with worse values of weight-related variables and that (II) high control dimensions are associated with better values of weight-related variables. We hypothesised that gender is significantly associated with (IV) all links between SIRs and weight-related variables and that (V) females will show higher emotional representation.To the best of our knowledge, no existing studies have focused on gender differences in SIRs and their relation to weight-related variables in obesity. This research therefore constitutes an innovative approach.The study was part of a larger project, which was entirely approved by the ethics committee of the University of Bamberg, Germany. The project was conducted in accordance with the Declaration of Helsinki. The Institutional Review Board of the Ruhr-University Bochum approved the project (no. 18-6415). Data collection for this cross–sectional study took place via online assessment from April, 2017 until March, 2018, with participants having the chance to win one of four €50 shopping vouchers. The link to the self-report questionnaire was public and promoted by email to encounter groups, nutrition experts, and clinical institutions, as well as by postings on social media platforms. The recruitment message stated that we were looking for evaluating psychological factors and self-perceptions of one's obesity. To avoid a systematic selection effect of a pseudo-random sample, we targeted especially male groups or associations. Consequently, the sample is disproportionately stratified concerning gender, given that the proportion of males is still less than in the population.SD = 10.7; Min = 21; Max = 76), whereby the male sample was significantly older . The participants were affected by either obesity class I , class II , or class III . Mdn = 34.0; Min = 30.2; Max = 77.2; BMI ≥ 40: 27.3 %) and female's BMI  differed significantly, t(425) = 4.10; p < 0.001; |d| = 0.52. Females had higher BMIs, such that the average of the female sample was in the obesity class III.All participants were informed about the contents of the study, and they provided written informed consent. A total of 962 participants completed the online questionnaire, and after applying the inclusion criteria , the final sample comprised 427 participants of which 350 (82%) were female and 77 (18%) were male. The recruitment process explains the reduction of the participants. Given that the link to the questionnaire was distributed very broadly to the general public, we first omitted data from participants who provided illogical inputs  . The cut-off value was 10 according to the manual. Scores ≥10 are equivalent to a positive screening for depressive symptoms.We assessed the demographic variables such as age and gender at the beginning of the questionnaire. The screening for e ].High results for consequences and emotional representations indicate that individuals with obesity associate their illness with many or severe consequences or with negative feelings like shame or guilt. The coherence scale demonstrates that the illness is more coherent and makes sense to the patients. For both control dimensions, high scores show that participants represent their illness on a manageable level, and they feel able to control the illness without help  or with a physician's help (treatment).In addition to BMI, we analysed bodyweight satisfaction, shape concerns , 71, eatBodyweight satisfaction was assessed by using a bipolar rating scale with a slider question type .concerns about body shape (within the last 28 days) were assessed by using the mean of the 8 item subscale “Shape Concern Scale” of the Eating Disorders Examination-Questionnaire . ThEating behaviour was examined using the total score of the German version of the Dutch Eating Behaviour Questionnaire . Th. ThEatinPhysical wellbeing (PW) was assessed using a German standardised questionnaire with the mean of the total scale . We recoded the items so that a higher score represents low physical wellbeing .al scale . The FEWal scale . It operp < 0.05 and was maintained through a Bonferroni correction for multiple testing . The partial regression plots and a plot of studentized residuals against the predicted values indicated linearity. The independence of residuals was assessed by Durbin-Watson values (between 1.81 and 2.11). We found no evidence of multicollinearity based on tolerance values (>0.10) and correlations (<0.70) that were all within accepted limits. The few outliers (±3 standard deviations) that were found seemed to be logical scores, and given that leverage values (<0.200) and values for Cook's distance (<1) were accepted, no outliers were deleted from the data. The assumption of normality was not met for bodyweight satisfaction and shape concern (assessed by Q-Q Plot), but this deviation was negligible because of our sample size. After checking for homogeneity by using a plot of studentized residuals vs. unstandardized predicted values, the regression analyses with body satisfaction, shape concern, and BMI as dependent variables were conducted with bootstrapping .Three-step hierarchical multiple regressions were conducted to assess the extent that the SIRs and gender add predictive value to the weight-related variables. This statistical procedure was used to answer the