The restrictive measures adopted worldwide against SARS-CoV-2 produced a drastic reduction in respiratory pathogens, including RSV, but a dramatic rebound was thereafter reported. In this multicenter retrospective observational study in 15 Pediatric Emergency Departments, all children <3 years old with RSV infection admitted between 1 September and 31 December 2021 were included and compared to those admitted in the same period of 2020 and 2019. The primary aim was to evaluate RSV epidemiology during and after the COVID-19 pandemic peak. The secondary aims were to evaluate the clinical features of children with RSV infection. Overall, 1015 children were enrolled: 100 in 2019, 3 in 2020 and 912 in 2021. In 2019, the peak was recorded in December, and in 2021, it was recorded in November. Comparing 2019 to 2021, in 2021 the median age was significantly higher and the age group 2–3 years was more affected. Admissions were significantly higher in 2021 than in 2020 and 2019, and the per-year hospitalization rate was lower in 2021 (84% vs. 93% in 2019), while the duration of admissions was similar. No difference was found in severity between 2019–2020–2021. In conclusion, after the COVID-19 pandemic, an increase in RSV cases in 2021 exceeding the median seasonal peak was detected, with the involvement of older children, while no difference was found in severity.  Orthopneumovirus, family Pneumoviridae. It is characterized by three membrane proteins called small hydrophobic (SH), attachment glycoprotein (G) and fusion protein (F). Its name comes from the large cells, known as syncytia, which form when infected cells fuse. The RSV is divided into A and B subtypes based on the protein G sequence. Subtype A appears to be related to more severe infections. Both subtypes circulate simultaneously during the annual epidemic season, although generally one of the two predominates each year [The RSV  represents the most frequent viral cause of acute lower respiratory tract infection (LRTI) in children, with a worldwide distribution . The RSVach year . The RNAach year .The severe manifestations of RSV disease include pneumonia and bronchiolitis; the latter is usually self-limiting but, in infancy, it accounts for a significant number of hospitalizations and pediatric intensive care unit (PICU) admissions even in previously healthy, full-term children ,4. BroncIn 2015, the estimated global impact of RSV infections in children aged less than 5 years old was approximately 33 million LRTI episodes (uncertainty range: 21.6–50.3 million), 3.2 million hospitalizations (uncertainty range: 2.7–3.8 million) and 120,000 deaths  [The RSV is a seasonal virus, characterized by variable epidemiology, depending on geographic area and climate. In the Northern hemisphere, the virus usually spreads between November and March with peak incidence in January/February, whereas in the Southern hemisphere, the RSV season is from June to September. The RSV epidemics are driven by a complex interaction between the climate, the host and the virus. Cold temperatures stabilize the RSV lipid envelope, humidity allows the deposition of heavy droplets on surfaces and, during cold and rainy periods, people gathering indoors facilitate RSV transmission. Moreover, it seems that new variants could drive RSV outbreaks, finding a susceptible population. The simultaneous isolation of different RSV strains in distant geographic areas supports the hypothesis that epidemics are driven by locally evolved variants ,8.The restrictive measures adopted worldwide against the SARS-CoV-2 virus  produced a drastic reduction in respiratory pathogens in Europe, including RSV. In particular, bronchiolitis almost disappeared during the 2020/21 season, but a dramatic rebound was reported both in the Northern and Southern hemisphere during the 2021/22 season, largely due to RSV infection ,10. MoreAdditionally, in Italy, we recorded a reduced circulation of RSV and other respiratory pathogens during the 2020/21 season detected by the Italian Influenza Surveillance Network (InfluNet) system . Herein we present our epidemiological survey on RSV infection in children in Northwestern Italy in the last three years. The primary aim of our study was to evaluate RSV epidemiology during and after the COVID-19 pandemic peak in order to collect preliminary data on possible variations in the epidemiology and seasonality of RSV infection in our region. The secondary aim was to evaluate the clinical features of children with RSV infection.Out of the 22 Pediatric Emergency Departments (EDs) of Piedmont, Northwestern Italy, that were invited to participate in this multicenter retrospective observational study, 15 accepted. Among the centers involved, 3 were major Pediatric EDs of hospitals provided with PICU and 12 were Pediatric EDs of hospitals without PICU.All children <3 years old with RSV bronchiolitis and/or pneumonia admitted to the 15 Pediatric EDs between 1 September and 31 December 2021 were included and compared to those admitted in the same period of 2020 and 2019. The following diagnostic ICD codes (10th revision) were considered: 466.11, 079.6 and 480.1. Only children <3 years old at admission were enrolled, as this group has been reported to have the highest disease burden with RSV and in order to limit potential overlaps with other respiratory conditions. Epidemiological, clinical and microbiological data were retrospectively collected. The data were deidentified, recorded through a targeted registration form and transferred to a specifically designed database at the Coordinating Center before the analysis.The following variables were included: demographic data (age and sex), clinical characteristics  and outcome ; furthermore, both the overall and PICU length of stay (LOS) were recorded. ®). SARS-CoV-2 determination was carried out using nasopharyngeal swab/aspirate by real-time reverse transcription-PCR (RT-PCR) in each patient with respiratory symptoms since the beginning of SARS-CoV-2 pandemic.Identification of the causal viral agent for bronchiolitis was carried out using nasopharyngeal aspirate or tracheal aspirate/bronchoalveolar lavage (in intubated patients) with an antigen test and/or with a multiplex polymerase chain reaction (PCR) assay . p < 0.05. All p-values were 2 tailed. In the descriptive analysis, categorical variables are reported as absolute numbers and percentages, and continuous variables as mean, median and interquartile range (IQR), as appropriate. To compare the continuous variables of the study groups, a Student’s t-test was used. To evaluate the discrete variables, Pearson χ2 and correlation Fisher exact tests were performed, as appropriate. The statistical analysis was performed using IBM SPSS Statistics 25.0 . Significance was set at During the three study periods , 1015 children <3 years old with RSV infection were enrolled: 100 in 2019, 3 in 2020 and 912 in 2021, respectively. The number of hospital admissions for each participating center is represented in Overall, in 2019, most RSV admissions in the four-month period under consideration occurred in December , while in 2021, most admissions occurred in November , as represented in Considering only children tested at the major regional Pediatric Hospital and Coordinating Center of this study , laboratory results showed that in 2019, 20.0% of the children tested for RSV were positive, compared to 57.6% in 2021. Weekly test results for RSV, influenza and SARS-CoV-2 during the study periods of these two years are shown in Demographic and epidemiological characteristics of the total population are summarized in p = 0.018). Moreover, the age group between 2 and 3 years was more affected by RSV in 2021 than in 2019 . Males were more represented than females (54.3% vs. 45.7%), and the majority of children were ≤2 months old (36.9%) or 3–6 months old (37.3%). The median age was 2.8 months, IQR 1.5–6.3 months. Comparing 2019 to 2021, the median age was significantly higher in 2021  and 2019 (p = 0.007); furthermore, there were significantly more admissions in 2019 than in 2020 (p = 0.0019).Mean annual RSV admissions were significantly higher in 2021 than in 2020 ; admissions in 2021 had a similar duration compared to admissions in 2019 . Hospitalization rates and LOS were different between the three major pediatric hospitals provided with a PICU and the twelve without a PICU (p = 0.67). The per-year hospitalization rate (HR) was 93% in 2019 and 84% in 2021 (t a PICU . The neeThe adjusted odds ratio (OR) of hospitalization and admission to PICU among the age groups is shown in Moreover, the adjusted OR of hospitalization among age groups in 2021 compared to 2019 is shown in p = 0.00001) and age ≤ 2 months old (p = 0.00001). By analyzing the risk factors for the need for oxygen supplementation, we found a significant relationship with prematurity (p = 0.0001), age ≤2 months (p = 0.0001) and viral coinfections (p = 0.0002) were significantly related.Regarding admissions to the PICU, we found that prematurity  between 2019-2020-2021. No difference was found in the severity of RSV cases (LOS—p = 0.10); no patient was transferred in 2020. On the contrary, from the main regional Children’s Hospital (Regina Margherita), 19 patients with RSV bronchiolitis , of whom 17 were <6 months old, were moved to other hospitals due to a lack of beds between October and December 2021, compared to no transfers in the previous years. The number of patients who were transferred to one of the three hospitals with a PICU were, respectively, 3 in 2019 and 70 in 2021  compared to 2019, as previously reported by other authors and an epidemiological report ,12,13,14Our data confirmed previous observations of different new epidemiological trends of RSV infections worldwide during the COVID-19 pandemic, not only in the Northern hemisphere ,24,25,26Better understanding of the seasonality of RSV and strict surveillance are required to improve the planning of health services. For example, redefining the start of the RSV season is important to ensure the optimal timing to deliver Palivizumab, a humanized monoclonal antibody (mAb) against RSV labeled for the prevention of severe respiratory infections due to RSV in high-risk children ,34,35, aDuring our atypical anticipated RSV peak in 2021, and despite the noticeable increase in RSV cases admitted to the EDs, we found a lower hospitalization rate compared to 2019, in contrast to what was previously described by Agha and Avner (two thirds of the cohort required admission) and Foley et al. (a 2.5-fold higher admission rate) during their atypical RSV surges. The hospitalization rate was lower especially in hospitals with a PICU compared to other hospitals: this finding confirms that the massive increase in the number of cases was not accompanied by any increase in the severity of the infection, compared to previous years.Agha and Avner also reported that most of their hospitalized cohort required admission to the PICU. This is in contrast with our cohort, as only a minority of our patients required intensive care. Prematurity, age ≤2 months and viral coinfection was significantly related to PICU admission. Other studies in France , the USAInterestingly, we noted an exceptionally low coinfection rate of SARS-CoV-2 unrelated to oxygen need or PICU admission. The same results have been described in previous studies, with no severe disease burden in the case of RSV and SARS-CoV-2 coinfection ,38,39,40Anyway, the spike in cases in late 2021 has challenged the Italian National Health Care System: hospital reorganization, with the provision of temporary facilities to increase the number of inpatient beds, was necessary , particuNewborns, younger infants and children >12 months old were found to be at a higher risk of hospitalization. In 2021, the risk of hospitalization for patients younger than 2 months old was particularly high (OR 5.8 vs. 3 in 2019). Another interesting finding is that the age group between 2 and 3 years was more affected by RSV infection in 2021 than in 2019, and for children older than 12 months of age, the odds of hospitalization was higher (OR 2.97 vs. 0.2 in 2019). These local data are consistent with what was reported by Saravanos and Foley ,41 and AThere is an urgent need to develop a robust management approach to detect, contain, deal with and potentially prevent new RSV outbreaks. They are not so easy to predict, considering the impact of extreme situations such as the recent pandemic and, last but not least, the evolving climate change. A great effort should be made in this direction, because timely and accurate data collection and national surveillance about RSV infection is essential to inform public health responses and to be ready to manage new outbreaks. Our study has some strengths. First of all, our observation provides information from different settings  in the same region: this could be useful to prevent the misuse of healthcare resources in case of future outbreaks, independently from national healthcare system assets. Moreover, we focused not only on newborns and infants with bronchiolitis, which have already been largely investigated, but also on older children with other respiratory features related to RSV infection. Our study also has some limitations. It is a multicenter study with a significant sample, but not all the centers invited to participate were included; moreover, only children who were admitted to the hospital were included, while outpatients treated by general practitioners were not considered. As a consequence, our results might not reflect the overall RSV positivity rate in our region. Moreover, the retrospective nature of the study could have limited available information. Another limitation is that RSV was tested with a PCR assay in some cases and with antigen testing in others depending on the different participating centers. Finally, we did not consider the entire epidemic period of RSV infection in Italy, which is extended until March-April, and our observation was limited to the last four months of each year.The ongoing surveillance of RSV infection is necessary to recognize seasonal changes and to be ready to manage atypical spikes. After the COVID-19 pandemic, an increase in RSV cases in 2021 exceeding the median seasonal peak of previous years was detected. The unusual resurgence of RSV infection has also been reported in several other countries, as confirmed by our findings. Improved awareness of the timing of RSV epidemics ensures that optimal levels of protection are achieved in a cost-effective manner. In addition, better knowledge on the timing of RSV activity will allow healthcare providers to reorganize hospitals and manage resources to be ready to receive large numbers of patients with respiratory diseases outside the usual seasonal peaks, as was the case in 2021. Further studies that also consider the possible role played by climate change are needed to redefine the seasonality of RSV infection following the COVID-19 pandemic.


Urinary tract infection (UTI) is a common complication in pediatric urological surgery patients and is associated with long-term sequelae, including subsequent recurrent infections and renal scarring. In this study, we aimed to explore the risk factors for UTI in pediatric urological surgery patients and construct a predictive model for UTI.A total of 2,235 pediatric patients who underwent urological surgery at a tertiary hospital between February 2019 and January 2020 were included. A multivariate logistic regression model was applied to identify the predictive factors, and a predictive model was constructed using a receiver operating characteristic curve. A multifactorial predictive model was used to categorize the risk of UTI based on the weight of the evidence.A total of 341 patients with UTI were identified, which corresponded to a prevalence of 15.26% in pediatric urological surgery patients. Multivariate analysis identified six significant risk factors for UTI, including age <12.0 months, upper urinary tract disease, not using an indwelling drainage tube, hospital stay ≥10 days, administration of two or more types of antibiotics, and stent implantation. A combination of the aforementioned factors produced an area under the curve value of 88.37% for preventing UTI in pediatric urological surgery patients. A multifactorial predictive model was created based on the combination of these factors.The constructed multifactorial model could predict UTI risk in pediatric urological surgery patients with a relatively high predictive value. Urinary tract infection (UTI) is the most common nosocomial infection, and it is reported that approximately 7% of children diagnosed with UTI present with fever in the first year of life. The prevalence of UTI in boys was higher during the first 3 months of life and then declined, whereas it was more common during the first year in girls . StudiesKlebsiella species, long-term catheter retention or double-J catheter retention, and bilateral double-J catheter retention  who underwent pediatric urological surgery at a tertiary hospital from February 2019 to January 2020 were prospectively analyzed. The exclusion criteria were as follows: children with UTI upon admission and children with intellectual disability. The study was approved by the Institutional Review Board of Xinhua Hospital (XHEC-D-2021-158). Written informed consent was obtained from the parents or guardians during the preoperative appointment. The sample size was based on the number of independent variables, and the expected incidence of UTI was defined as 10–20%. Given the retrospective cohort design, the required sample size had to ensure occurrence of at least 10 events for each predictor parameter for potential inclusion in the prediction model. Considering that the loss to follow-up was 10%, the minimum sample size was 612 patients.A total of 11 factors were identified based on the literature review, including sex, age, upper urinary tract disease, indwelling drainage tube, length of stay, invasive procedures, types of antibiotics used, stent implantation, catheter indwelling time, underlying diseases, and clinical outcomes. Data were collected by six primary nurses after they were trained regarding data collection processes.UTI was diagnosed according to the 2010 Guidelines for the Diagnosis and Treatment of Common Renal Diseases in Children . UTI symt-test and Mann–Whitney U-test were used to assess between-group differences for continuous data exhibiting normal distribution. Categorical data between groups were analyzed using the chi-square test. Univariate analysis was then performed to identify the risk factors, which were subsequently subjected to the multivariate logistic regression model, using α = 0.05 and β = 0.10, respectively. Multivariate logistic regression was performed to identify the risk factors for UTI after the continuous adjusted variables underwent multivariate analysis. The importance of each specific factor was obtained from the regression coefficients to calculate the weight of the evidence, and the categorical risk-scoring system was constructed. Scores were obtained for numbers rounded to the nearest unit. The scores were then combined to construct a prognostic model, and the receiver operating characteristic (ROC) curve was constructed to assess multifactorial risk for UTI, while the risk accuracy was analyzed and the area under the curve (AUC) was applied. The inspection level was two-sided. Statistical significance was set at P < 0.05 for the identified risk factors.Statistical analyses were conducted using SPSS 13.0 . The baseline characteristics between patients with and without UTI were categorized as continuous or categorical variables. The n = 112), hospitalization time ≤ 24 h (n = 11), and patients with intellectual disability (n = 2). The remaining 2,235 patients  were included. A total of 341 UTI cases (15.26%) were observed. A total of 2,360 pediatric urological surgery patients were recruited, and 125 patients were excluded owing to incomplete data (P < 0.001), age ≥12 months , upper urinary tract disease , indwelling drainage tube , hospital stay ≥10 days , two or more types of antibiotics used , stent implantation , catheter indwelling time ≥5 days , and underlying disease . However, there were no significant differences between the UTI and non-UTI groups for invasive procedures  and clinical outcome .There were significant differences between the UTI and non-UTI groups for sex , upper urinary tract disease , not using an indwelling drainage tube , hospital stay ≥10 days , two or more types of antibiotics used , and stent implantation  were associated with an increased risk of UTI. These six risk factors were combined to construct the ROC curve to determine the risk of UTI, and the AUC was 88.37%  for the publication of any potentially identifiable images or data included in this article.YC conceived and designed the experiments. YW, S-MZ, J-NY, and WZ performed the experiments. YC analyzed the data and wrote the paper. X-HG and QY contributed to reagents, materials, and analysis tools. All authors have read and approved the final version of this manuscript.This study was funded by Science and Technology Fund project of Shanghai Jiaotong University (Jyhz1920). The funder played no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


