One radiologist evaluated the presence of nodules on both scans in random order, with discrepancies judged by two independent radiologists and consensus reading. Sensitivity of nodule detection on RDCT and ULDCT was compared to reader consensus. Systematic error in semi-automatically derived diameter and volume, and 95% limits of agreement (LoA) were evaluated. Nodule classification was compared by κ statistics.p < 0.001). 45 nodules were present, with diameter range 4.0–25.3 mm and volume range 16.0–4483.0 mm3. Detection sensitivity was non-significant (p = 0.503) between RDCT 88.8% (95% CI: 76.0–96.3) and ULDCT 95.5% (95% CI: 84.9–99.5). No systematic bias in diameter measurements (median difference: −0.2 mm) or volumetry (median difference: −6 mm3) was found for ULDCT compared to RDCT. The 95% LoA for diameter and volume measurements were ±3.0 mm and ±33.5%, respectively. κ value for nodule classification was 0.852 for diameter measurements and 0.930 for volumetry.ULDCT resulted in 83.1% (95% CI: 81.0–85.2) dose reduction compared to RDCT (ULDCT based on Sn100 kV enables comparable detectability of solid pulmonary nodules in COPD patients, at 83% reduced radiation dose compared to RDCT, without relevant difference in nodule measurement and size classification.Pulmonary nodule detectability and measurements in ULDCT are comparable to RDCT. The optimization of radiation dose in lung cancer screening using CT has become of major interest due to the accumulation of radiation exposure from short-term and annual follow-up examinations.With a potentially massive increase in the number of chest CT scans worldwide, the potential radiation related health risks from lung cancer screening have become a major concern. While evidence in support or against the use of a linear no-threshold dose–response model Yet, radiation dose reduction causes degradation of image quality, which is seen as an increase in image noise. Various iterative reconstruction (IR) methods and image processing techniques can be utilized to reduce image noise while possibly trading-off image detail by smoothing the image.Currently, several techniques can be used to reduce the radiation dose, which include the optimization of X-ray tube voltage, reduction of X-ray tube current, automated dose modulation, and more recently introduced tin filtration. the knowledge of their application in vivo is limited, especially for how the smoothing of image may affect semi-automatic volumetry of pulmonary nodules.The purpose of this study was to investigate the accuracy of ultralow-dose CT (ULDCT) with tin filtration for detection and semi-automatic volumetry of pulmonary nodules in a patient cohort, compared to regular-dose CT (RDCT).While the evaluation of tin filtration and Advanced Modeled Iterative Reconstruction (ADMIRE) in previous chest CT phantom studies, on lung nodule detection have yielded favorable results, This prospective, single-center study was approved by the local medical ethics committee, and each participant gave his or her informed consent. The inclusion criteria for the treatment study were: age between 40 and 80 years, smoking history of ≥10 pack years, COPD with a forced expiratory volume (FEV1) <80% predicted with or without inhaled corticosteroids, and at least one COPD exacerbation for which oral prednisolone was prescribed 2 years prior to the inclusion of the study. Based on the FEV1 results, each patient was classified into a Global Initiative for Obstructive Lung Disease (GOLD) category. Exclusion criteria were history of asthma, recent exacerbation, or respiratory tract infection within a month prior to study enrollment, and females with childbearing potential. For the current substudy, participants underwent an ULDCT scan on top of the RDCT scan that was part of the treatment study. From February 2018 to July 2018, 50 patients were enrolled in this substudy. Sample size was based on the cohort size of prior articles comparing emphysema in ULDCT to non-contrast chest CT. The scanning procedure of both RDCT and ULDCT was explained to the participants.The current analysis is a substudy of a treatment study in chronic obstructive pulmonary disease (COPD) patients. Third-generation dual-source CT was used to acquire an ultralow-dose chest CT scan at 100 kVp with 0.6 mm tin filter for spectral shaping, and tube current modulation  with tube current time product of 70 mAs (reference mAs). The purpose of tube current modulation in ULDCT scanning is to maintain constant signal-to-noise ratio across different sections of the body. Both CT scans were reconstructed with a field of view of 350 mm and slice thickness of 1.0 mm, at 0.7 mm increment. For nodule detection and semi-automatic volumetry, medium smooth kernel, B30f and Br40, were reconstructed for 64-multidetector CT and third-generation dual-source CT, respectively.Inspiratory chest CT scanning was performed on a 64-multidetector CT system  and on a third-generation dual-source CT system  with a maximum of 30 min between the two acquisitions, with random order per patient. Each participant received the bronchodilator Salbutamol  before CT scanning. As reference, a regular-dose CT (RDCT) scan was acquired using the 64-multidetector CT system at tube voltage 120 kVp, and a fixed tube current time product of 40 mAs, in line with the Quantitative Imaging Biomarkers Alliance (QIBA) profile.To reduce effect of learning curve and recall bias, the first reader  was blinded from patient information. Additionally, RDCT and ULDCT patient scans were randomized and presented to the reader in an alternating manner within 2 weeks on four different days. The CT reconstructions were evaluated using image analysis workflow software MM Oncology . The first reader was allowed to freely use maximum intensity projection and multiplanar reformation for nodule detection. Nodules of at least 4 mm in maximum transverse diameter were included in this study. To avoid missing nodules due to possible fluctuations in nodule measurement on RDCT and ULDCT, all nodules greater than 2 mm by visual estimation were first marked with a circular region of interest (ROI) by the first reader. Subsequently, diameter and volume of all marked nodules were measured by a researcher (DH) by point and click method using a semi-automatic volumetry function in the MM Oncology software, which also provided maximum transverse diameter of the nodule. Unsatisfactory segmentation of a nodule due to attachment was manually corrected using the modify function. Nodules that were marked with ROI on RDCT and ULDCT were paired based on anatomical landmarks. Nodules with at least 4 mm in transverse diameter measured on RDCT were selected for further analysis.Discrepancy in nodule detection between RDCT and ULDCT by the first reader were reviewed independently by two radiologists (RV and GdJ) with 15 years and 12 years of experience in chest imaging, respectively. Disagreements were resolved through a consensus meeting. Nodules that were missed on either RDCT or ULDCT were retrospectively detected and measured to be included in the nodule measurement comparison. Maximum transverse diameter measured on RDCT of at least 4 mm determined inclusion for further analysis.Image noise was assessed by drawing an ROI in the lumen of trachea, 1 cm above the bifurcation of the trachea. The standard deviation of Hounsfield unit (HU) of 1 cm in diameter was used as measure of noise. The ROIs were drawn by a trained researcher (DH) on both RDCT and ULDCT data sets.vol) and dose–length product (DLP), were retrieved from the dose report of each CT scan. The effective dose was calculated by multiplying DLP with the chest conversion coefficient (k = 0.014 mSv/mGy*cm).Radiation dose parameters for both LDCT and ULDCT, including computed tomography dose index  and volume , in line with recommendations from the European Position Statement on Lung Cancer Screening. The difference in image noise between RDCT and ULDCT was evaluated by comparing the median standard deviation of the Hounsfield unit, and tested using Wilcoxon signed rank test. Normality of data distribution was determined using Kolmogorov–Smirnov test. Normally distributed variables were presented as mean and standard deviation (SD), non-normally distributed variables were presented as median and interquartile range (IQR). A p-value < 0.05 was considered statistically significant. Statistical analysis was performed using SPSS v. 23 .Nodule detection was compared between ULDCT and RDCT using reader consensus as the reference standard for nodule detection. Residual plot and 95% limits of agreement (95% LoA) were used to analyze the impact of ULDCT on nodule diameter and volume measurements compared to RDCT as reference standard. For the purpose of comparability with the findings from literature,2 (IQR: 25.0–31.3), and the median number of smoking pack-years was 37.5 (IQR: 27.8–59.3). Based on the (GOLD) classification for COPD, 31/50 (62%) of patients had GOLD Stage 2, 14/50 (28%) GOLD 3, and 5/50 (10%) GOLD 4.Mean age of participants was 65.4 ± 7.3 years, range 50–82 years. Of the study participants, 34/50 were male (68%). The median body mass index (BMI) was 27.1 kg/mp < 0.001) (The median difference