research questions. (1) Which expression of the SIRs are favourable in regard to the weight-related variables? (2) Does gender moderate these associations? Given that age has been analysed as a weight loss predictor in previous studies, we controlled also for age in addition to BMI , 82. Bott-tests, and homogeneity of variance was checked with Levene's test. The Welch test was conducted for the emotional representations because of the heterogeneity of the variances. Hedge's g was calculated for effect sizes. The common abbreviation |d| was used, with |d| < 0.2 indicating a small, |d| < 0.5 a medium, and |d| < 0.08 a large effect. The dataset contained missing values for some scales up to 9.6% of the participants who completed the IPQ-R . Thus, the values were missing completely at random (MCAR). Given that only dependent variables had missing values, an imputation of the missing values was not necessary and a listwise exclusion was performed for the regression analysis, as set by default in SPSS [see  and the emotional representation was significantly more favourable (IdI = 0.74). This result means that women reported more negative emotions, such as anger, worry, fear, or depression, associated with their obesity than men. No significant gender differences were found in the other dimensions of the IPQ-R: timeline (IdI = 0.21), consequences (IdI = 0.32), coherence (IdI = 0.06), personal (IdI = 0.38), and treatment control (IdI = 0).The results obtained from the IdI = 0.38–0.72), with shape concern (IdI = 0.72) and emotional eating behaviour (IdI = 0.71) having the greatest effect. This indicates that men had significantly lower BMI (IdI = 0.52), less restraint (IdI = 0.51), or external (IdI = 0.54) eating behaviour. No significant gender differences were revealed for bodyweight satisfaction (IdI =.38) or physical wellbeing  and showed no depressive symptoms, whereas women generally exceeded the cut-off value of PHQ-9 (IdI = 0.51).All significant differences in weight-related variables were more favourably pronounced for men  for restraint eating.Overall, these results indicate not only gender differences in SIRs and in weight-related variables but also that most of the SIRs, especially the timeline and emotional representation, explain a moderate to high amount of variance in weight-related scales.To the best of our knowledge, this study is the first to systematically examine gender differences in the effect of SIRs of individuals with obesity on weight-related variables according to the CSM. Specifically, we analysed the relationships between the cognitive SIRs  and emotional SIRs with shape concern, bodyweight satisfaction, BMI, physical wellbeing, and eating behaviour. Especially notable is the comparatively high proportion of male participants in our sample, which is why our study stands out from other studies in this area of research. One of the main goals of the current study was to determine the favourable expressions of the SIRs in participants with obesity. The results of this study indicate that low representations of emotions, consequences, timeline, coherence, and personal control as well as a high representation of treatment control were associated with more favourable weight-related variables. Accordingly, female participants had worse SIRs than men, and female gender was associated with worse emotional and restraint-eating behaviour. Interestingly, after adding SIRs and gender to the regression models, the level of BMI and age had no additional effects on weight-related variables.Females reported significantly more cyclic and as hypothesised (V) emotional representations of their obesity, but female gender only accounted for significant variance in the two eating behaviour scales (hypothesis IV rejected), thus again underlining the importance of the emotional representation of one's obesity. This result for the gender difference of the cyclic representation has been reported in the literature. For example, women tend to show more weight-cycling and go on more diets, and their craving for food depends on their female hormone cycle , 85. OurFemale gender accounted for significant variance in emotional eating and restraint eating behaviour, which is consistent with other studies , 87. A pAlthough our female sample had a significantly higher BMI, male's and female's representations of their obesity as chronic were the same. This result could explain the unrealistic goal-setting for weight-loss in women  who may Our suggestion based on the current results and the study of  is that Our findings indicate that a more chronic representation is more prevalent in women with severe obesity and is more likely to affect individuals prone to emotional and external eating behaviour. This association between increased timeline representation and maladaptive outcomes is in line with our hypothesis (I) and other studies reporting on chronic diseases and BMI levels , 94. MorExisting research emphasises that representations about the cyclic character of illness are associated with the maintenance level of motivation for eating disorders  and coulStudies on other chronic diseases have revealed a strong link between the subjective representation of consequences and disease outcomes, as well as a negative correlation