Numerous studies have confirmed the effects of low carbohydrate diet (LChD) on metabolism and chronic diseases. However, there were no bibliometric studies on LChD. This study was conducted through a bibliometric analysis to investigate the current status, hotspots and frontiers trends.We searched all research publications related to LChD from 2002 to 2021 on the Web of Scientific Core Collection (WoSCC). CiteSpace and VOSviewer software was used to analyze countries/regions, institutions, journals, authors, references, and keywords.Obesity” were considered to be the most co-cited and cited reference respectively. The hotspots of LChD are four aspects, “ketogenic diet”, “metabolism disease”, “cardiovascular disease” and “cancer”. We summarized that “oxidative stress”, “gut microbiota”, and “inflammation factors” are becoming frontiers trends of LChD research in the future and deserve further study.A total of 6938 papers were included, with an increasing trend of annual publication. LChD categories mainly included nutrition, endocrinology, and neurosciences which reflected the interdisciplinary characteristics. USA was with the largest number and the world science center in LChD field. Universities were main research institutions and five of the top 10 institutions were from USA. Eric Heath Kossoff had 101 publications and ranked first. Nutrients was the leading journal. “A randomized trial of a low-carbohydrate diet for obesity” and “Over the past 20 years research on LChD has gained great attention. To better explore LChD field, multilevel mechanism studies will be required in the future. Dr. Atkins' New Diet Revolution,” in which the intake of carbohydrate was rigorously limited while the intake of protein and fat is raised  and VOSviewer (1.6.18) for a bibliometric analysis of 6,938 publications on LChD from 2002 to 2021. The java-based program CiteSpace does bibliometric analysis of publications using distribution network maps, co-citation network maps, dual maps of journal overlay, and keyword burst citation maps . Nodes aA total of 6,938 publications including 5,350 articles and 1,588 reviews, related to LChD from 2002 to 2021 were retrieved by searching the WoSCC database. The flowchart was shown in LChD publications in the past 20 years can be divided into 2 stages. The initial stage (2002–2010) was a steady growth period. The average number of publications was 188 publications every year, with the lowest number of publications being 72 publications in 2002 and the highest number being 273 publications in 2009. In 1927, a low carbohydrate ketogenic diet had been reported for epilepsy . As an eThe categories refer to the disciplines covered by the dissertation research. At top 10 categories , NutritiIn total, 112 countries/regions participated in 6,938 publications on LChD from 2002 to 2021. CiteSpace generated the countries/regions distribution map, and 112 nodes and 880 links were shown in the map . Table 2A total of 604 institutions provided research in the field of LChD. CiteSpace generated the institutions distribution map with 604 nodes and 2,103 links . The insIn total of 890 authors participated in 6,938 publications on LChD from 2002 to 2021. CiteSpace generated the institutions distribution map with 890 nodes and 1965 links . The topResearchers can accurately understand the core journals in a topic by analyzing its source journals, which also serves as a reliable resource for further field research . A totalThe co-cited reference analysis is one of the important indicators in bibliometric research and is usually used to explore research priorities in specific academic fields . CiteSpaHigh cited references lay the foundation and accelerate the development of research in the field . The topThe map of keywords can present the main research objects and the hot topics and frontiers trends. In this study, VOSviewer software performed the keyword co-occurrence of overlay visualization . A totalWe performed a bibliometric analysis of the publications from WoSCC on LChD from 2002 to 2021 using CiteSpace and VOSviewer software. We then summarized the current status, hotspots and frontiers trends in this field.A total of 6,938 publications including 5,350 articles and 1,588 reviews, related to LChD from 2002 to 2021 were retrieved by searching WOSCC database. The number of annual publications on LChD showed an overall upward trend in spite of fluctuation slightly in some years. LChD research mainly involved the categories of nutrition, endocrinology, and neurosciences, reflecting the multidisciplinary nature and comprehensive knowledge about LChD research. USA was with the largest number and the world science center in LChD field, and Australia, Canada, England, France and Germany maintained close cooperation relationships. Universities were major institutions for LChD research. Five of the top 10 institutions were from USA, which further confirmed US predominance in the field of LChD research. Duke University, Harvard University, Johns Hopkins University and University of Toronto had close collaboration relationships. The most productive authors were Eric Heath Kossoff, Jeff Scott Volek, Jong M. Rho, William S. Yancy, and Maria Luz Fernandez. The authors' collaboration showed a geographical concentration and general decentralization. The most productive journals were Nutrients, Epilepsia, Epilepsy Research, PLoS One, and American Journal of Clinical Nutrition. “A randomized trial of a low-carbohydrate diet for obesity” and “Obesity” were considered to be the most co-cited and cited reference respectively.Based on the keywords the keyword co-occurrence of overlay visualization, we can explore the hotspots. From Ketogenic diet: The KD is a type of low-carb diet, characterized by high fat and very low carbohydrate. KD works on the basis of the biological principle of starvation, using fat as the main energy source of the body . KD initMetabolism disease: In this study, obesity and diabetes are common metabolic diseases. By consuming less carbohydrates, restricting the body's usage of exogenous glucose, and boosting lipolysis and fatty acid oxidation to meet the body's energy needs, low carbohydrate nutrition enable individuals to lose weight . The stuCardiovascular disease: The risk of cardiovascular disease rises with a high carbohydrate diet . The risCancer: Nutrition is receiving increasing attention in oncology clinical research . Proper Burst keywords can explore the future development trends. Therefore, we summarized the burst keywords into three aspects, and considered them to be frontiers trends of LChD field and anticipated to occur frequently in the future years.Oxidative stress: Oxidative stress is a negative effect produced by free radicals in the body, and it is considered to be an important pathogenic factor, such as diabetes mellitus, obesity, heart disease, and cancer . The metGut microbiota: Gut flora can regulate body metabolism and participate in the occurrence of diseases through a variety of mechanisms. With increasing research on gut microbiota, the dietary pattern was identified as one of the main drivers of gut microbiota change. Recently, carbon aquatic ketone diet has been shown to effectively treat neurological diseases , tumor , 86, metInflammation factors: With the development of life science and technology, the current literature also further explains the disease treatment and prevention of LChD from the inflammation level. Tumor necrosis factor-a, interleukin-6, lipocalin, and C-reactive protein are inflammation factors produced by adipose tissue – 94. DieTo the best of our knowledge, the present study is the first bibliometric analysis to assess LChD. However, it has many limitations. First, considering that the data difference and incompleteness of other database data, we only analyzed publications from the WoSCC. Next, to better present the analysis result and to ensure the quality of the included literature, we included only articles and reviews published in English. This may lead to some screening bias.We searched all research publications related to LChD on the Web of Scientific Core Collection (WoSCC). CiteSpace software was used to analyze countries/regions, institutions, journals, authors, references, and keywords. LChD is a popular diet, attracting attention from scholars. The hotspots of LChD are three aspects, “metabolism disease,” “cardiovascular disease,” and “risk factor.” We summarize that “research on prevention and treatment,” “research on diet,” and “research on molecular level” are becoming frontiers trends of LChD research in the future directions and deserve further study.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.HP and GL: conceptualization. XH: methodology, writing-original draft preparation, and writing-review and editing. CL and LZ: software. LZ: investigation, data curation, and supervision. GL and XH: resources. GL and CL: visualization. All authors have read and agreed to the published version of the manuscript.