in the standard deviation in HU between RDCT and ULDCT was 13.8 HU (< 0.001) . The est or ULDCT, the consensus panel excluded seven nodules from RDCT and six nodules from ULDCT because they were considered false positive nodules, such as pleural thickening or fibrosis. Five nodules (11.4%) were missed on the RDCT scan, whereas two nodules (4.5%) were missed on the ULDCT scan (p = 0.453). Nodules that were missed on either RDCT or ULDCT were all found in retrospect and subsequently included in size measurement comparison.On the RDCT images, the first reader found a total of 45 solid nodules. On the ULDCT images, 49 solid nodules were found. There were a total of 57 unique nodules found on the RDCT and ULDCT scans, of which 37/57 nodules (64.9%) were found on both the RDCT and the ULDCT scan ; these wDCT scan . Ultimat3 (IQR: 48.8–229.8) and the median volume of nodules on ULDCT was 94 mm3 (IQR: 39.5–250.8). Significant difference in diameter [median difference: −0.2 mm (IQR: −0.7–0.2), p = 0.033) and volume [median difference: −6 mm3 (IQR:−12.3–4.0), p = 0.026) was found for ULDCT when compared to RDCT. The 95% LoA in diameter measurement was ±1.4 mm  nodules on RDCT was 7.3 mm (IQR: 5.6–10.9), and the median diameter on ULDCT was 7.0 mm (IQR: 5.5–10.5). The median nodule volume of nodules on RDCT was 106 mm ±1.4 mm .3 (38 nodules), the differences in volumetry between RDCT and ULCT were less pronounced with a 95% LoA of ±24.9% (k = 0.927); 2/44 (4.5%) nodules were classified into a lower size category on ULDCT compared to RDCT . There was a statistically significant, but clinically irrelevant underestimation of nodule diameter and volume for ULDCT. This caused 4 (9.1%) and 2 (4.5%) of the nodules to be misclassified into lower size categories based on diameter and volume, respectively. Furthermore, for clinically relevant nodules, sized 30 mm3 or more on RDCT, the 95% LoA between ULDCT and the reference,RDCT, was similar (24.9%) compared to the clinically relevant 25% measurement error, used as cut-off to define nodule growth. Our findings suggest that semi-automatic volumetry on ULDCT with tin filter and ADMIRE could be used for serial imaging in lung cancer screening or in clinical setting, for detection and follow-up of lung nodules. The 95% LoA for semi-automatic diameter measurement was ± 1.4 mm, which is lower in measurement variability compared to the 95% LoA of ±1.7 mmin RDCT reported by Revel et al.The purpose of this study was to investigate the detectability and diameter and volume quantification of pulmonary nodules in ULDCT compared to RDCT in a patient cohort with relatively high prevalence of lung nodules. Our study demonstrates comparable if not better detectability, with a sensitivity of 95.5% for ULDCT  has led to its support in lung cancer screening. Semi-automatic volumetry is currently the nodule assessment method recommended by European experts and the British Thoracic Society. Recently, Lung-RADS (v. 1.1) has included volume measurements next to diameter measurements to facilitate transition to 3D volume measurements over time. Although manual diameter measurement is still the most widely used method for nodule assessment, there is a gradual transition towards semi-automatic volumetry in lung cancer screening.A key feature in our study is the use of semi-automatic volumetry for lung nodule assessment on ULDCT. Benefits of volumetric measurements, such as reproducibility and sensitivity to detect nodule growth, A previous phantom study evaluated third generation dual-source CT with ADMIRE for pulmonary nodule detection, with a scan protocol similar to ours. In their phantom study, Gordic et al found that ADMIRE strength levels 3 and 5 at 1/10th dose of a standard protocol offered similar sensitivity (94%) in nodule detection as compared to the standard protocol on the same CT system. Another study reported 91% sensitivity in nodule detection for ULDCT with ADMIRE level 3 compared to standard of reference in a diverse patient cohort. However, in their study, a different scanning protocol was used and the majority of participants, 169/202 (84%), underwent contrast-enhanced CT as reference method, which complicates comparison as iodine contrast enhancement impacts size measurements.A recent phantom study by Janssen et al, using the same acquisition and ADMIRE strength as in this study, compared ULDCT to low-dose CT in nodule detection, and showed comparable sensitivity of 83% vs 84%, respectively. However, their study was limited by the use of an anthropomorphic phantom; with predetermined nodule size, shape and location. In our study, 50 patients were scanned with RDCT and ULDCT protocol. The readers were blinded from nodule information, and the RDCT and ULDCT scans were randomized and alternatively presented to reduce recall bias. More recently, Guo et al reported 93.6% sensitivity in nodule detection for ULDCT with ADMIRE level 3 in overweight or obese patients (BMI≥25 kg/m2), at 85% reduced radiation dose, which is similar compared to the sensitivity (95.5%) and radiation dose reduction (83%) in ULDCT in our study. This provides further evidence that ULDCT can be potentially used in a screening setting without being limited by screenee characteristics. In terms of nodule volumetry, two studies have reported slight underestimation of nodule volume in ULDCT when compared to RDCT, using comparable reconstruction settings as in our study. However, the underestimation was negligible in absolute volume, which is in line with our findings.A couple of studies has evaluated the influence of major radiation dose reduction on lung nodule detection using submillisievert chest CT scans with IR. Although consensus double reading can lead to more nodules being detected compared to single reading, it has been shown that consensus double reading does not offer substantial benefit in the detection of cancer, compared to single reading and a nodule management strategy based on semi-automatic volumetry.All patients included in our study were diagnosed with COPD. These patients often have architectural distortion with focal abnormalities and fibrosis on chest CT that can be difficult to distinguish from pulmonary nodules. Therefore, we used a consensus panel to review discrepant nodules found in RDCT and ULDCT. This is different compared to previous studies where two blinded readers reviewed the images independently, and discrepant results were discussed in a consensus meeting. Secondly, recall bias was avoided by blinding the readers from patient information and presenting the ULDCT and RDCT images in a random alternating order across several weeks. Thirdly, nodule diameters were measured semi-automatically by software, preventing inaccuracy from manual measurement. Manual diameter measurements in clinical practice are likely to be less precise and less accurate than the semi-automatic measurements used in our study. This has been shown in a previous study, which reported less variability and better nodule size classification based on Lung-RADS for semi-automatic diameter and volume measurements than for manual diameter measurements. This study has several limitations. Firstly, all participants in our study were known to have COPD. The difference between our study sample and a lung cancer screening population may limit the generalizability of our results. However, as the lung cancer screening population contains a much smaller proportion of COPD patients with severe lung abnormalities, we expect better sensitivity and less discrepancy in nodule detection. Moreover, studies have shown that patients with COPD have two- to five-fold greater lung cancer risk than smokers without COPD. Therefore, the result of our study is relevant for the lung cancer screening population. Thirdly, we did not evaluate the influence of ULDCT on the detection and quantification of subsolid nodules as these were not found in the participating patients. Fourthly, we used semi-automatic nodule measurement software of one vendor. Whether the results can be generalized to other types of semi-automatic software is uncertain. Lastly, our study is limited by its small sample size. However, this has not led to type II error, as small but significant differences were found between RDCT and ULDCT for both diameter and volume measurements.There are several strengths in our study. Firstly, we used a standardized RDCT scanning protocol, in line with the QIBA profile. However, careful validation of ULDCT in the evaluation of emphysema is needed before utilization in the clinical practice.ULDCT may not only prove itself useful in reducing radiation exposure for lung cancer screenings but may also be of benefit for the evaluation of emphysema in COPD patients outside the lung cancer screening setting. CT-based analyses can help quantify and differentiate phenotypes of COPD, which is crucial in determining appropriate management strategy.In conclusion, at 83.1% reduced radiation dose, the nodule detectability in ULDCT remained comparable to RDCT. Agreement in size categories was good to excellent. Thus, the results shown in this study indicate that ULDCT with tin filter and ADMIRE may potentially be applicable in lung cancer screening.