between perceived consequences and maladaptive outcomes such as poorer physical quality of life , 38, 41.A possible explanation for the relationship is that higher weight is associated with more comorbidities , 99, risA high representation of personal control explained the variation in more emotional and external eating behaviour. We suggest that individuals with a high personal control representation are more sensitive to food cues such as the smell of food or an obesogenic environment, for example, passing by a café or restaurant , 87. TheThe treatment control scale was only significant for higher levels of physical wellbeing. This finding confirms the link between treatment control and positive health outcomes, which was found in previous research and supports our hypothesis (III) . We suggOur results indicate that emotional eating behaviour is especially associated with a high sense of coherence, which could be a coping strategy to regulate emotions . MoreoveThe emotional representation was, hypotheses conform (I), the most consistent, significant correlate of the dependent variables such as less bodyweight satisfaction, less physical wellbeing, more shape concerns, and increased emotional and external eating. The latter has been shown to mediate the relationship of impulsivity and food intake . The linThe results of this study indicate that low representations of emotions, consequences, coherence, and personal control as well as a high representation of treatment control are associated with more favourable weight-related variables. Accordingly, female participants had worse SIRs than men, and female gender was associated with worse emotional and restraint eating behaviour.This study is based on a cross-sectional survey, and therefore no causal conclusions can be drawn. Given that no systematic investigation of SIRs with regard to gender and weight-related variables had previously been undertaken for obesity and that men in particular are under represented as participants in this field of research, obtaining a large sample was important to be able to generalise the results. Such cross-sectional designs concerning the CSM have already been conducted for other chronic diseases , 94. GivSome aspects, which were not considered because of the focus on gender, could play a role in the association of SIRs and weight-related variables. Previous research, for example, has indicated that the education level of the participants can be a moderator of the link between obesity and cognitive mechanisms , 110. EaThis study lends further support to previous research findings  to the eThe results indicate that the CSM and its assumptions can be adapted to obesity and that the integration of this model is promising for an individual- and gender-sensitive therapy. Particular attention should be paid to cognitive representations of timeline and consequences, as well as the emotional representation of obesity. Ultimately, gender-sensitive interventions should be developed, especially in the treatment of pathological eating behaviour in females. Males should be made more aware of their obesity and the physical and psychological problems it causes to increase their willingness to undergo therapy. In addition, an all-encompassing examination of the CSM components including the self-system and the illness stimuli for obesity is recommended for the two different phases (weight reduction and maintenance) of treatment.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethic Committee of the University of Bamberg. The patients/participants provided their written informed consent to participate in this study.CH, SS, SS-L, and JW contributed to conception and design of the study. SS designed the first draft of the questionnaire. CH organised the database, performed the statistical analysis, and wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.This work was supported by the German Federal Ministry of Education and Research (BMBF Grant Number. 01GL1719A).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Coronavirus 2019 (COVID-19) pandemic led to a massive global socio-economic tragedy that has impacted the ecosystem. This paper aims to contextualize urban and rural environmental situations during the COVID-19 pandemic in the Middle East and North Africa (MENA) Region.p < 0.001) reported a reduction in noise, gathering in tourist areas, and gathering in malls and restaurants. Concerning the pollutants, most urban and rural areas have reported an increase in masks thrown in streets . Plastic bags and hospital waste also increased significantly with the same p-value of < 0.001 in urban areas compared with rural ones. The multifactorial logistic model for urban resident predictors achieved acceptable discrimination (AUROC = 0.633) according to age, crowdedness, noise and few pollutants.An online survey was conducted, 6770 participants were included in the final analysis, and 64% were females. The majority of the participants were urban citizens (74%). Over 50% of the urban residents significantly (The COVID-19 pandemic had a beneficial impact on the environment and at the same time, various challenges regarding plastic and medical wastes are rising which requires environmental interventions.The online version contains supplementary material