Whether a pig should be placed on its back or sternum to facilitate endotracheal intubation is currently not known and a subject of debate. Enrolling participants with different clinical anaesthesia backgrounds, we aimed at assessing which recumbency  is advantageous, and if operator experience can influence the results. Using objective and subjective outcomes, we found that sternal recumbency is advantageous if compared to dorsal, but that this is true only for operators lacking experience in anaesthetising animals. Experts’ confidence in intubating various animal species with different techniques probably minimized the influence of recumbency.p = 0.002) and time (p = 0.002) to correctly perform ETI were needed in SR for the ST group. In 21/119 and 5/48 ETI attempts, oesophageal intubation was performed in DR and SR, respectively. Larynx visualization (p < 0.001) and endotracheal tube introduction (p < 0.001) were perceived as easier in SR for the ST group. No difference between recumbencies was found in perceived ease to advance the endotracheal tube. For inexperienced operators, intubation in SR can be recommended.Endotracheal intubation (ETI) is challenging in pigs. We compared the number of attempts and time to perform ETI, and the subjective perception of ease, while the animal was positioned in dorsal (DR) or sternal (SR) recumbency, as well as assessed whether operator experience influences the outcome. Participants were divided into three groups: undergraduates , graduates  and experts . Each participant intubated one freshly euthanised pig in DR and ST. Number of attempts and time to correctly perform ETI, number of oesophageal intubations and answers to Likert-scale questions on larynx visualization and ease of endotracheal tube introduction and advancement were recorded. Thirty-three participants were enrolled . Less attempts ( Airway management of pigs undergoing general anaesthesia can be challenging ,2,3. WhiParticipants were enrolled from the Veterinary Faculty and the Experimental Surgery Facility of the University of Bern. Three groups were foreseen: undergraduates , graduates  and experts .An invitation to participate in the study was sent to students (ST group) via email. Participants belonging to the GR and EX groups were personally invited. No ethical authorization was needed for the present study according to the judgement of the competent authorities .Sixteen juvenile mixed sex pigs, freshly euthanized for a separate experimental trial, were used for the present study. The animals’ age and weight (mean (standard deviation)) were 10.8 (0.6) weeks and 28.9 (4.7) kg, respectively. In order to avoid bias due to deformation of the upper airway tissues caused by repeated intubations, a maximum of three participants per pig was set. Thus, a maximum of 48 participants was foreseen.https://www.randomizer.org/, (accessed in January 2021). In case of intubation in DR, no help was provided; in case of intubation in ST, one investigator (AM) assisted with mouth opening and moving the animal’s head, as requested by the participant. Number of attempts and time to perform a correct endotracheal intubation (ETI) were recorded. The timing of the procedure began when the laryngoscope was placed on the tongue and ended when a correct ETI was confirmed by one of the main investigators . Intubation time was calculated summing the time of each single attempt . The number of oesophageal intubations was recorded and the soft palate entrapment (presence/absence) was evaluated, by one of the main investigators (FM or AM), during the first attempt, for each recumbency and participant.Within the 48 h preceding the trial, each participant (except for experts) received a file explaining how to perform pig intubation in both recumbencies. The investigation was always performed in the early afternoon, within one hour after euthanasia. Each participant intubated the pig in DR and SR, following a computer-generated random order ((1)I can easily visualize the larynx;(2)I can easily introduce the endotracheal tube;(3)I can easily advance the endotracheal tube.After the procedure, an online questionnaire consisting of three Likert-scale questions was filled-up by each participant. Respondents indicated their agreement with the statement: strongly disagree; disagree; neither agree nor disagree; agree; strongly agree. Questions were structured as clear, concise and fulfilling the end goal, avoiding assumptions:Finally, one open-ended question was also asked: “Which technique  would you choose to intubate a pig? Explain your preference”.p < 0.05. Answers to the open-ended question were classified according to the items reported.Statistical analysis was performed using the software SigmaPlot Version 14.0 . Normality was assessed using the Shapiro–Wilk test. Data with a normal distribution are presented as the mean (standard deviation) and those with a non-normal distribution as the median (interquartile ranges). For all the Likert-scale questions, the possible answer options were scored into five progressive point categories . In order to evaluate the difference in answers to the Likert-scale questions, the number of attempts and total intubation time between DR and SR, the Wilcoxon Signed Rank Test was used. Comparison among groups was performed using the Kruskal–Wallis one-way analysis of variance on ranks, followed by Dunn’s Method, when appropriate. Level of significance was defined as Thirty-three participants were enrolled in the study . Among the students, none had previously performed an intubation.p < 0.001) were needed to perform a correct ETI in SR compared to DR (Less attempts (ed to DR .p < 0.001) was needed to perform a correct ETI in SR compared to DR  and endotracheal tube introduction (p < 0.001) were judged to be easier in SR. No difference was found between recumbencies in the ease of advancing the endotracheal tube  and 5 (10.4%) times an oesophageal intubation was performed. Analysing the answers to the questionnaire, larynx visualization  to correctly perform ETI were needed in SR for the ST group, but not for the GR and EX groups (p = 0.002) and the GR group (p = 0.037), but not for the EX group.Less attempts (X groups . Similarp < 0.001) and endotracheal tube introduction (p < 0.001) were easier in SR for the ST group, but not for the GR and EX groups. No significant difference between recumbencies was found in the ease to advance the endotracheal tube in all groups . Two participants in the ST group and one in the EX group did not express any preference. Mentioned reasons for recumbency preference (answer to open ended question) were visualization, second person help, ease of ETT advancement, laryngoscope ergonomic holding, landmarks recognition and previous experience. The main reasons were visualization (16/24) and previous experience .p = 0.01), and the time to perform it was significantly lower for the EX group compared to the GR group (p = 0.048). No other differences among groups were detected.When differences among groups were assessed, ETT introduction in DR was deemed significantly easier for the EX group compared to the ST group (In the present study, overall, fewer attempts and faster intubation were achieved with the animal in SR, which was also correlated with fewer oesophageal intubations. Moreover, larynx visualization and ETT introduction were perceived to be easier in SR compared to DR.However, to notice is that most of the statistical differences decreased or disappeared with increasing operator experience. Indeed, while the ST group mirrored the overall results, only the time to perform a correct ETI was statistically less in SR for the GR group, and no differences between recumbencies were found in any of the considered outcomes for the EX group.Initially, we hypothesized that the higher number of small-animal anaesthesia performed at our faculty would have created a bias in the more experienced participants in favour of SR, most commonly adopted for dogs and cats. However, the results from the present study show that the wider the anaesthesia experience, the lower the preference toward one of the two approaches. Confidence in intubating various animal species with different techniques could have minimized the influence of recumbency on the outcomes.Ease of larynx visualization was shown to be a critical issue during intubation in DR. The veterinary literature typically provides a description of anatomical structures with the animals in a standing position; this could have facilitated the recognition of the anatomical landmarks with the animal in SR. The higher number of oesophageal intubations performed by students with the animal positioned in DR supports this theory.The outcomes of the present study are in line with those of Theisen et al. , who recSoft palate entrapment more often was found with the animal in DR compared to SR. We cannot infer that the occurrence would be higher in live animals, but the higher prevalence of this observation in DR could have prolonged the intubation time, increased the number of attempts and made the overall intubation performance more difficult.The present study has some limitations. First, only juvenile pigs were included. Even if animals around this age are commonly used for experimental studies, care should be taken in translating these results to adult animals. Second, participants in the different groups were not homogeneous due to the voluntary-based enrolment. Third, participants knew they were being observed, possibly leading to increased stress and anxiety, perhaps influencing their performance. However, each participant accomplished intubation in both recumbencies; thus, the preference toward one or the other should not have been influenced.Intubation in SR seems to be advantageous, but only for inexperienced operators. Experts’ confidence in intubating various animal species with different techniques probably minimized the influence of recumbency on the outcomes.