Limited cross-sectional or case–control studies have identified the relationship between basilar artery (BA) curvature and posterior circulation infarction (PCI). This study aimed to identify the influence of BA curvature severity on the risk of PCI occurrence in patients without vertebrobasilar stenosis through a prospective cohort study.In this study, we enrolled 171 patients with BA dolichosis but without vertebrobasilar stenosis. The BA geometric parameters were evaluated on MRA. The primary outcome was the occurrence of PCI, mainly referring to cerebellar and/or brainstem infarction. Cox proportional hazard models were used to detect possible predictors of PCI.HR = 6.09; 95% CI: 1.36–27.28; P = 0.018) significantly increased the risk of PCI occurrence, and bending length (BL) was also significantly associated with PCI occurrence, with the adjusted HR per 1-mm increase of BL of 1.09 . In the subgroup analysis stratified by age, BA prominent curvature was highly associated with PCI occurrence in patients aged > 61 years . Additionally, good antiplatelet therapy adherence could significantly reduce the risk of PCI occurrence.Among them, 134 (78.4%) patients were diagnosed with BA curvature, including 124 with moderate curvature and 10 with prominent curvature. The defined PCI occurrence was observed in 32 (18.7%) patients with a median follow-up time of 45.6 months. Cox proportional hazard analysis showed that BA prominent curvature (BA curvature may increase the risk of PCI occurrence, especially in elderly patients with prominent curvature. Improving adherence to antiplatelet therapy can help reduce the risk of PCI occurrence. The vertebrobasilar system is the main blood supply for the posterior circulation, and stenosis or occlusion of the vertebrobasilar artery is naturally of great concern. Vascular curvature, a common morphological variant of the basilar artery (BA), has the most common alignment of a C-shape . HoweverMost previous studies considered that BA curvature is a vascular congenital variation and does not require special intervention. Recently, some studies have suggested that BA curvature is closely associated with the progression of BADE and the occurrence of posterior circulation infarction (PCI) , 4, possOur previous study indicated that BA dolichosis increased the risk of brainstem infarction recurrence in patients with acute pontine infarction, with one potential mechanism possibly being altered hemodynamics due to BA curvature, but this study also did not exclude patients with BA stenosis . TherefoIn this prospective cohort study, we included patients with acute cerebral infarction (ACI) who were admitted to the Department of Neurology of our hospital from January 1, 2015 to December 31, 2019. Patients were consecutively enrolled if they were diagnosed with BA dolichosis but without vertebrobasilar stenosis on magnetic resonance angiography (MRA). We excluded patients with any causative stenosis in the vertebrobasilar artery, cardioembolism with evidence of embolic origin , other determined etiologies , S-shaped BA, BA aneurysms, intracranial tumors, or poor image quality affecting our measurements, patients without taking secondary stroke prevention medication for various reasons at discharge, and patients who refused to be followed up or died during hospitalization. This study was approved by the ethical committee of the Second People’s Hospital of Hefei. All patients or their guardians provided written informed consent.Clinical-related data were acquired on the following factors: demographic data (including age and gender), and vascular risk factors such as current smoking, hypertension, diabetes mellitus, dyslipidemia, and ischemic heart disease. All patients with vascular risk factors had been previously diagnosed as such and/or were already taking medications for these conditions. Secondary prevention medications for ACI, including antiplatelet agents and statin therapy, were also collected at discharge and followed up throughout the study. Adherence to antiplatelet and statin therapy was estimated by calculating the proportion of days covered (PDC) during the entire follow-up period. The PDC is calculated as the total days of medication supplied divided by the duration of the follow-up period. If the PDC by antiplatelet agents or statin was above 80%, the patients were considered to have good adherence, otherwise poor adherence .Magnetic resonance imaging (MRI) and MRA were performed with a 1.5-Tesla scanner  on all patients. The DWI scan was conducted in the axial plane with a repetition time/echo time of 3400/102 ms and a slice thickness of 5 mm. We conducted MRA using a three-dimensional time of flight (TOF) sequence with a repetition time/echo time of 25/7 ms and a slice thickness of 0.6 mm. The geometric parameters of the BA and vertebral arteries (VAs) were evaluated in the posterior-anterior position. The methods for evaluating BA features, such as BA diameter, BA curve length, BA length (BAL), and bending length (BL), have been previously described in detail . The sevPatients were followed up by periodic telephone interviews or clinic visits every 6 months by a trained neurologist blind to clinical and imaging data. The primary outcome was the occurrence of DWI-confirmed PCI, mainly referring to cerebellar and/or brainstem infarction other than temporo-occipital and (or) thalamic infarction here. If new stroke symptoms or signs appeared, they would be hospitalized and scheduled for imaging to determine whether acute PCI had occurred or whether they were stroke mimics. Infarct occurrence at other sites was not considered an endpoint event associated with morphological changes in the BA. The endpoint date for follow-up was December 31, 2021. The follow-up interval was defined as the time between enrollment and the initial occurrence of PCI, loss to follow-up, or death.P value of < 0.1 in the univariate analysis were included in the multivariate Cox proportional hazard regression model with a forward stepwise procedure. Hazard ratio (HR) and 95% confidence interval (CI) were subsequently calculated. A two-sided P value of 0.05 was used as the threshold for statistical significance. GraphPad Prism 8.0 and Microsoft PowerPoint were used for graph drawing.All statistical analyses were performed with SPSS 22.0 package for Windows . Continuous variables were tested for normality by the Kolmogorov–Smirnov test. Comparability between the three groups was analyzed using the Kruskal–Wallis test for non-normally distributed continuous variables or the ANOVA test for normally distributed continuous variables. Comparisons of categorical variables were performed using the Chi-square test for categorical variables. The Kaplan–Meier curve was performed to analyze the survival probability and compared using a two-sided log-rank test. Potential risk factors with a As of December 31, 2019, a total of 324 patients with ACI combined with BA dolichosis were screened for this study; 171 patients were finally enrolled, including 112 patients with anterior circulation infarction and 59 patients with PCI, as shown in Fig. During the median follow-up time of 45.6 months (ranging from 3.1 to 78.2 months), 32 (18.7%) patients developed defined PCI with the average time from admission to occurrence of 34.4 ± 18.3 months. Of these, 3 occurred in the cerebellum, 25 in the brainstem (mainly in the pons), and 4 in the brainstem and cerebellum. Additionally, 10 patients experienced anterior circulation infarction or temporo-occipital and (or) thalamic infarction during follow-up, which was not considered an endpoint event, as it was probably unrelated to the morphological changes in the BA. The estimated 1-year, 3-year, 5-year, and 7-year incidence rates of PCI occurrence were 1.1%, 10.5%, 15.8%, and 18.7%, respectively. During the entire follow-up period, 9 patients were lost to follow-up, for a loss to follow-up rate of 5.3%, and 11 (6.4%) patients died. In detail, 1 patient died of recurrent ischemic stroke and related complications, 2 of esophageal cancer, 1 of acute coronary syndrome, 1 of traumatic cerebral hemorrhage, and 1 of falling injuries. The remaining 5 patients suffered sudden death and the cause of death was unknown. In addition, 3 patients had non-fatal cerebral hemorrhages (none in the brainstem), and 1 patient developed hemoptysis during the follow-up period.P = 0.039 and 0.008, respectively, log-rank test)  with no curvature as a reference and BL  were associated with an increased risk of PCI occurrence, while the difference looked clinically relevant even though not formally statistically significant in patients with moderate curvature   significantly increased the risk of PCI occurrence, while BA moderate curvature could also increase the risk of developing PCI, although not statistically significant  . The subgroup analysis stratified by age showed that BA prominent curvature was highly associated with PCI occurrence in patients aged > 61 years , but no significant association was found between BA curvature and PCI occurrence in patients aged ≤ 61 years.Further analysis showed that age grouped by median had interaction effects with BA curvature for the risk of PCI occurrence . A previous study showed that among the 17 patients without BA stenosis on MRA, HR-MRI found a BA plaque in 7 patients . TherefoIn this prospective study, patients with BA prominent curvature may have a higher risk of PCI occurrence, especially in elderly patients, and therefore deserves more attention in clinical practice. Improving adherence to antiplatelet therapy can help reduce the risk of PCI occurrence.