available at 10.1186/s12889-021-12313-3. In December 2019, the first coronavirus disease 2019 (COVID-19) case was reported in China. COVID-19 was declared a global pandemic four months later, in March 2020, due to its rapid spread and severe health consequences . The Pan2) and particulate matter that have a diameter of less than 2.5 μm (PM2.5) [Lockdown and restricted travel have had mostly positive impacts on air and water quality. Several reports around the world have recorded a substantial reduction in air quality indices such as reduced concentrations of nitrogen dioxide (NO (PM2.5) , 13. Thi (PM2.5) . As a re (PM2.5) . Moreove (PM2.5) .Further, beaches are also used as a vital economic resource for coastal areas that are threatened by pollution, mostly due to tourism. The lockdown, on the other hand, has turned the tables. With each passing day, not only is the skyline getting brighter, but the waterways are becoming visibly purer, and the once-endangered flora and fauna are now coming back to life indicating how the Earth has been healing since the lockdown . Thus, aHowever, due to the ongoing COVID-19 epidemic, the usage and disposal of face masks, gloves, face shields, and other forms of PPE has grown considerably. Many countries require the use of PPE as an effective and low-cost method of reducing viral transmission. This, however, may represent a new challenge to solid waste management and increase plastic pollution . AccordiExamining and understanding the environmental effects of COVID-19 precautionary measures in combination with people’s behavior toward their environment is crucial for stakeholders to develop and implement necessary policies to protect the environment. However, the practices and perceptions of people living in the Middle East and Northern Africa (MENA) region about the effect of COVID-19 on their environmental parameters  are poorly understood. Thus, the primary objective of this study is to investigate the current environmental situation during the COVID-19 pandemic in the MENA region. A secondary objective is to contextualize urban vs. rural environmental situations.An online survey was conducted in nine countries  from the MENA region in April and May 2021. The questionnaire included observational information on environmental status and multiple pollutants during the COVID-19 period. Multiple logistic regression was performed to determine urban residents’ predictors.Participants had to be at least 18 years old, residing in any MENA region country through COVID-19 pandemic, speaking Arabic or English, and had to fill the entire survey confirming the consent to participate in the study. The current study’s participants were residing in 9 countries, and incomplete responses were excluded . The final version of the questionnaire , and it was hosted on Google Forms. The collaborators were responsible for distributing the survey using social media and mailing lists. Participation was voluntary - participants did not receive any monetary compensation for their participation.t-test and confirmed by Mann–Whitney U test and Fisher test, this statistical approach to analyze Likert scale data was applied in previous studies [p-value < 0.05 is considered statistically significant for all the results.Data were analyzed using IBM SPSS Statistics (version 26) and TIBCO Statistica . Categorical data were reported as frequency/percentage and continuous data as mean/standard deviation. Normality was calculated using Shapiro-Wilk tests. Differences between rural and urban results were calculated by unpaired sample  studies , 22. MorA total of 6770 participants were included in the final analysis, 64% were females and 36% were males. The majority of them were urban citizens 74%. Participation between the ages of 18 and 25 had the highest percentage of participants (49%) compared to only 2% of those over 60.p < 0.001). Comparison between the environmental status in rural and urban areas is represented in  in the number of masks thrown in the street in both urban and rural areas. Although only 33 and 29% of the participants reported an increase in the aforementioned waste in rivers and lakes in urban and rural areas, respectively, the increase is still significantly different (p = 0.001). No significant increase in the number of plastic gloves has been noticed in rivers or lakes, while plastic bags were shown to be more likely thrown in streets in the urban area compared with rural (p < 0.001). Half of the respondents reported a significant increase (p < 0.001) in hospital waste in urban areas compared with 45% in rural ones. While the variations in laboratory waste increase and places designated for medical wastes between rural and urban areas were not significant (p = 0.077). Pollution indicators for urban and rural areas are shown in , increase in the number of plastic gloves  and plastic bags thrown in the street , respectively. However, among those participants, a reduction in noise , gathering in touristic areas , and crowdedness in the public transportation  were noticed. Observing the increase in the number of plastic gloves in rivers and lakes was inversely associated with urban residents . The Multifactorial model of the significant urban resident predictors is visible in Table According