Despite the dramatic growth of primary care in China, little evidence showed what general practitioner (GP) do and how GP provided medical service in Beijing.This study aimed to explore the work content of GPs in primary care in Beijing.A multi-method study was conducted in five community health service institutions using non-participant observation and critical incident technique interview. Eleven GPs was recruited by purpose sampling, with each GP recording details of 100 patient encounters. Health problems of patients and activities of GPs were observed in consultations. Then, critical incident technique interviews were conducted focusing on GPs' works out of clinics and challenge.A total of 1, 100 patients encounters and 1,897 reasons for encounter (RFEs) were recorded from 11 GPs. There were 1897 RFEs (1.72 per encounter) and 2,762 health problems (2.51 per encounter) from 1,100 encounters during our observation. GPs' work related to consultation was focus on disease diagnoses and treatment. Physical examination and investigations were performed in only 15.5 and 17.1% consultations, respectively. Procedures for chronic disease management were infrequently provided to patients (0.4–26.6%). Time spent in each work process in consultations ranged from 0.68 ± 0.27 min for reservation to 4.00 ± 2.45 min for surgical treatment. In addition to clinical work, there were tasks about health files, contracted family doctor services, health education, teaching students, and scientific research.This study illustrated the complexity of GPs' work and heavy workload in Beijing, China. More attention and effort are needed to develop GPs performance and release GPs' work workload in primary care. Primary health care (PHC) is an essential component of high-performing health care system. Patients with access to a regular primary care physician are more likely to receive recommended screenings, have fewer preventable hospital admissions, and experience lower mortality . HoweverGeneral practitioners (GPs) are the first contact for patients within PHC system, providing medical care for patients with any undiagnosed sign symptom, or health concern (the “undifferentiated” patient) not limited by problem origin , organ system, or diagnosis . In addiAlthough PHC in China has developed rapidly, patient expectations were still focused on specialist diagnostic aids and procedures rather than cost-efficient primary care . Most reIn recent years, general practice in Beijing developed rapidly. In 2017, the comprehensive medical reform of separating drug sales from medical treatment was launched in Beijing, to promote the development of hierarchical diagnosis and treatment by guiding the patients to seek healthcare rationally via the pricing leverage . In 2018This multi-method study was conducted using non-participant observation and critical incident technique interview.This study was conducted in 5 CHSIs in Beijing, recruited by purposive sampling, with four in urban district and one in suburban district. GPs were recruited by purposive sampling with: (i) more than 2 years of working experience in general practice clinics, (ii) a stable amounts of daily patient visits, and (iii) consent to this study.In the observation study, a nested sample composed of GPs and their patients was recruited in this study. Patients were recruited if they attended to the participating GP during our observation period until 100 records of consecutive GP–patient encounters of all types were completed . PatientNon-participant observation of GP–patient consultations was undertaken to explore work content of GPs in the clinics. Prior to the main study, 26 consultations with two different GPs were observed to develop a proforma for the analysis of content of consultations. This proforma recorded data about demographic information of patients and the content of general practice consultation, which including two parts: (i) reasons for encounter (RFEs) and health problems, which referred to the reasons or problems patients come with, and (ii) the medical services provided by GPs, referring to the process of consultation , according to the Subjective-Objective-Assessment-Plan (SOAP) .During the observation, the processes of GPs' consultation were recorded, which started from the time of their workday began to the time of their workday end (from 8 am to 5 pm), excluding time spent in other activities . The observation for each participating GP was finished when the information about 100 consecutive patient consultations were recorded. One observation unit for each GP lasted for 1.5–2.5 days. After the observation, the information about participated GPs was collected which including age, sex, education, working years, professional position, and training experience.Three research assistants  were hired as observers who were postgraduate students, majored in general practice and had a solid foundation in general practice research. A training session was conducted before the observation. During the observation, the observers were seated in the least intrusive corner of consulting room and will not talk to the GPs and patients.Critical incident technique interviews were undertaken to supplement the observation. Information about work out of clinics and the challenging and meaningful work of GPs were collected by this method. The critical incident technique interview utilizes a process rather than an interview schedule. The focus is on a participant's description of one specific incident and the interviewer works to enrich the initial summary provided by soliciting further information and pertinent detail. There are four stages to a critical incident technique interview: (i) selecting an appropriate incident; (ii) developing a detailed description of specific events using probing questions to understand the rationale; (iii) exploring cues and reasoning for the actions taken by team members and (iv) identifying the root causes of the incident using a series of probing questions , 22. DurThe same GPs as in non-participant observation were invited to participate in the interview. YW and FYW conducted interviews in clinical settings (meeting rooms or offices), based on the participants' preference. All interviews were recorded with the recording equipment on the mobile phone. At the same time, researchers kept field notes to capture key information. Data collection continued until new topics stopped emerging and saturation of themes was reached . The poiThe RFEs and health problems were coded using the International Classification of Primary Care (ICPC-2), based on codes that are classified in 17 chapters representing body systems and problem areas , 24. In The encounter is the primary unit of inference, each 100 encounters forming a cluster around each GP participant. Descriptive statistics were used to describe the demographic information of GPs, RFEs, and practice content in observation, with means [with standard deviation (SD)] being used to report continuous variables and frequencies being used to report categorical variables. Analyses were performed using Statistical Package for Social Science (SPSS), version 22.0. Interviews were transcribed and analyzed using inductive thematic analysis  which inA total of 11 GPs were recruited, with two male and nine female. The mean age (with SD) of GPs was 39.4 ± 4.3 years (ranged from 35 to 48 years). Nine GPs had more than 10 years of work experience. There were six associate chief doctors, four attending doctors, and one resident doctors. Three GPs had the experience of standardized residency training, six were transferred from other specialties after the on-job training, and other two GPs had no training experience of general practice. The observation unit for each GP lasted for 1.5–2.5 workdays, with the patient visits to each GP per workday ranging between 41 and 88. The mean length of consultation was 3.87 ± 3.20 minutes.n = 737, 38.9%), respiratory symptoms  and digestive symptoms . The RFEs referring to other chapters were all <10%. “K: Circulatory” , “T: Endocrine, metabolic and nutritional” , and “R: Respiratory” , were among the top three chapters for health problems.A total of 1,100 patients encounters were recorded from 11 GPs. There were 1,897 RFEs (1.72 per encounter) and 2,762 health problems (2.51 per encounter) from 1,100 encounters during our observation. The distribution of RFEs and health problems according to the ICPC-2 were shown in GP-patient consultation is the major part of GP work. Information about the content of GPs' practice in consultations was shown in In addition to clinical work, there were also other tasks undertaken by GPs, including establishing and managing the health files of residents, contracted family doctor services, conducting lectures on health education for residents, teaching clinical students or trainees, and conducting scientific research.In addition to GP-patient consultation, we also have some work about family doctor contract, including introducing family doctor service, signing contract with patients, providing family doctor service and community follow-up. There are some works about teaching student, including outpatient teaching, lectures, case discussion, etc. Besides, we also do some work about research, such as conducting experiments, collecting and analyzing data, and writing articles. (GP 2 and GP 5)In addition to clinical work, we also be responsible for management of health records, and conduct health education lectures for chronic patients, which are held about 2-4 times a month. Four categories about challenging and meaningful work of GPs in primary care from critical incidents, including management of emergency conditions, detection diseases at early stage presenting in an undifferentiated way, reasonable referral, and doctor-patient communication . Good peIn the present study, we have conducted a multi-method study to explore the work content of GPs in Beijing, China. GP-patient consultation is the major part of GP work. In consultations, health problems managed by GPs are distributed in almost all organs and body systems, including acute and chronic problems. GPs' work content in consultations focused mostly on the diagnosis and treatment procedures. Physical examination, test, and some procedures for chronic disease management were infrequently occurred in GP-patient consultations. In addition to GP-patient consultation, GPs also undertake work like health file management, contracted family doctor services, teaching student, and scientific research. It is worth noting that management of emergency conditions, detection diseases at early stage presenting in an undifferentiated way, reasonable referral, and doctor-patient communication are challenging and meaningful work of GPs.GP-patient consultation is the major part of GP work in Beijing. Complex situation with several problems appeared commonly for patients coming to GPs' clinics, with 1.72 RFEs and 2.51 health problems per encounter. This finding was similar to the study by Salisbury C in UK , with anAlthough the processes related to disease diagnosis and treatment were all involved in GP-patient consultations in this study, physical examination, test, and procedures for chronic disease management were infrequently occurred in general practice consultations.In this study, physical examination was observed in only 15.5% GP-patient consultations, while it was observed in 64.5% of GP-patient consultations in Australia , 79% in Another insufficient of GPs' performance is that procedures for chronic disease management were infrequently occurred in general practice consultations. GPs just satisfy patient's need for medicine refill, neglecting services like evaluation, follow-up, and complications screening. In recent years, there is a progressive shift in the burden of disease to chronic Non-Communicable Diseases (NCDs). Almost 80% of deaths in China in people aged 60 years are from chronic NCDs . HoweverAnother finding in this study is that there are many tasks out of consultations, which plays an important role in GPs' work content, such as health file management, health education, contracted family doctor services, teaching student, and scientific research.In recent years, the Chinese government has invested