International travel increases the risk of acquisition of antibiotic-resistant bacteria and antibiotic resistance genes (ARGs). Previous studies have characterized the changes in the gut microbiome and resistome of Western travellers; however, information on non-Western populations and the effects of travel-related risk factors on the gut microbiome and resistome remains limited.We conducted a prospective observational study on a cohort of 90 healthy Chinese adult residents of Hong Kong. We characterized the microbiome and resistome in stools collected from the subjects before and after travelling to diverse international locations using shotgun metagenomic sequencing and examined their associations with travel-related variables.aadA, TEM, mgrB, mphA, qnrS9 and tetR, were significantly enriched in relative abundance after travel, eight of which were detected in metagenomic bins belonging to Escherichia/Shigella flexneri in the post-trip samples. In sum, 30 ARGs significantly increased in prevalence after travel, with the largest changes observed in tetD and a few qnrS variants . We found that travel to low- or middle-income countries, or Africa or Southeast Asia, increased the number of ARG subtypes, whereas travel to low- or middle-income countries and the use of alcohol-based hand sanitizer (ABHS) or doxycycline as antimalarial prophylaxis during travel resulted in increased changes in the beta diversity of the faecal resistome.Our results showed that travel neither significantly changed the taxonomic composition of the faecal microbiota nor altered the alpha (Shannon) or beta diversity of the faecal microbiome or resistome. However, travel significantly increased the number of ARGs. Ten ARGs, including Our study highlights travel to low- or middle-income countries, Africa or Southeast Asia, a long travel duration, or the use of ABHS or doxycycline as antimalarial prophylaxis as important risk factors for the acquisition/enrichment of ARGs during international travel. The neighbouring countries and regions of Hong Kong have reported higher rates of AMR bacteria.Hong Kong is an international travel hub. In 2019 alone, there were over 94 million departures from Hong Kong (http://blogs.worldbank.org/) and geographical regions. Anthropometric parameters such as body weight and height were measured by research staff at the time of recruitment. The inclusion criteria for the current study were ethnically Chinese aged ≥18 years at the time of recruitment. Subjects with gastrointestinal diseases, including malignancy, inflammatory bowel disease and resection of small or large bowel, or who used antibiotics within last three months before travel, except for prophylaxis required for travel, were excluded. All samples were collected before the COVID-19 pandemic broke out. No statistical methods were used to determine the sample size. The study was approved by the Joint Chinese University of Hong Kong—New Territories East Cluster Clinical Research Ethics Committee (CREC 2018.272). Written informed consent was obtained from all participants prior to sample collection according to the Declaration of Helsinki.Healthy subjects who planned to travel abroad were prospectively recruited from students and staff members of The Chinese University of Hong Kong and The Hong Kong Polytechnic University from November 2018 to January 2020. Each participant provided a stool sample and completed a questionnaire before and after travel. Information collected includes subject demographics such as sex and age and travel-related information such as destination and duration . Travel Stool samples were collected from the subjects before and within 1–2 days after return from travel using stool collection kits provided. The samples were stored in their home freezers before pickup and stored at −80°C in the laboratory until further processing. Prior to storage, subsamples were screened for ESBL-E and CPE by culture methods using selective media  as for the surveillance protocol for screening of MDR Enterobacteriaceae. Total DNA was extracted using the DNeasy PowerSoil Pro Kit  according to the manufacturer’s protocol. DNA library was prepared using the NEBNext Ultra II DNA Library Prep Kit  and sequenced on an Illumina NovaSeq platform following the 2 × 150 bp paired-end sequencing protocol.,,Raw sequence reads were first quality-filtered using Trimmomatic v0.39 with the default parameters, except for MINLEN = 50.Microbial and ARG feature tables were imported into QIIME2 2020.11.,,Metagenomic binning was performed using three different algorithms, namely MetaBAT 2,P-values were adjusted using the Benjamini–Hochberg procedure to control for multiple comparisons. Differences were considered statistically significant when P < 0.05 or q < 0.1.Differences between paired samples were tested using the Wilcoxon Signed-Rank test, whereas differences between non-paired samples were tested using the Kruskal–Wallis or Mann–Whitney test. Differences in beta diversity were tested using permutational multivariate analysis of variance (PERMANOVA) with 9999 permutations using the adonis function in q2-diversity. For variables found to be significantly associated with the changes in the alpha or beta diversity of the faecal microbiome or resistome after travel as detected by q2-longitudinal, linear mixed effects (LME) models were built using q2-longitudinal. Travel-related variables, their interactions with time (travel), sex and age were used as fixed effects, whereas subject ID was used as a random effect. For the analysis of beta diversity, the first coordinate (PC1) of PCoA was used as the input metric. Differentially abundant microbial species and ARGs were identified using LEfSe with the default threshold at linear discriminant analysis (LDA) score > 2, unless specified otherwise.A total of 110 healthy Chinese travellers from Hong Kong were recruited for this project. After exclusion of subjects with recent antibiotic use, 90 subjects were included in this study. This study cohort had a median age of 21 years (range: 19–65 years) and was mostly female (68.9%) . The majBifidobacterium adolescentis (9.5%), Fusicatenibacter saccharivorans (7.2%), Ruminococcus bromii (6.2%) and Faecalibacterium prausnitzii (5.9%) (P > 0.05) (P > 0.05). However, culture-based screening for MDR bacteria revealed that the carriage rate of ESBL-E in the stool specimens increased significantly from 52.8 (47/89) to 72.4% (63/87) after return of travel (P = 0.0083). CPE was only detected in one post-trip specimen.An average of 21 491 900 quality-filtered non-human reads were obtained for each of the 180 stool samples. The baseline (pre-trip) faecal microbiota of the travellers was dominated by the bacterial phyla Firmicutes (58.3%), Actinobacteria (23.8%) and Bacteroidetes (15.2%)  and the i (5.9%) . Travel  > 0.05) . In partermB (0.08%), rpoB2 (0.07%) and tetM (0.06%) being the most abundant members (P > 0.05); however, travel significantly increased the number of observed ARG subtypes (P = 0.0332) (P < 0.01) and total ESBLs (P < 0.0001).DeepARG and ShortBRED with CARD predicted a total of 441 and 295 ARGs from all samples, respectively  and S2.  members . Similar 0.0332) . PhenotyaadA, TEM, mgrB, mphA and qnrS9 (Escherichia/Shigella flexneri from the post-trip samples (q < 0.1) (tetD (12.2 to 41.1%), qnrS9 (21.1 to 44.4%), qnrS (16.7 to 38.9%), qnrS8 (16.7 to 38.9%), Escherichia coli mdfA (32.2 to 54.4%) and tetB (15.6 to 37.8%)  post-trip, including nd qnrS9 . We then samples , suggestq < 0.1) . The laro 37.8%) . Most ARP > 0.05)  or region , travel purpose  and use of ABHS  or doxycycline during travel  (P = 0.0154) or SE Asia (P = 0.0002) was also significantly associated with the acquisition of ESBL-E based on culture test (We then examined the effects of 14 travel-related variables  on the c > 0.05) . In cont 0.0007) . Notablyure test . Howeverure test .P = 0.0001, q = 0.0014), destination_region  and travel purpose  . Notably, travel to low- or middle-income countries, Africa or SE Asia, or a longer travel duration of more than seven days resulted in significantly larger changes in the alpha diversity of the faecal resistome. Except for travel purpose, all these variables remained significant for at least one of the alpha diversity indices in LME models  . These tE models .P = 4.70E-05, q = 0.0007; destination_region: P = 0.0017, q = 0.0079; travel purpose: P = 0.0048, q = 0.0168; use of ABHS: P = 0.0005, q = 0.0035; use of doxycycline: P = 0.0068, q = 0.0190)  . Destina 0.0190) . LEfSe ag travel . The fulEscherichia/S. flexneri from the post-trip samples, suggesting this species as an important source of these ARGs acquired during travel. Escherichia/S. flexneri can be found in the environment, food and untreated water. Therefore, it is tempting to speculate that travellers acquired ARG-bearing Escherichia/S. flexneri via contaminated environment or food during travel. The prevalence of 30 ARGs increased in our study cohort after travel, with a rate of increase of at least 13% (and up to 6.5-fold). A recent study also reported significant acquisition of 56 ARGs in Dutch travellers after travel to countries in Asia and Africa.Our results showed that travel did not significantly alter the taxonomic composition of the dominant ARGs; however, the relative abundances of 10 low abundance ARGs were enriched post-trip. This echoes the results of a Swedish study, in which only nine rare ARGs were enriched after travel,n = 39) and/or differences in the travel destinations. The effects of travel destination on the gut resistome have been extensively characterized in a recent study on Dutch travellers.We showed that destination grouped according to income or region significantly affected the changes in the beta diversity of the gut microbiome and the alpha and beta diversity of the gut resistome, with travel to low- or middle-income countries, Africa or SE Asia, resulted in significantly larger changes in all diversity indices. In contrast to our finding, the only other study that has examined the effect of travel destination on the gut microbiome did not observe any significant influence of the visited region  on the beta diversity of the gut microbiome in French travellers.Acinetobacter baumannii.We showed that ABHS use during travel significantly changed the gut microbiome and resistome composition. ABHS use during travel led to an overall net gain of ARGs , albeit The use of doxycycline during travel also significantly changed the gut microbiome and resistome composition and enriched multiple tetracycline ARGs. Doxycycline is commonly used by travellers as antimalarial prophylaxis during travel to countries where there is high risk of malaria transmission, such as those in Africa and South America. This drug is taken 1–2 days before travel, daily during travel and for 28 days after return from trip.The normal gut microbiota is capable to protect against the invasion and/or outgrowth of indigenous and foreign microorganisms via a process called colonization resistance.We found that a longer travel duration resulted in significantly larger changes in the alpha diversity of the gut resistome. A significant but weak effect of travel duration on the acquisition of ARGs was also reported in a previous study.We observed significant associations between travel to low- or middle-income countries or SE Asia and ESBL-E acquisition based on culture test. A high number of acquisitions of ESBL-E has also been reported among European travellers who travelled to southern Asia,There are several limitations to our study. First, all participants were university staff or students and therefore do not represent the general population in terms of socioeconomic status nor ethnic Chinese from the mainland. Second, most metadata collected in this study were self-reported. Third, stool samples from travellers while abroad were not collected. Lastly, no non-travel controls were included in this study. Nevertheless, our study has elucidated the effects of travel and specific travel-related risk factors on the entire communities of microbes and ARGs in the gut and provided insights into the potential risk factors for the acquisition/enrichment of ARGs during international travel. Our findings highlighted current practice related to travel in the context of antimicrobial resistance, particularly advocating the use of alternatives to doxycycline as antimalarial prophylaxis.Suppl_figure_taad027Click here for additional data file.Suppl_tables_new_taad027Click here for additional data file.Suppl_data_sets_taad027Click here for additional data file.