to the information collected, 74% of the respondents were resident in urban areas, and this was associated with higher age  affected the environment in the MENA region, as well as to compare urban and rural environmental settings.2 and carbon oxide (CO) levels have decreased by almost half [3) enhancement in these regions [2 density and O3, which displayed a significant improvement in Air Quality Index [2 emissions by 30-60% in several European cities, including Barcelona, Madrid, Milan, Rome, and Paris [People in the MENA region reported a reduction in noise and pollution, and an improvement in the air quality, especially in urban areas, as an industry, transportation, and companies partially or totally shut down during the pandemic. Google’s Community Mobility Reports for Egypt, Iraq, Libya, Saudi Arabia, and Yemen during the observed period are available in (Supplementary file ost half . Moreove regions . In Indity Index . The Eurnd Paris . Rodrígund Paris . As a rend Paris –7. It isnd Paris . Unlike nd Paris . Martorend Paris , which aNoise reduction was reported in urban areas by other studies such as in Dublin , Boston Similar to what we found in our study, the level of crowding in tourist and commercial areas reduced in the tourist spots around the world due to the outbreak of COVID-19 and local restrictions . The locOne of the most serious issues that arose as a result of the COVID-19 lockdown, as reported in the current study and other studies, is the increased use of facial masks, hand gloves, gowns, and face shields, as well as the creation of a large volume of hospital waste containing plastic materials. Ryan et al. have reported an increase in plastic waste due to single-use hygiene products such as cotton wool and wet wipes in Durban streets . SimilarFinally, it is critical to point out the limitations of our research. First, the elements affecting pollution and environmental status were not explicitly measured; instead, they were self-reported, which could lead to bias and misreporting. Second, in some countries, the data collection period was connected with partial lockdown; as a result, the participant’s observation may not be accurate owing to limited outgoing and may have been influenced by other external variables such as media, family, and friends’ perspectives. Also, even though the number of participants may be representative of each country, it may not be representative of urban or rural areas in some countries. Finally, data representing the MENA region and individual country analysis may provide different results. The strengths of this study, however, are the large amount of data collected and the high quality of the data since we avoided mass distribution; country coordinators advised respondents to distribute the questionnaire to colleagues and trusted individuals. As a result, the data can be used as a source of knowledge for the examined region’s environmental policy.In urban areas, the COVID-19 pandemic was associated with a higher positive impact on the environment compared with rural areas, such as noise and crowdedness reduction. However, pollution risk was more prevalent in urban areas. The main sources of pollution were plastic masks and bags, and hospital wastes. Environmental interventions are required to address the pollution issues raised in urban areas during the COVID-19 pandemic. Further studies should be conducted to confirm the current results using administrative data.Additional file 1.Additional file 2.Additional file 3.


To elucidate the therapeutic efficacy of needle-warming moxibustion (NWM) combined with hyperbaric oxygen therapy (HBOT) in the treatment of patients with ischemic stroke and its effect on neurological function.  One hundred patients with ischemic stroke admitted to the Xuzhou Medical University Affiliated Hospital of Lianyungang from January 2019 to July 2021 were enrolled. Among them, 45 patients treated with NWM were set as the control group, and the rest 55 patients treated by NWM combined with HBOT were included in the research group. The curative effect, neurological deficit score, activity of daily living (ADL), balance ability, and the levels of serum proinflammatory factors in both groups were observed and recorded. Of them, the neurological deficit of patients was evaluated by the National Institutes of Health Stroke Scale (NHISS), the ADL ability was determined by the Barthel index score, and the balance ability was assessed by the Berg balance scale. α (TNF-α), and interleukin-8 (IL-8) in the serum of patients in the research group were statistically lower than those before treatment and the control group.  