increasing financial resources in purchasing essential public health services for all citizens. For example, the minimum amount of per capita subsidies for basic public health package rose from RMB 15 (US $2.2) in 2009 to RMB 45 (US $6.6) in 2016 . So far,Another important work of GP is about contracted family doctor service, also called GP team-based service, which has been promoted since 2011 at the national level. In this model, GPs, nurses, and, sometimes, public health doctors work as a team to provide continuous and comprehensive medical services to enrolled residents, who has contracted with a family doctor team . ResidenFor GPs views, works related to management of emergency conditions, detection diseases at early stage presenting in an undifferentiated way, reasonable referral, and doctor-patient communication were challenging and meaningful. GP is the first contact of patients in PHC. As in the World Organization of Family Doctors (WONCA) tree, specific problems solving skills for early undifferentiated stages, comprehensive approach for acute and chronic health problems, and person-centered care were core competencies of GP . HoweverIn this study, it can be found that numerous tasks were undertaken by GPs in PHC. The imbalance between the growing number of patient visits in PHC and the shortage of GPs has persisted. Therefore, training for the new and current PHC workforce should be enhanced. There are three GP training models in China: (1) the “5+3” residency training model , (2) the on-job training (1-year training for doctors who want to register as GP), (3) the “3+2” rural GP residency training  , 46. TilThere are two main strengths to this study. First, to our knowledge, this is the first article describing the details about work content of GPs in patient consultations, including the health problems GPs handled and the work process GPs conducted. Besides, the detailed length of time for each component was also calculated to give an explicit view of GPs work. Second, non-participant observation truly reflected GPs' work in GP-patient consultations, critical incident technique interview enabled a depth of coverage of issues out of consultation. The multi-method of this research enabled some practical insights into work content of GP in primary care.Several limitations of our study should be considered. First, as only 11 GPs from five CHSIs in Beijing were purposive sampled, the generalizability of these findings is uncertain. It is possible that GPs' performance varies with differences in variety of cases, characters of GPs at different work conditions, motivation, and time. As this is a preliminary study researching in exploration of GPs' work content, investigations in other settings even in other areas and larger sample are necessary in further researches. Second, these five CHSIs were teaching bases of Capital Medical University, the work content of GP may be different from that in non-teaching bases, such as teaching student, which may be the unique work content of the teaching base. Third, observations might be influenced by observer bias. We developed a structured encounter form for observation and modified it through a pilot study. We also provided careful training for observers about principles of observation and information recording to help overcome these limitations before the start of formal observations.This study described the work content of GP in primary care, and illustrated the complexity of GPs' work in Beijing, China. Insufficient of GPs' performance was also indicated in this study. More attention was needed for physical examination and chronic disease management. Besides, heavy workload of GPs is still a challenge in primary care, PHC workforce development should be strengthened to share GPs' work and improve the quality of primary care.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the Ethical Committee of Capital Medical University, Beijing, China. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.YW and XL designed the study. XL obtained ethical approval. YW, FW, and ZP were responsible for data collection. YW drafted the manuscript. DW was responsible for the revision of the manuscript. GJ was responsible for the improvement of the English language within the manuscript. QC and XL contributed to the interpretation of the results and critical revision of the manuscript for important intellectual content and approved the final version of the manuscript. All authors have read and approved the final manuscript.This work was supported by the Capital General Practice Research Project (17QK06). The funding organization had no role in the design, conduct, analysis and interpretation or preparation of this study.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.


There is a bidirectional association between diabetes and periodontitis. However, the effect of diabetes on the periodontitis salivary microbiota has not been elucidated. The aim of this study was to determine the effect of the presence of diabetes on the microbiota among Chinese patients with periodontitis.Unstimulated whole saliva samples were collected from the periodontitis with diabetes group (TC), chronic periodontitis group (CP), and periodontally healthy and systemically healthy group (H) by spitting method. Bacterial genomic DNA was PCR-amplified at the V4 variable region of 16S rRNA gene. The library was constructed according to the obtained sequence results, and biological analysis and statistical analysis were carried out. Functional prediction of three groups of microbial communities was performed by the PICRUSt algorithm.Firmicutes, Streptococcus, Haemophilus, Veillonella, and Haemophilus parainfluenzae dominated the H group. Corynebacterium, Leptotrichia, Dialister, Comamonas, Capnocytophaga, Catonella, Filifactor, Campylobacter, Treponema, Campylobacter concisus, Prevotella oralis, and Porphyromonas gingivalis were significantly enriched in the TC and CP groups. Among them, Treponema and P. oralis were the most abundant in the TC group. The PICRUSt results showed that many pathways related to cell motility and functional metabolism of the salivary microbial flora changed in the TC group and the CP group.There was no significant difference in bacterial diversity between the TC and CP groups. Compared with the H group, the TC group and CP group presented a higher diversity of salivary flora. Diabetes was not the main factor causing the altered diversity of salivary microbiota in patients with periodontitis; however, the presence of diabetes altered the abundance of some microbiota in saliva. Diabetes mellitus is a common metabolic disorder characterized by chronic hyperglycemia. The latest epidemiological studies have shown that more than 440 million people worldwide suffer from diabetes , mainly Periodontitis is the sixth most common complication in people with diabetes . CurrentIn the Chinese population, the impact of diabetes on periodontitis salivary flora is relatively unknown. In the study of inflammatory mediators and microbiota in periodontitis and systemic diseases, saliva has been proven to be a viable substitute for serum and gingival crevicular fluid , which hThe subjects of the study were patients who visited the Department of Stomatology and Endocrinology of the First Affiliated Hospital of Jinan University from January 2021 to January 2022. Thirty volunteers were recruited by convenience sampling and divided into the periodontitis with diabetes group , chronic periodontitis group , and healthy group .1C) ≥6.5% and fasting blood glucose (FBG) ≥7.0 mmol/L  ≥4 mm and clinical attachment loss (CAL) ≥2 mm . T2DM wa0 mmol/L . IndividThe following patients were excluded from our study: 1) any patient diagnosed with metabolic disease other than diabetes and systemic disease that may have affected the progression of the periodontitis, such as hyperthyroidism or cancer; 2) prior to the experimental history of special medication, such as antibiotics or hormones, within 6 months; 3) received periodontal treatment, such as scaling, within 6 months; 4) pregnant or breastfeeding; 5) current smokers ; 6) remaBefore the periodontal assessment, unstimulated whole saliva samples were collected by spitting. All research subjects were asked to fast for at least 8 h and to avoid eating, rinsing, brushing their teeth, and performing other oral exercises for at least 2 h before sampling. Then, 2 ml of saliva was collected between 9:00 am and 11:00 am and immediately stored in a −80°C refrigerator. The genomic DNA of the samples was extracted by the conventional cetyl trimethylammonium bromide method (CTAB), and the purity and concentration of the DNA were then detected by agarose gel electrophoresis.® DNA PCR-Free Sample Preparation Kit  was used for library construction. The library quality was assessed on the Qubit@ 2.0 Fluorometer  and Agilent Bioanalyzer 2100 system . After the library was qualified, the Illumina NovaSeq 6000 platform was used for on-machine sequencing.With the use of the diluted genomic DNA as a template and specific primers with Barcode, PCR amplification was performed on the 16S rRNA gene V4 variable region. The forward primer sequence was 515F (5′-GTGCCAGCMGCCGCGCTAA-3′), and the reverse primer sequence was 806R (5′-GGACTACHVGGGTTWTCTAAT-3′). The TruSeqhttp://www.drive5.com/uparse/) was used to perform operational taxonomic unit (OTU) clustering on the effective tags of all samples. Species annotation taxonomic analysis was performed using the Silva database (http://www.arb-silva.de/) based on the Mothur algorithm. Differences in dominant species between groups were compared using MUSCLE software . After the data were normalized, alpha diversity analysis and beta diversity analysis were performed using QIIME software (Version 1.9.1) and R software (Version 2.15.3). With the use of R software (Version 2.15.3), statistical analysis methods, such as T-test, MetaStat, and analysis of similarity (ANOSIM), were used to test the significance of differences in the species composition and community structure of the grouped samples. PICRUSt predicted microbial function, and a T-test was used to detect functional differences between groups. Statistical analysis was performed on the baseline data of the study population using ANOVA or Tukey’s test and the chi-square test in GraphPad Prism software.The original sequence was spliced and filtered to obtain clean data (effective tags). Then, Uparse software . The bacterial community structure between the CP group and the H group  and the TC group and the H group  were statistically significant.The beta diversity among the three groups is shown in As shown in Neisseria, Prevotella, Haemophilus, Streptococcus, Veillonella, and Porphyromonas. The MetaStat and T-test results  database for the three groups of microbial communities. As shown in Periodontitis is an inflammatory disease that is thought to be associated with a variety of microbial disturbances . ConsideSimilar to our findings, Liu  and FariCompared with the H group or the CP group, the TC group showed an increasing trend in the flora biodiversity. This is similar to that reported by Balmasova  and ChenTreponema. At the genus level, differential expression of this genus was observed in the TC group. It has been reported that the Spirochaetota flora accounts for 50% of the subgingival microbial population in periodontitis and less than 1% in healthy individuals  in periodontitis has been extensively studied, while research on C. concisus in periodontitis is still limited. Studies have reported that the abundance of C. concisus is associated with increased levels of attachment loss in subjects with periodontitis , Guangzhou Science and Technology Plan Foundation and Application Foundation Research Project (grant No. 202102020020), Guangdong Foundation for Basic and Applied Basic Research (grant No. 2019A1515110161), Fundamental Research for the Central Universities (grant No. 21621410), Scientific Research Project of Guangdong Provincial Administration of Traditional Chinese Medicine (grant No. 20201107), and Starting fund for doctoral research of the Sixth Affiliated Hospital of Jinan University (grant No. JDLY2022001).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.