Given a prolonged course of Cervical spondylosis (CS) could cause irreversible neurological deficits, it is crucial to disseminate CS-related health information to the public to promote early diagnosis and treatment. YouTube has been widely used to search for medical information. However, the reliability and quality of videos on YouTube vary greatly. Thus, this study aimed to assess the reliability and educational quality of YouTube videos concerning CS and further explore strategies for optimization of patient education.We searched YouTube online library for the keywords “cervical spondylosis”, “cervical radiculopathy” and “cervical myelopathy” on January 15, 2023. Ranked by “relevance”, the first 50 videos of each string were recorded. After exclusions, a total of 108 videos were included. All videos were extracted for characteristics and classified based on different sources or contents. Two raters independently evaluated the videos using Journal of American Medical Association (JAMA) benchmark criteria, Modified DISCERN (mDISCERN) tool, Global Quality Scale (GQS) and Cervical-Spondylosis-Specific Scale (CSSS), followed by statistical analyses. All continuous data were described as median (interquartile range).P = 0.009) and JAMA (P = 0.001), mDISCERN (P < 0.001), GQS (P < 0.001) and CSSS (P < 0.001) scores among different sources. Videos from academic source had advantages in reliability and quality scores than other sources. VPI (P < 0.001), mDISCERN (P = 0.001), GQS (P < 0.001) and CSSS (P = 0.001) scores also significantly differed among videos of various contents. Spearman correlation analysis indicated VPI was not correlated with either reliability or quality. Multiple linear regression analysis showed a longer duration and an academic source were independent predictors of higher reliability and quality, while a clinical source also led to the higher video quality.All videos had median values for JAMA, mDISCERN, GQS and CSSS scores of were 3.00 (1.00), 3.00 (2.00), 2.00 (1.00) and 7.00 (8.88), respectively. There were significant differences in VPI (The reliability and educational quality of current CS-related videos on YouTube are unsatisfactory. Users face a high risk of encountering inaccurate and misleading information when searching for CS on YouTube. Longer duration, source of academic or clinician were closely correlated to higher video reliability and quality. Improving the holistic reliability and quality of online information requires the concerted effort from multiple parties, including uploaders, the platform and viewers. Cervical spondylosis (CS) is a chronic and progressive degenerative process of the cervical spine featuring the pathological change of vertebrae, joints, intervertebral discs, and other relevant structures.  As the cGiven that the protracted course of CS could result in an irreversible detrimental outcome, , 4 earlyWith the development of the internet and the exponential growth of digital information, an increasing number of netizens choose to consult and seek disease-related information online. , 12 YouTHitherto, to the best of our knowledge, no research has quantified the reliability and quality of CS-related information available on YouTube. Herein, this study aims to assess the reliability and educational quality of YouTube videos regarding CS, and analyze relevant influencing factors, furtherly exploring strategies to optimize the quality of online health resources and guide patients to obtain valuable medical information related to CS.Since data from YouTube was all publicly available and no patients were involved in this study, the ethics committee approval and information consent were not required.https://www.youtube.com, January 15, 2023). Before conducting the search, we created an exclusive account and cleared browser cache and search history, also turning off data recording to avoid potential influence on the results. By default settings and ranking of “relevance”, we preliminarily recorded the first 50 videos in results of each string. This strategy could simulate the common browsing habit in most viewers and had been reported feasible in previous literatures. [To evaluate the reliability and quality of online videos, we standardly searched for the keywords “cervical spondylosis”, “cervical radiculopathy” and “cervical myelopathy” on YouTube online library  Title and URL, (2) uploader, (3) date of publication, (4) time since uploaded , (5) video duration, (6) number of views, (7) number of likes, (8) number of dislikes, (9) number of referrers, (10) number of comments, (11) view ratio (views/day), (12) like ratio (like × 100/(like + dislike)), (13) uploader verification, (14) country/region of origin, (15) total views of host channel, (16) sum of subscribers of host channel and (17) Video Power Index (VPI). The specific calculation of VPI was as follows: view ratio × like ratio/100. VPI was an objective index to quantify the video popularity and had been applied in previous research.  Some of In accordance to previous studies , 25 and The videos were also classified into the following categories based on the content: (1) exercise training (exercise related to CS); (2) CS-specific information ; (3) surgical technique; (4) non-surgical management; (5) advertisement. A single video was limited to one theme. If a video involved several content topics, the content that occupied the largest proportion or which viewers gained most from the video would be determined.Journal of American Medical Association (JAMA) benchmark criteria Table , proposeThere was no existing method to assess the educational content of CS videos specifically and comprehensively. Combining opinions from previous articles, reviews, guidelines and our clinical practice, we developed a novel scoring system entitled Cervical-Spondylosis-Specific Scale (CSSS). CSSS comprised four sections  and 19 sub-items in total. Diverse points were allocated to each item based on different priority and value. The total score was calculated by summing up the corresponding point(s) for all fulfilled items, with a maximum of 25 points indicating the highest educational quality for CS. Under this evaluation system, a high-quality CS-related video needs to elucidate the following information: the typical symptom of CS  and general nosogenesis (compression) and risk factors ; the main classification of CS ; diagnostic methods ; treatment strategies ; posttreatment course . More specific items were shown in Table Two independent orthopedic doctors  assessed all the included videos using above scoring systems and repeated once after two weeks. For a single video, both the video itself and its description were taken into account. The original results assessed by two doctors were recorded separately. Any discrepancy between both was arbitrated by the third reviewer (H.L.) to achieve a unanimous result.P < 0.20) with the target index or that were considered or reported relevant were incorporated into the regression model. Variables were carefully selected based on the number of events available to ensure the final model was parsimonious. [Video characteristics, reliability and educational quality were quantified by descriptive statistics. The missing data were processed using multiple Imputation. All continuous data in the study were described as median (interquartile range) as they didn’t comply normality. Qualitative data were expressed as fractions. Kruskal–Wallis test was utilized to evaluate intergroup differences of variables based on different video sources or contents, followed by post-hoc analyses of Bonferroni correction. Spearman correlation analysis was used to explore the correlation among VPI, JAMA, mDISCERN, GQS and CSSS scores. Then multiple linear regression analysis was applied to determine the independent predictor of the five above indexes from video characteristics, sources and contents. Variables that showed a univariate relationship  were appraised by intraclass correlation coefficient (ICC), respectively. ICC values were interpreted referring to the guidelines: excellent (> 0.90), good (0.75–0.90), moderate (0.50–0.75) and poor (< 0.50). .All the statistical analyses were performed by IBM SPSS Statistics v.26 . All reported P values were two-sided, and the difference was considered statistically significant when the P value < 0.05.Of the 150 videos screened, 108 were eligible and included in the study. The earliest video was published on April 13, 2010. Among all included videos, the number of each year generally increased by time, and more than a half  were released in 2019–2022 , followed by non-clinician , academic , clinician , commercial source , and trainer . , followed by exercise training , surgical technique , non-surgical management , and advertisement  , 3.00 (2.00), 2.00 (1.00) and 7.00 (8.88), respectively Table . The IntP = 0.009) and JAMA (P = 0.001), mDISCERN (P < 0.001), GQS (P < 0.001) and CSSS (P < 0.001) scores among different video uploading sources. The only significant discrepancy in VPI existed between videos from non-clinician and medical source (28.06 (111.34) vs. 12.34 (19.04), P < 0.05). Videos from academic source showed significant (P < 0.05) higher scores in the four scales than any other source, except for clinician source in GQS and CSSS (P > 0.05). Meanwhile, VPI (P < 0.001), mDISCERN (P = 0.001), GQS (P < 0.001) and CSSS (P = 0.001) scores significantly differed among videos of various contents. Videos about exercise training had higher VPI than those covering CS-specific information, surgical technique and non-surgical management with significance (P < 0.05). In contrast, the contents of surgical technique and non-surgical management led to significantly (P < 0.05) higher scores in mDISCERN, GQS and CSSS scales than exercise training. More detailed analytical results are displayed in Table There were significant differences in VPI (P < 0.001 