The total effective rate of the research group was higher than that of the control group. Better ADL and balance ability and milder neurologic impairment were determined in the research group compared with the control group. After treatment, the secretion levels of proinflammatory factors such as C-reactive protein (CRP), tumor necrosis factor- NWM combined with HBOT is effective in the treatment of patients with ischemic stroke, which can not only improve patients' neurological function, ADL, and balance ability but also inhibit serum inflammatory reactions. Ischemic stroke is an ischemic and hypoxic disabling disease, which accounts for 80% of the total stroke cases with a predilection for males , 2. Its The acupuncture and moxibustion are important techniques of traditional Chinese medicine, which is simple, effective, and convenient, and can quickly relieve the pain of patients . The neeA total of 100 patients with ischemic stroke admitted to the Xuzhou Medical University Affiliated Hospital of Lianyungang from January 2019 to July 2021 were selected as the study participants. Of them, 45 patients were treated with NWM and set as the control group, including 30 males and 15 females, with an average age of (61.18 ± 8.31) years. The rest 55 cases were treated with NWM combined with HBOT and set as the research group (the research group), including 40 males and 15 females, with a mean age of (63.12 ± 9.74) years. This study was approved by the Ethics Committee of Xuzhou Medical University Affiliated Hospital of Lianyungang, and all participants knew the purpose of this research and provided informed consent. Inclusion criteria: diagnosis of ischemic stroke; patients with first onset and onset time within 24 hours; treatment-naive patients; patients with tolerance to the treatment; and patients with stable vitals and clear consciousness. Exclusion criteria: those with a family history; those with ischemic attack diseases; those with acute or unstable conditions; pregnant or lactation patients; those with disabilities before onset; those with severe liver and kidney dysfunction; and those with a history of mental illness or mental retardation.Acupoints Baihui, Fengchi , Hoku, Jianshu, Quchi, Shousanli, Chize, Zhongzhu, Houxi, Wangu, Taichong, Zusanli, Sanyinjiao, Juegu, Liangqiu, Fengshi, Xuehai, Qihai ,and Juxu (upper and lower) were selected, among which Hoku, Shousanli, Quchi, Jianyu, Liangqiu, Zusanli, and Juxu (upper and lower) were dotted. Each acupoint was disinfected with 75% ethanol before the acupoint selection. The needle was inserted into the needle handle of a 1.5 cm moxa roll, and then the moxa roll was lit until it burned-out. The NWM treatment at each acupoint lasted for 30 min and was performed once daily. Patients were treated for three four-week courses spaced 5 days apart.The oxygen in the hyperbaric oxygen chamber was set at 0.2 mpa, and the treatment was performed once a day for 80 min each time. The treatment lasted for 3 courses, with a course lasting for 12 days and an interval of 2 days between courses. During the treatment, extra attention was paid to the patient's blood pressure, heart rate, and respiratory status.If the patient is conscious and speaks clearly, with normal mobility and the ability to take care of himself/herself, it is regarded as cured. If the patient is conscious, with ordinary language expression and the ability to take care of himself/herself in a simple life, it is regarded as markedly effective. Effective is defined as the patient is conscious, occasionally absent-minded and inarticulate, and needs assistance in normal life. Ineffective is indicated if the patient is unconscious, with no significant improvement in clinical symptoms and signs from those before treatment. The total effective rate of treatment was the percentage of cured, markedly effective, and effective cases to the total cases.The neurological deficit of patients was evaluated by the National Institutes of Health Stroke Scale (NHISS)  before aBefore and 4 weeks after treatment, the ADL and balance ability of patients were evaluated using the Barthel index score and the Berg Balance Scale, respectively . The Barα (TNF-α), and interleukin-8 (IL-8) by enzyme-linked immunosorbent assay (ELISA) [Fasting cubital venous blood was drawn from patients in the early morning before and 4 weeks after treatment to detect the serum proinflammatory factors such as C-reactive protein (CRP), tumor necrosis factor- (ELISA)  with then/%) and compared by the chi-square test between groups. Measurement data, such as average age and NHIS score, were expressed as mean ± SD, and the methods for intragroup comparison before and after treatment as well as intergroup comparison were paired t-test and independent samples t-test, respectively. When P < 0.05, the difference was statistically significant.The SPSS 22.0 (Bioeasy (Beijing) Technology Co., Ltd., Beijing, China) and GraphPad Prism 6  were used for data analysis and image rendering, respectively. Count data, such as gender and age, were recorded in the form of number of cases/percentage (P > 0.05)  .P < 0.05)  .P < 0.05); However, the score was significantly reduced in both groups after treatment and was lower in the research group compared with the control group (P < 0.05)  .P > 0.05), while significantly increased scores of both scales in the two groups after treatment, with higher scores in the research group compared with the control group (P < 0.05)  .