Objective: Based on TCGA database, a prediction model for 1-, 3-, and 5-year overall survival rates of gastric cancer (GC) patients was constructed by analyzing the critical risk factors affecting the prognosis of gastric cancer patients.Method: Clinicopathological features as well as gene signature of GC patients were obtained from TCGA database. Patients were randomly divided into a training cohort and an internal validation cohort. Independent predictors of GC prognosis were analyzed by univariate and multivariate Cox analyses to construct nomogram. The accuracy and reliability of the model was further validated by calibration curves, ROC curves, and C-indexes, and the clinical utility of the model was analyzed by decision analysis curves.Result: Age, sex, N stage, M stage, METTL16, RBM15, FMR1, IGFBP1, and FTO were significantly associated with the prognosis of GC patients, and these predictors were further included in the construction of nomogram. The C-indexes for the training cohort and validation set were 0.735 and 0.688, respectively. The results of the ROC curve analysis indicated that the area under the curve (AUC) exceeded 0.6 in training and validation sets at 1, 3, and 5 years.Conclusion: We have constructed and validated a nomogram that provides individual survival condition prediction for GC patients. The prognostic model integrating gene signatures and clinicopathological characteristics would help clinicians determine the prognosis of patients with GC and develop individualized treatment plans. Helicobacter pylori infection  is one of the most common, aggressive malignancies worldwide, with over 1 million newly diagnosed cases annually, and persists to be the third leading cause of cancer-related mortality . Accordinfection . Among fc cancer . Up to nc cancer . TherefoRNA modification plays an indispensable role in the post-transcriptional regulation of gene expression . NumerouThe tumor lymph node metastasis (TNM) staging system, proposed by the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC), is widely used to evaluate tumor staging and predict the prognosis of cancer patients . NeverthIn this study, we obtained the clinical data and m6A-related gene expression data provided by TCGA database. We retrospectively analyzed all of them for potential risk factors for GC and then constructed a predictive nomogram to assess the probability of survival at 1, 3, and 5 years.https://portal.gdc.cancer.gov/). TCGA database is a collaboration between the National Cancer Institute (NCI) and the National Human Genome Research Institute (NHGRI) of the United States project to provide a large, free reference for cancer research by collecting and organizing a variety of histological data related to cancer. In this study, the transcriptome profiling for the GC project was selected in the format of HTSeq-FPKM, which included 32 normal tissue samples and 375 cancer tissue samples. Clinical data for the “bcr xml” workflow type were also downloaded for 443 GC patients. Patients with missing clinical data will be excluded from subsequent analyses. This study investigated the prognosis of GC patients using the Cancer Genome Atlas (TCGA) database , readers , and erasers (FTO and ALKBH5). Clinical variables extracted from TCGA database were listed as follows: age, sex, tumor differentiation grade, AJCC stage, T stage, M stage, N stage, survival time, and survival status. The outcome was overall survival (OS), which was defined as the time from initiation to death due to any cause. For subjects lost to follow-up before death, the time of the last follow-up visit was usually considered as the time of death.After setting the seed number, patients were divided into training set and validation set at a ratio of 1:1.Univariate Cox analysis was performed to determine the association between survival outcomes and variables. These variables included demographic characteristics (age and gender), tumor characteristics , and 23 m6A-related genes. Statistically significant potential risk factors were further analyzed by multivariate Cox regression, and hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated. Considering that the AJCC stage is a comprehensive result of T, M, and N stages, the AJCC stage is not considered as one of the variables in the multivariate regression analysis.According to the results of multivariate regression analyses, clinical characteristics and m6A-related genes were integrated through the “rms,” “foreign,” “survival,” and “regplot” packages of R software to construct prognostic nomogram. Scores for each risk factor listed in the nomogram were summed to predict OS at 1, 3, and 5 years for individual GC patients. Simultaneously, we grouped GC patients into low-risk groups and high-risk groups according to median scores. Survival analyses were performed between the high-risk and low-risk groups.Discrimination is measured by the area under the curve (AUC) of the ROC curve and the concordance index (C-index). Ranging from 0.5 to 1, excellent discrimination is represented by values of 0.6 or more for both AUC and C-index. Furthermore, we also used the calibration plot to measure the extent of proximity between predicted risk and actual risk. Decision curve analysis (DCA) also was used to determine whether the predictive nomogram can improve the prognosis of GC patients in the clinical decisions.A total of 317 patients with GC were obtained from TCGA database. Fifty percent of the patients from TCGA database were used as the training cohort and the remaining patients were treated as the internal validation cohort. The detailed selection process and study process are presented in p-value cutoff of 0.2 for univariate Cox analysis and multivariate Cox analysis, the potential risk factors were listed as follows: age, gender, M stage, N stage, and five m6A-related genes  (At a and FTO) . We perfand FTO) . The resCalibration curves illustrated that there is a strong agreement between predicted survival probabilities and actual survival outcomes . The C-iIncorporating the results of the DCA curve, C-index, ROC curve, and calibration curve, we found that the prediction model constructed based on the abovementioned factors had a significant predictive value for OS in GC patients with high accuracy and clinical applicability.p < 0.05).After summing the risk scores of all independent risk factors, patients were divided into low-risk group and high-risk group according to the median score. Considering all prognostic factors and the different risk groups, survival analyses were performed by Kaplan–Meier plots for both the training and internal validation groups . The proGastric cancer represents the second most common cause of cancer . GC is ain vitro and in vivo experiments confirmed that METTL16 promotes the growth of the tumor by GC cell proliferation. Consistent with our study, other studies have similarly shown that RBM15 is associated with the prediction of gastric cancer. However, the precise mechanism has not been fully elucidated and requires subsequent research . Our results showed that men had a worse prognosis than women. In line with our findings, research . Luo andy needed . Li et ar cancer .There are some inevitable constraints in this cohort study. First, retrospective studies may be subject to selection bias in the selection of patients. Second, due to the limited clinical information available on patients in TCGA database, more valuable clinical factors were not considered in the analysis. In addition, we did not consider other genes, particularly immune genes, which have been shown to be strongly correlated with the development and proliferation of cancer. Despite these drawbacks, our study has some notable strengths. As far as we are concerned, it is the first nomogram that integrates clinicopathological features and m6A-related genes to predict the prognosis of GC patients, which makes the predictive model more comprehensive and able to predict the survival time of each patient more accurately. Second, in addition to building the model, this study also verified the model, and the validation results showed the stability and reliability of the model.In summary, based on the clinical and genetic data of GC patients extracted from TCGA database, we have established a relatively effective prediction model to assess the survival of GC patients at 1, 3, and 5 years, and the m6A-related genes may subsequently be targeted for the treatment of GC. The accuracy and usefulness of the nomogram still need to be further validated in subsequent clinical work.