for each pair). However, none of these scores were significantly correlated with VPI , a verified uploader (P = 0.034), fewer subscribers to the host channel (P = 0.011). And compared to the CS-specific information, the content about exercise was a independent predictor to higher VPI (P = 0.005); A higher JAMA score was associated with longer video duration (P < 0.001), greater like ratio (P < 0.001), a verified uploader (P = 0.002). The videos from academic source were correlated to higher JAMA scores than medical source (P = 0.003); A higher mDISCERN score was closely related to longer video duration (P < 0.001), greater like ratio (P < 0.001). In comparison to medical source, the sources of academic (P < 0.001) and trainer (P = 0.001) were associated with higher and lower mDISCERN scores, respectively; A higher GQS score was correlated to longer video duration (P < 0.001). The sources of academic (P = 0.001) and clinician (P = 0.002) were independent predictors of higher GQS scores compared to medical source, and the contents about exercise training (P = 0.021) and advertisement (P = 0.009) were related to lower GQS scores than the CS-specific information; A higher CSSS score was in correlation with longer video duration (P < 0.001). And Compared to the medical source, the sources of academic (P = 0.005) and clinician (P = 0.006) were associated with higher CSSS scores while the sources of non-clinician (P = 0.024) and trainer (P = 0.033) were related with lower CSSS scores.Multiple linear regression analysis showed that a higher VPI was correlated with a higher number of comments , 3.00 (2.00), 2.00 (1.00) and 7.00 8.88), respectively. This suggests that the common netizens or patients searching for information about CS on YouTube may be at a relatively high risk of encountering inadequate, inaccurate, or even misleading information. Our finding is consistent with previous research in the field of spinal health. Erdem et al. revealed the poor quality of videos covering kyphosis on YouTube, which had the mean JAMA, GQS and Kyphosis-Specific Scores (range: 0–32) of 1.36, 1.68, 3.02, respectively.  Similarl.88, respThe low reliability and quality of medical videos on YouTube may be due to the absence of an access and censorship system. , 46 ThisIn terms of specific content, the included videos were quite homogenous and shared several common issues. Nearly half 43%) of the videos discussed CS-specific information  and neck pain relief” from “Dr. Andrea Furlan” were the top three videos that showed distinguished performance under our evaluation system. Our analysis revealed that the high-reliability and high-quality of videos tend to coexist with each other, and associated with certain video characteristics. Apparently, video duration is a crucial factor for reliability and quality, with a significant positive regression among them Table . This fiThe VPI, i.e. video popularity, comprises two components: views and likes.  SpearmanBy deconstructing the VPI into two sub-indexes, we further focused on the view ratio. The diagram demonstrated that those shorter videos exceled in engaging viewers Fig. , howeverThe simply short videos yet to have incontrovertible dominance to users that shorter duration didn’t independently predict a higher VPI Table . And as Enhancing the quality of internet medical information and optimizing the online patient education requires the concerted efforts of multiple parties. One solution to improve the overall reliability and educational quality of CS-related videos on YouTube may be to motivate academics and clinicians to produce more contents. As professionals, academics and clinicians should devote more effort on popularizing medical knowledge for the public. The dominance of short videos should be reconsidered. There is a need for deeper consideration of how to extract important, systematic knowledge from expertise and present it comprehensibly within a limited duration. Lightweight but not necessarily short videos could benefit to both gaining preference and delivering accurate information. Simultaneously, the professional videos could be wrapped and presented in an appropriate way that caters to the viewers’ mentality to direct them to the high-quality content more effectively. In another aspect, it is essential to strengthen the cognition of information reliability of the uploaders. The importance of unbiased and evidence-based information, copyright awareness and disclosure of interests etc. should be emphasized to engage users and, more importantly, to reduce the possibility of users being exploited by commercial interests. For the YouTube platform, advanced artificial intelligence could be used to establish more stringent admission requirements and screening systems to resist poor and misleading contents. Additionally, combining with big-data analysis, the platform could selectively promote and push high-quality videos and relevant evidence-based information to the target population. Last but not least, the public should improve their ability to obtain and utilize the internet information dialectically, striving to understand the underlying mechanisms and scientific managements of the diseases.Our study had some unavoidable limitations. Given the popularity and clout, we only included English videos on YouTube as subjects, which may induce selective bias and reduce external validity. The quality scales, GQS and CSSS, were subjective and lacked strict validation. Although we adopted a double-review process, confounders were inevitable. Additionally, due to the inherent limitations of the scoring systems, our assessment was limited to the breadth of the covered topics in a video and did not evaluate the comprehensibility and efficiency of specific information delivering for the common users. It should also be mentioned that our statistics were limited by timeliness. Most characteristics data of videos changed dynamically and may not be representative for all periods. Besides, users may obtain more complete CS-related information from multiple complementary videos on YouTube. The results evaluated from each single video may not accurately quantify the holistic information that users could perceive from YouTube. More comprehensive evaluation methods remain to be explored. Beyond the scope of this study are other factors that may affect video popularity, such as potential social and commercial influences. Therefore, our findings about video popularity should be considered with caution.The internet has shown great potential in the medical field for patient education. However, the quality of online information is uneven and unregulated. This study indicated that the overall reliability and educational quality of current CS-related videos on YouTube are unsatisfactory. Users and patients searching for CS on YouTube are at high risk of encountering inadequate, inaccurate, or even misleading information. The videos with longer duration or from academic or clinician source could lead to higher reliability and quality. Optimizing the overall reliability and quality of online information requires a collaborative effort from multiple parties. We suggested motivating academics and clinicians to produce more concise and accurate contents. Meanwhile, the platform needs to establish stringent admission requirements and screening systems. And the public should endeavor to obtain and utilize internet information critically.


To clarify the long-term visual prognosis and prognostic factors for vision loss in patients with vitreoretinal lymphoma (VRL). This retrospective longitudinal study included 64 consecutive patients with VRL. We analyzed the best-corrected visual acuity (BCVA), optical coherence tomography findings, and clinical features at every visit. Significant vision loss was defined as a final BCVA ≥ 0.5 logMAR. Predictors of significant vision loss following treatment were evaluated using univariate and multivariate linear regression analyses. We included 113 eyes of 64 patients , and 49 patients (76.6%) showed bilateral ocular involvement. The mean follow-up duration was 35.4 ± 25.8 months. At diagnosis, 36 (56.3%), 17 (26.6%), and 11 (17.2%) patients had primary, secondary, and concurrent VRL, respectively. All eyes received intraocular methotrexate injections . The mean BCVA improved from 0.44 ± 0.28 at diagnosis to 0.33 ± 0.29 1 month after treatment initiation. Vision improved significantly after treatment . Univariate and multivariate analyses showed that baseline BCVA and retinal/subretinal infiltration were significantly correlated with vision loss. In this study, a good visual outcome was maintained for > 35 months in patients with VRL. Baseline BCVA and retinal/subretinal infiltration were significant predictors of vision loss after treatment for VRL. VRL presents as high-grade B-cell lymphoma (diffuse large B-cell lymphoma) in > 95% of cases, and T-cell lymphoma is rare (< 5% of cases)4. VRL can present as an isolated disease or develop before, after, or concurrently with PCNSL6. Rates of non-ocular CNS involvement with VRL at diagnosis and over the course of the disease are 41% and 69%, respectively6.Vitreoretinal lymphoma (VRL), previously known as primary intraocular lymphoma, is a rare intraocular malignancy that is a subtype of primary central nervous system lymphoma (PCNSL)10, which is longer than that in concurrent VRL/ central nervous system (CNS) lymphoma (18–34 months)9. Because the long-term survival rate of the disease is significantly low, reports on long-term visual prognosis are lacking.The prognosis of VRL should be considered in two parts: survival and visual prognoses. Despite recent advancements in the diagnosis and treatment of VRL, the overall survival of patients with VRL remains poor. The overall survival period of isolated primary VRL is 31–58 monthsIn recent years, diagnostic procedures and therapeutic options for VRL have advanced