α, and IL-8 in both groups of patients. The three serum proinflammatory factors, which showed no significant differences between groups before treatment (P < 0.05), reduced significantly in both groups after treatment, with lower parameters in the research group compared with the control group (P < 0.05). . .As a common central nervous system disease, the ischemic stroke is one of the major causes of death and disability worldwide . Reporteα, and IL-8, can promote the neuroinflammatory response of patients with ischemic stroke, thus aggravating the disease progression [α, IL-8, and other proinflammatory factors. Qing et al. [The NWM, a traditional Chinese medicine therapy that combines acupuncture and moxibustion, can not only activate qi and collaterals but also promote blood circulation and remove stasis, which is feasible for the treatment of diseases caused by qi deficiency and blood stasis such as ischemic stroke , 25. Thegression . In thisg et al.  showed iThe novelty of this study lies in confirming that NWM combined with HBOT is effective in treating patients with ischemic stroke, which can significantly improve their neurological function, ADL and balance ability, and inhibit neuroinflammation. However, this study still has some limitations. First, this study lacks the related clinical follow up of the long-term efficacy of patients and the analysis of the patient prognosis, which requires further evaluation. Second, the participants enrolled in this study are mainly Chinese, which may limit the extrapolation of different groups to some extent. Third, this is a small sample retrospective study, and the heterogeneity of patients' conditions may have some influence on the research results. These limitations of this study should be addressed in future studies to further validate our conclusions.All in all, while effectively inhibiting neuroinflammation, NWM combined with HBOT is significantly beneficial to the neurological function, ADL and balance ability of patients with ischemic stroke, with a better therapeutic effect than NWM alone, which provides a new choice and basis for the treatment of ischemic stroke.


These data suggested that administration of CS to patients with SFTS should be carefully considered.Severe fever with thrombocytopenia syndrome (SFTS) is an emerging viral hemorrhagic fever in China, Korea, and Japan. To date, no standardized treatment protocol for SFTS has been established. Corticosteroids (CS) may be administered to patients with SFTS and hemophagocytic syndrome, but its effectiveness and safety are still debatable. We conducted a retrospective case series review at four medical facilities in Miyazaki, Japan. Based on the medical records, clinical data, including the patients background, symptoms, physical findings, laboratory data at initial presentation, treatment, and outcome, were compared between the CS-treated and the non-CS-treated group. A total of 47 patients with confirmed SFTS in each hospital were enrolled in this study; there were 14 fatal cases and 33 nonfatal cases. The case fatality ratio was 29.8%. After adjusting patients’ background by propensity score matching, the case fatality ratio was higher ( Banyangvirus of the family Phenuiviridae, Huaiyangshan bangyangvirus and is generally called the SFTS virus (SFTSV). SFTSV infection has been one of the most important public health issues in endemic areas because of its high case fatality ratio, which was reported to be 10–20% in China and South Korea [Severe fever with thrombocytopenia syndrome (SFTS) is a fatal hemorrhagic condition that was first reported in China in 2011 [th Korea  and 27–3th Korea ,5. The pth Korea , and undth Korea ,8, high th Korea , coaguloth Korea . Supportth Korea . Howeverth Korea . Owing tth Korea , the safThis study used the data of the registry study on tick-borne infectious diseases in Miyazaki, Japan . We condThe observation period was the duration of hospitalization or outpatient visit. To identify poor prognostic factors, the baseline clinical and laboratory parameters, treatment, and outcomes, including complications of secondary infections, were compared between the fatal and nonfatal groups. The previously reported poor prognostic factors ,5,6,8,9 p < 0.05 was considered statistically significant. All statistical analyses were performed using EZR , which is a graphical user interface for R .We used Fisher’s exact test and the Mann–Whitney U test to compare the categorical and continuous variables, respectively, between the fatal and nonfatal groups and between the CS-treated and non-CS-treated groups. The PS was estimated using a multivariate logistic regression model with the key variables mentioned above. To compare the outcomes between the CS-treated and non-CS-treated groups, matching was performed with a 1:1 matching protocol and a caliper width equal to 1/4 of the standard deviation of the PS. The duration from SFTS onset to death was analyzed using Kaplan–Meier estimates and was compared between the groups. Cox proportional hazards model was used to investigate the hazard ratio of whether CS was a potential risk factor for fatal outcomes. All tests were two-tailed, and A total of 47 patients (46 inpatients and 1 outpatient) with confirmed SFTS were enrolled in this study; there were 14 fatal cases  and 33 nonfatal cases. The case fatality ratio was 29.8%. Mortality in the early phase within 14 days from onset was noted in 12 cases and was caused by shock, respiratory failure, disseminated intravascular coagulation, and multiorgan failure. On the other hand, two cases died in the late phase after 14 days from onset ; both had invasive pulmonary aspergillosis (IPA).The clinical characteristics of the patients are