This meta-analysis intended to systematically evaluate the clinical implications of indocyanine green fluorescence (ICG) in patients undergoing laparoscopic colorectal surgery. PubMed, MEDLINE, Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Wanfang Database, VIP Medical Information System and China Biomedical Database were synthetically searched for studies published from inception to April 14, 2022. The randomized controlled trials comparing ICG-use with controls were selected. The incidence of anastomotic leakage (AL), lymph node detection, operation duration, intraoperative bleeding, postoperative morbidity, and hospitalization time were evaluated in summary analysis, and calculated the corresponding 95% confidence intervals (CI). Subsequently, in addition to subgroup analyses, studies for heterogeneity, sensitivity, and publication bias were carried out. Consequently, 3453 patients in the enrolled 15 studies were included; 1616 patients were allocated to the experimental group, and 1837 patients were assigned to the control group. The ICG group had a significantly decreased risk of AL  and shorter hospitalization time  compared to the control group. Meanwhile, the ICG showed clearly better lymph node detection . However, when the content of operation duration  and intraoperative bleeding  were compared, no statistical significance was found. Furthermore, the pooled analysis of postoperative morbidity was not statistically significant . The results of the subgroup analysis of AL indicated that there may be regional variations in AL  but not in postoperative morbidity . In conclusion, the application of ICG in laparoscopic colorectal surgery can effectively reduce the AL, lymph node detection, and hospitalization time. However, more multicenter large-sample randomized controlled trials are required to further confirm its advantages. The meta-analysis was registered in PROSPERO (no. CRD42022288054). Colorectal cancer (CRC) is one of the most prevalent gastrointestinal malignancies with high incidence and mortality, seriously threatening human life and health. The latest global statistics show 1,148,515 new cases of colon cancer and 732,210 new cases of rectal cancer in 2020, with a 9.4% mortality rate for CRC patient . TherefoIndocyanine green (ICG) is a near-infrared light contrast agent with good biocompatibility. It is excited by external light at a wavelength of 750–800 nm, and in-turn emits near-infrared light of a longer wavelength for visualization of tissues and organs . More anhttps://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=288054).This agreement was previously registered in PROSPERO in December 2021.  Patients with laparoscopic colorectal surgery for CRC  were of different sex, age, race, and nationality. (ii) The experimental group was allocated in laparoscopic colorectal surgery by ICG, while the control group was assigned in laparoscopic colorectal cancer without ICG. (iii) The effectiveness between conventional laparoscopic colorectal surgery and laparoscopic colorectal surgery with ICG was compared. (iv) At least one of these outcome indicators must be reported, including the main outcome indicators such as AL and lymph node detection. The secondary outcome indicators include postoperative morbidity, operation duration, hospitalization time, and intraoperative bleeding. (v) The design of these studies were prospective randomized controlled trials (RCTs). Studies were asked to meet the following exclusion criteria: (i) Full text or specific values of the required indicators were not available. (ii) Comparison of the efficacy of two procedures was not included; (iii) duplicate publications; (iv) case reports, conference reports, reviews, animal experimental papers, and meta-analysis.Two researchers conducted a search in the following databases: pubMed, MEDLINE, Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Wanfang Database, VIP Medical Information System, and China Biomedical Database (CBM). Meanwhile, the period was limited from the database’s creation until April 14, 2022. The search terms were composed of the following medical themes (MeSH) and additional conditions:  AND (indocyanine green/fluorescence/spectroscopy near-infrared) AND . Furthermore, manual studies would be conducted to find potential references. Language was not an obstacle to publication.The program Endnote™, Version X8 (Thompson Reuters) was used to combine all search results. Repeated studies were manually removed. Two researchers independently screened the original studies and then read the full text to select the literature that met the inclusion criteria. Disagreements should be settled through discussion or by reaching an agreement with a third party.The data extraction was completed independently by two researchers who cross-checked the results using a uniform data extraction form. The following information was included in the data extraction: (i) The research ID, including the first author’s name and publication date. (ii) The research participant, including the number and age of the participants. (iii) The treatment program for the experimental and control groups. (iv) the main outcome indicators, such as AL and lymph node detection, and the secondary outcome indicators included postoperative morbidity, operation duration, hospitalization time, and intraoperative bleeding. The original author was contacted if the necessary information was not available, and the data was considered missing if there was no response. Furthermore, the disagreements between two researchers were settled through discussion or consensus, and a third researcher was requested to solve the conflict if required.The quality of the included studies was evaluated by two researchers independently, and conflicts among them were resolved through discussion or third-party consensus. Risk bias assessments were produced using RevMan 5.3 software based on the Cochrane Risk of Bias Assessment Tool. The evaluation included the following seven major components: random sequence generation; allocation concealment; blinding of patients and testers; blinding of outcomes assessors; incomplete results; selective reporting; and other bias . Finally, judgments should be made in this study, such as “low bias risk,” “high bias risk,” and “uncertain bias risk.”I2 test was initially used to investigate heterogeneity. If P ≥ 0.1 and I2 ≤ 50%, heterogeneity between studies was small and a fixed-effect model was used; if P < 0.1 and I2 > 50%, heterogeneity existed between studies and a random-effect model was used for meta-analysis. Subgroup analysis was carried out based on the various included study areas, and sensitivity analysis was carried out using the leave-one-out method for outcome indicators with high heterogeneity, as well as the contour-enhanced funnel plot.The data was statistically analyzed using Stata 14.0 (Stata Corporation). Relative risk (RR) and standardized mean difference (SMD) were used as effect statistics for dichotomous and continuous variables, and 95% confidence intervals (CI) were calculated. The Initially, 523 potentially relevant papers were screened, and 50 duplicate items were completely removed. Furthermore, 423 papers were excluded after reading the titles and abstracts because they were not suitable for the inclusion criteria. 35 articles were retained after carefully reviewing the abstracts and full texts of the remaining 50 articles. Finally, 15 studies were enrolled after rigorous screening using inclusion and exclusion criteria Figure 1A total of 3453 individuals –28 were The methodological quality assessment of the 15 included studies was displayed in The GRADEpro, which was developed by the Cochrane Collaboration Network, was used to assess the quality of evidence. A classification of the evidence was made for these studies and based on their limitations, inconsistencies, indirectness, imprecision, and publication bias. The quality of the evidence was classified as high, moderate, low, or very low. The quality of evidence was moderate for these outcome indicators due to a lack of blinding in RCTs. The profile of GRADE evidence was displayed in P=0.405, I2 = 3.9%) so a fixed-effect model was used to combination. The result showed a significantly lower incidence of AL  in the ICG group. Meanwhile, a subgroup analysis of AL was conducted by different regions. The studies were divided into two subgroups based on their geographical location: Asia and Europe/America. Four studies were reported from Europe/America  and six from Asia . The subgroup analysis revealed statistically significant differences  across regions  in the eight studies. The pooled analysis of postoperative morbidity was performed by a fixed-effects model, and there was no statistically significant  in the ICG group compared with the control group. Meanwhile, a subgroup analysis was performed, the result revealed no significant variance  between the different locations . A fixed-effects model was used to combine the pooled analysis, and the result revealed that this indicator was noticeably higher in the ICG group than in the control group . However, a subgroup analysis was not performed due to the small number of enrolled studies  across the nine studies that reported operation duration. A random-effect was used to do the pooled analysis. The result revealed that there was no statistically significant difference among these studies , Z = 1.53, P = 0.126). However, a subgroup analysis was not conducted because of the same distribution  among these studies. A random-effect model was chosen to combine, and the pooled analysis showed that hospitalization time in the ICG group was considerably decreased , Z = 5.96, P = 0.000). A subgroup analysis was not carried out due to the small number of included studies coming from America/Europe  among these studies. Consequently, a pooled analysis was carried out using a random-effect model. The result showed that there was no statistically significant difference between the ICG group and the control group . A subgroup analysis was not carried out in this meta-analysis since intraoperative bleeding was distributed similarly across regions  in the study. The robustness of the hospitalization time may have been impacted if Wu.G.C.  was exclP < 0.01, P < 0.05, P < 0.1, or P > 0.1). The contour-enhanced funnel plots of hospitalization time  the quantity of articles was insufficient and the included literature’s quality was average; (ii) although the inclusion studies were RCTs, not all of them mentioned the use of blinding; (iii) some indicators have a significant degree of heterogeneity when combined, which could affect the article’s results; and (iv) according to the findings of the subgroup analysis, regional differences in AL outcomes may exist. These factors may have an impact on the final conclusions, which must be validated further by a large sample, multicenter, prospective randomized controlled trials.Conclusively, ICG is dependable and effective in laparoscopic colorectal surgery, and it can be used to precisely locate the tumor and thoroughly clear the lymph node area intraoperatively, as well as to determine the blood supply to the intestine at the anastomosis, which has important practical value for reducing AL and improving lymph node detection.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.JD performed the search and drafted the manuscript. WH and YL performed the data extraction. TY and KX analyzed the data. XL and TX designed the study and amended the original draft. YL, WH, TY and KX equally involved and equally contributed into the study conduction. All authors contributed to the article and approved the submitted version.This study is supported by the National Natural Science Foundation of China  and the National Natural Science Foundation of China’s Post Grant Fund (No. 2018YFC170610512).We are grateful to the authors for providing detailed data for this meta-analysis, as well as to all colleagues in this study for their hard work.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.