dramatically. However, studies on lymphoma have focused on the prognostic factors for survival. Thus, there is an unmet need for sufficient studies on visual prognosis, which significantly affects the quality of life of patients with VRL. In this study conducted at a tertiary referral center, we evaluated the clinical features of VRL and prognostic factors for vision loss in patients with VRL.A total of 113 eyes of 64 patients were evaluated and followed up for 35.4 ± 25.8 months. The baseline demographic and disease characteristics of the study population are shown in Table The baseline ocular characteristics of eyes with VRL are shown in Table The treatment strategies for VRL are summarized in Table P = 0.031). The proportion of eyes with vitreous opacity also decreased significantly (P = < 0.001). Cytokine analysis showed that the IL-10 level and IL-10/IL-6 ratio significantly decreased 1 month after treatment initiation and > 6 months after treatment .Improvements in the clinical parameters according to treatment are shown in Table P = 0.014), exudative retinal detachment (P = 0.011), and retinal/subretinal infiltration (P = 0.019) were significantly correlated with significant vision loss. Statistically significant variables were included in the multivariate analysis using backward stepwise selection methods. Baseline BCVA  and retinal/subretinal infiltration  were significantly correlated with significant vision loss. Concurrent CNS lymphoma, response to local treatment at 1 month, and treatment strategy showed no correlation with significant vision loss  deposits, and RPE undulation13. When clinically suspected, a confirmative diagnostic test should be conducted. In the past years, the gold standard for diagnosis was the detection of malignant lymphoid cells in vitreous samples15. Immunohistochemistry, cytokine concentration analysis (IL-10/IL-6 ratio), flow cytometry, and polymerase chain reaction tests to detect immunoglobulin heavy chains or T-cell receptor gene rearrangement, respectively, may also support the diagnosis of VRL16. In our study, cytological analysis of vitreous specimens (56.6%) and cytokine analysis (36.3%) were the most commonly used methods to confirm the diagnosis of VRL.The diagnosis of VRL is challenging and usually delayed because of the diverse clinical presentations, small volume of intraocular fluid available for testing, and initial response to steroid therapy7 evaluated 53 patients with VRL and reported good vision after treatment; the mean final BCVA was 1.047 ± 1.068 after follow-up for 32.5 ± 24.6 months. The final visual acuity did not differ in the primary, secondary, and concurrent VRL groups. Habot-Wilner et al.17 reported that in 129 patients with VRL, 62.8% of the eyes improved or maintained their initial vision after treatment. Dalvin et al.18 reported that eyes with sub-RPE infiltration were more likely to have a poor final visual acuity (< 20/200) than eyes without sub-RPE infiltration. This result is consistent with our findings. In our study, baseline BCVA, exudative retinal detachment, and retinal/subretinal infiltration were significant predictors of significant vision loss . In our study population, exudative retinal detachment and retinal/subretinal infiltration were observed in 3.5% and 41.6% of the eyes, respectively. A worse visual outcome after treatment for VRL with subretinal infiltration and exudative retinal detachment is considered to result in RPE atrophy with secondary photoreceptor dysfunction18. Alessandro et al.19 reported that 52% (41 eyes of 79 eyes) of their VRL cohort showed chorioretinal atrophy (CRA) and the eyes with CRA had a significantly worse vision. Major risk factors of developing CRA were retinal infiltrates, vertical hyperreflective lesions, and macular involvement.In this report, we present the prognostic factors for vision loss in patients with VRL. In our study, the overall visual outcome was relatively good; the baseline mean BCVA was 0.44 ± 0.28, and the final mean BCVA was 0.24 ± 0.21. Our findings are consistent with the overall good visual outcomes in patients with VRL reported in the literature. However, few studies have evaluated factors predicting visual outcomes following treatment. Cho et al.21. Systemic management of isolated VRL and PCNSL with ocular involvement should be performed in collaboration with ophthalmologists and other experts, such as neuro-oncologists, hematologists, and radiologists22.The optimal treatment strategy for VRL remains controversial and nonuniform. Therapeutic options range from local to systemic treatment, including chemotherapy and radiation. Local ocular treatment includes intravitreal methotrexate (MTX) or rituximab injection or external-beam radiotherapy25. However, the necessity for additional systemic treatment for patients with isolated VRL without CNS lymphoma is unclear. In our study, physicians did not administer additional systemic chemotherapy to most patients without CNS involvement . Only 3 patients with primary VRL  were treated with systemic high-dose MTX chemotherapy in addition to intravitreal MTX injection. Recent studies have shown that in patients with isolated VRL, supplementary systemic chemotherapy or radiotherapy has no additional benefit in terms of survival rate, time to relapse or progression, or mean time to CNS lymphoma development. In 2011, the International Primary Central Nervous System Lymphoma Collaborative Group published treatment guidelines for primary VRL14. They suggested that the addition of systemic chemotherapy to intravitreal therapy should be considered in cases of bilateral involvement. However, if VRL occurs in only one eye and there is no CNS or systemic involvement, local treatment alone is sufficient. Local treatment includes intravitreal MTX, intravitreal rituximab, or external-beam radiotherapy to the eye.Intravitreal MTX injection remains the gold standard for the management of VRL and is usually effective in controlling intraocular inflammationOur study had some limitations that must be considered when interpreting our findings. First, owing to the retrospective design, the results were susceptible to ascertainment bias, and the treatment strategies were not standardized. Second, in patients with the more aggressive subtype of lymphoma, the long-term visual prognosis is difficult to determine because of the short survival period and high mortality. Third, the results may be confounded by a lack of data on relevant variables, such limited multimodal imaging findings and combinations of treatment strategies.In summary, we report a relatively good and well-maintained overall visual outcome at > 35 months. Baseline BCVA and retinal/subretinal infiltration were significant predictors of vision loss after treatment with VRL.This retrospective longitudinal study included consecutive patients with VRL treated between January 2006 and December 2020 at Seoul St. Mary’s Hospital. The inclusion criteria were a diagnosis of VRL and age > 18 years.The exclusion criteria were (1) patients with a history of treatment for uveitis, including intravitreal injections or vitreoretinal surgery; (2) patients whose uveitis was unlikely to be related to VRL; (3) patients with concomitant ocular diseases, including retinal vein occlusion, glaucoma, diabetic retinopathy, or epiretinal membrane; (4) patients unable to undergo ophthalmic examination or treatment due to deterioration of their general condition; and (5) patients with recent serious or chronic infection . The study design followed the principles of the Declaration of Helsinki, and all protocols were approved by the Institutional Review Board of the Catholic University of Korea. The institutional review board waived the requirement for informed consent because of the retrospective nature of this study.27. All patients diagnosed with VRL were referred to the hematology and neuro-oncology departments for systemic evaluation and treatment. The cohort included patients with primary VRL, secondary VRL , and VRL concurrent with CNS or systemic lymphoma.The diagnosis of VRL was confirmed by combining typical clinical features with cytology and cytokine analysis of the anterior chamber and vitreous. Cytokine levels, including IL-10 and IL-6, were measured using a bead-based assay on a LUMINEX MAGPIX system . An elevated IL-10 level or IL-10-to-IL-6 ratio > 1 is indicative of VRLWe collected and reviewed clinical and demographic data, including age, sex, follow-up duration, medical history, and history of ocular and systemic treatments. During follow-up, comprehensive ophthalmic evaluations, including BCVA, slit-lamp examination, tonometry, and dilated fundus examination, were performed at each visit. BCVA was converted to logMAR for statistical analyses. Eyes underwent either spectral-domain optical coherence tomography (OCT)  or swept-source OCT . For each patient, the same OCT device was used throughout the follow-up period. The presence of clinical features, such as anterior-chamber cells, keratic precipitates, vitreous cells, retinal/subretinal infiltration, exudative retinal detachment, and optic-nerve infiltration/hemorrhage/edema, was evaluated. P < 0.05.An exploratory analysis was performed for all variables. Categorical data are expressed as absolute numbers and continuous data as mean ± standard deviation . We performed a linear mixed model to compare improvements in clinical parameters, including BCVA, vitreous opacity, and values of cytokine-assay parameters after treatment. Univariate and multivariate linear regression analyses were performed to evaluate predictors of significant vision loss following treatment in eyes with VRL. In this study, significant vision loss was defined as a final BCVA of ≥ 0.5 logMAR. All statistical analyses were performed using the Statistical Package for the Social Sciences for Windows . Statistical significance was set atSupplementary Figures.