shown in Treatment and outcomes, including complications of secondary infections, were comparable between the fatal and nonfatal groups . None ofThe results of the comparison of the clinical characteristics and outcomes after PS matching between the CS-treated and non-CS-treated groups are shown in p = 0.02) (p = 0.04). After PS matching, outcomes tended to be worse in the CS group than in the non-CS-treated group, although the difference was not statistically significant (p = 0.10) (p = 0.13).In the analysis before PS match, survival was significantly shorter in the CS group than in the non-CS-treated group ( = 0.02) A. Hazard = 0.10) B, and HRIn this study, the case fatality rate of SFTS was as high as 29.8% and was comparable with that in previous reports in Japan ,5. Of thIn this study, CS was administered more frequently in the fatal group than in the nonfatal group. Based on our data, there seemed to be a tendency to administer CS to severe cases that had poor prognostic factors or had more severe cytopenia that was suggestive of HPS. Disease severity rather than the use of CS may have predisposed patients with SFTS to a high risk of death. However, even after adjusting the patient backgrounds, the case fatality ratio was significantly higher with CS use than without CS use. The mechanisms of worsening outcome with CS administration may include the adverse effect on host immunity, such as prolonged SFTSV RNA shedding and suppression of the host immune response to SFTSV. CS-induced complications, such as hyperglycemia, hypertension, and heart failure, may have affected prognosis, but these factors could not be examined in this study. The duration of CS administration was 3–7 days in most cases. Whether CS therapy was associated with poor prognosis in patients who died within a few days of administration of CS was not determined. In severe SFTS cases, SFTS could have rapidly progressed despite CS therapy. To the best of our knowledge, no consensus has been achieved on the duration of CS therapy in SFTS. CS therapy was continued depending on disease severity in most cases. Furthermore, the association between the duration of CS therapy and poor prognosis could not be evaluated in this study. Therefore, in future the association between the duration of CS therapy and the outcome of SFTS should be investigated.Some severe cases that required mechanical ventilation or intensive care unit admission recovered after CS administration. Therefore, CS therapy may be useful in these serious cases. In some viral infections, CS administration has been reported to improve prognosis. Dokuzoguz et al. reported that concomitant use of CS with ribavirin was beneficial for patients with severe Crimean–Congo hemorrhagic fever , which i+ and CD4+ T lymphocytes in patients with SFTS led to the suppression of immune function, which can increase the risk for secondary infection [The increase in the rate of complications of secondary infections, especially IPA, with CS therapy in patients with SFTS remains unclear. In this study, there was a tendency for relatively frequent secondary infections, including IPA, in the CS-treated group. CS administration may affect host immunodeficiency and increase secondary infections. SFTSV infection itself was speculated to induce immunosuppression and lead to secondary infection as a result of leukopenia, thrombocytopenia, and interleukin 10 overexpression . Liu et nfection . In fungnfection , therebynfection .Our study had several limitations. First, the number of cases was small because only those that were registered in Miyazaki prefecture were included. The efficacy of CS administration should have been investigated by stratifying the severity of more patients. Moreover, some variables, such as the degree of mental status alteration, may have not been included in the PS matching between groups. PS matching could not fully adjust the differences in clinical characteristics between the CS-treated and non-CS-treated groups. Second, this study was retrospective in design. Although SFTS cases are often accompanied with hemophagocytosis, bone marrow puncture or biopsy was performed only in some cases in this study. A prospective study would be required to verify the efficacy and safety of CS. Third, this study did not assess cytokine kinetics and viral load to evaluate the effects of CS on SFTSV infection and host immunity. Unfortunately, with some cases, evaluation was only possible with stored samples, and we could not investigate the association between CS therapy and viral load, viral genome sequence, antibody response, or cytokine levels. Finally, we did not investigate the effect of CS in combination with antiviral agents, such as ribavirin and favipiravir.Approximately one-third of patients with SFTS died and developed secondary infections, including IPA, during their hospital course. After PS matching, the case fatality ratio was higher and the complications of secondary infections, such as IPA, tended to be more frequent with CS use than without CS use. Administration of CS to patients with SFTS should be carefully considered and take into account the balance between therapeutic efficacy and adverse effects, which may depend on the dose, duration, and combination with antiviral medication.