Periodontitis is a common inflammatory disease associated with systemic factors. Visfatin is a pleiotropic adipokine that exerts metabolic and immune functions. Studies have shown visfatin played roles in the development of periodontitis. The present study aims to compare the levels of visfatin in body fluids including serum, saliva, and gingival crevicular fluid (GCF) between periodontitis patients and healthy individuals, and to elucidate the alteration of visfatin levels after periodontal treatments.The database searched included Pubmed, Embase, Web of Science, and Cochrane Library. According to the Eligibility criteria, the records were screened and the eligible studies were included. The methodological qualities of the included case-controlled studies were assessed according to the Newcastle–Ottawa scale (NOS). The Methodological Index for Nonrandomized Studies (MINORS) was applied for assessing the qualities of the included clinical trials. The statistical analyses were processed using STATA 15.0.P < 0.05; Serum: SMD = 7.417, 95% CI: 3.068–11.767, Z = 3.34, P = P < 0.05; Saliva: SMD = 2.683, 95% CI: 1.202–4.163, Z = 3.34, P < 0.05). Visfatin levels of saliva serum and GCF were significantly decreased after periodontal treatment.Twenty-three studies were included in the statistical analyses. The meta-analysis showed significantly elevated visfatin levels of GCF, serum, and saliva in the periodontitis population compared with the controls .(Saliva: SMD = -1.338, 95% CI: -2.289—0.487, Z = 39.77, Periodontitis elevated the visfatin levels in GCF, serum, and saliva. Additionally, GCF, serum, and saliva visfatin levels could be reduced after periodontal treatment. Periodontitis is a common inflammatory disease induced by polymicrobial factors. The consequences of periodontal disease are frequently presented as gingival infection, alveolar bone destruction, as well as periodontal attachment loss . The staAdipokines are a complex cohort of cytokines produced by adipocytes, including leptin, adiponectin, resistin, and visfatin. etc.  It has bThe relationship between adipokines and periodontitis has been reported. Previously, the present author published a meta-analysis regarding the association between periodontitis and serum levels of leptin and adiponectin, finding that elevated serum leptin and decreased serum adiponectin were related to periodontitis . Recent We conducted the present meta-analysis following the Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement . The proThe database searched included Pubmed, Embase, Web of Science, and Cochrane Library, up to December 2022. The details of search strategies are presented in Table The inclusion criteria for the included studies were as follows: (1) the observational studies comparing visfatin levels in serum, saliva, or GCF between periodontitis patients and periodontally healthy individuals; (2) Clinical trials comparing visfatin levels in serum, saliva, or GCF before and after periodontal treatments; (3) Studies with sufficient data for the statistical analyses; and (4) Studies in English or Chinese.The exclusion criteria were as follows: (1) Conference abstracts; (2) Trial registry records; and (3) those with repeated data.Search results were downloaded to EndNote. According to the Eligibility criteria, the records were collated and separately reviewed by two independent authors. A third author was consulted when consensus on appropriateness was debated. The titles and abstracts were screened first and the full-text paper screen was conducted next.The information on study characteristics and outcomes was extracted, including (1) Name of the first author and year of publication; (2)Country; (3) study design; (4) Group and size; (5)Age; (6) Body mass index (BMI); (7) Systemic conditions; (8)Type of periodontal treatments; (9) The time interval after periodontal treatment; and (10) Serum, saliva, or GCF levels of visfatin.The methodological qualities of the included case-controlled studies were assessed according to the Newcastle–Ottawa scale (NOS). Three dimensions including selection, comparability, and exposure were considered. In the section on comparability, the most important factor was identified to be BMI. Eight items were graded, with a score range of 0–9 points. Overall, studies with final scores of 1–3, 4–6, and 7–9 were considered to be of low, moderate, and high qualities . Additio2. Random-effects model was used when the P value < 0.05 and I2 > 50%. Sensitivity analyses were performed to test the robustness. The statistical analyses were processed using STATA 15.0.The data of visfatin levels were presented as mean (M) ± standard deviation (SD). The results in the form of median (minimum – maximum) were shifted to M ± SD according to the estimation method reported by Hozo et al. . The staThe flow diagram of the selection process was presented in Fig. P < 0.05; I 2 = 93.0%, P < 0.05 Fig. P = 0.001; I 2 = 97.7%, P < 0.05 Fig. P < 0.05; I 2 = 54.4%, P = 0.087). 5 studies reported the comparison of visfatin levels in saliva between periodontitis patients and healthy individuals. The meta-analysis showed significantly increased saliva visfatin levels in the periodontitis population . 3 studies for each described the change of visfatin levels in serum and GCF after periodontal treatment. The results of the meta-analysis also showed significantly declined serum and GCF visfatin levels after periodontal treatment compared with the baseline . For other comparisons, Egger’s linear regression test was not conducted because the number of included studies was limited (n < 10).Egger's linear regression test was used to examine the potential publication bias. We found a significant publication bias in the comparison of visfatin levels in GCF between periodontitis patients and healthy individuals (Increasing evidence in the literature indicated the associations between adipocytokines and periodontitis. In 2016, Zohaib Akram et al. published the first meta-analysis researching the cytokine profile in periodontitis patients with and without Obesity, finding increased resistin levels in obese individuals with periodontitis than nonobese periodontitis subjects . AnotherThe present study is the first meta-analysis concentrated on the association between visfatin and periodontitis. 23 studies were examined in the present study, and the results showed that visfatin levels in GCF, serum, and saliva were significantly elevated in the periodontitis population. Additionally, we also found that GCF, serum, and saliva visfatin levels could be reduced after periodontal treatment.Human visfatin was first discovered in 1994 as a novel gene isolated from a human peripheral blood lymphocyte cDNA library . VisfatiPeriodontitis is a common bacterial infection associated with multiple risk factors. Despite the microorganisms' roles as etiologic agents, systemic conditions and inflammatory situations have also contributed to the prevalence and severity of periodontitis . PeriodoAmong the 3 kinds of physiological fluids investigated in the present study, GCF was mostly reported. GCF is the fluid and the inflammatory exudate secreted from the blood vessels in the gingival corium, subjacent to the epithelium lining of the dentogingival space. Cytokines presented in GCF have been proposed as potential diagnostic or prognostic markers of periodontal destruction . The preThe limitations of the presented study include the lack of enough included studies, especially randomized controlled studies. Although 9 clinical trials were included, only 3–6 studies were evaluated in each comparison for the change of visfatin levels after periodontal treatment. And, only single-armed results were applied in the meta-analysis to ensure consistency. Besides, significant heterogeneities were observed, and in some comparisons, we failed to find the exact source of heterogeneity, therefore the results should be interpreted with caution. Moreover, although the present study o included studies with case-controlled designs, the results of each study were considered cross-sectional, therefore the cause-effect relationship between visfatin and periodontitis could not be perfectly elucidated.In conclusion, the present study supports the findings that periodontitis elevated the visfatin levels in GCF, serum, and saliva. Additionally, GCF, serum, and saliva visfatin levels could be reduced after periodontal treatment. Further large-scale homogeneous studies were still needed to prove if visfatin could be used as a potential biomarker to predict periodontitis.


Epimedium species, has shown promising results in the treatment of Alzheimer's disease (AD), although its potential therapeutic mechanism remains largely unknown. This study aimed to investigate the therapeutic effects and the underlying mechanisms of ICA on AD by an integrated analysis of gut microbiota, metabolomics, and network pharmacology (NP).Icariin (ICA), an active ingredient extracted from The cognitive impairment of mice was measured using the Morris Water Maze test and the pathological changes were assessed using hematoxylin and eosin staining. 16S rRNA sequencing and multi-metabolomics were performed to analyze the alterations in the gut microbiota and fecal/serum metabolism. Meanwhile, NP was used to determine the putative molecular regulation mechanism of ICA in AD treatment.Akkermansia and reducing the abundance of Alistipe. Furthermore, the metabolomic analysis revealed that ICA reversed the AD-induced metabolic disorder via regulating the glycerophospholipid and sphingolipid metabolism, and correlation analysis revealed that glycerophospholipid and sphingolipid were closely related to Alistipe and Akkermansia. Moreover, NP indicated that ICA might regulate the sphingolipid signaling pathway via the PRKCA/TNF/TP53/AKT1/RELA/NFKB1 axis for the treatment of AD.Our results revealed that ICA intervention significantly improved cognitive dysfunction in APP/PS1 mice and typical AD pathologies in the hippocampus of the APP/PS1 mice. Moreover, the gut microbiota analysis showed that ICA administration reversed AD-induced gut microbiota dysbiosis in APP/PS1 mice by elevating the abundance of These findings indicated that ICA may serve as a promising therapeutic approach for AD and that the ICA-mediated protective effects were associated with the amelioration of microbiota disturbance and metabolic disorder.The online version contains supplementary material available at 10.1186/s12967-023-04137-z. Alzheimer's disease (AD) is a progressive neurological condition affecting over 35 million people worldwide. It is clinically characterized by cognitive impairment and memory deterioration, which occur in nearly 70% of all AD cases. Furthermore, AD is becoming a major global public health concern owing to its direct and indirect costs and the increasing aging population worldwide . HoweverEpimedium species, has broad biological application prospects [Icariin (ICA), an active component extracted from rospects . Numerourospects  and intrrospects . Furtherrospects  and interospects . Additiorospects . Furtherrospects , 9. HoweMulti-omics and multi-dimensional analyses are used to improve our understanding of disease development and drug therapeutic mechanisms. 16S ribosomal RNA (16S rRNA) gene sequencing is used for bacterial analysis, while metabolomics is used to track dynamic changes in metabolites (< 1000 molecular weight)  using hiIn this study, the Morris Water Maze (MWM) test and hematoxylin–eosin (HE) staining were used to assess the impact of ICA on cognitive performance and histopathological changes in APP/PS1 mice. Additionally, 16 s rRNA analysis was used to examine the changes in the gut microbiota of APP/PS1 mice, and liquid chromatography–mass spectrometry (LC–MS)-based untargeted metabolomics was used to determine the regulatory effects of ICA on the metabolic profiles of the serum and fecal samples of APP/PS1 mice. Lastly, NP was used to assess the current scientific understanding of ICA in AD treatment. This study intends to shed light on the intricacies of AD biology and discover regulatory networks for the ICA-mediated treatment of AD.ICA powder (≥ 98% purity) was purchased from ). ICA was dissolved in 2% dimethyl sulfoxide (DMSO) and 10% polyethylene glycol 400.Animal studies were conducted according to the Guide for the Care and Use of Laboratory Animals by the National Institute of Health (USA) and were approved by the Animal Ethics Committee of the Second Xiangya Hospital, Central South University (China) (2020038). All the procedures were conducted under pentobarbital sodium anesthesia, ensuring minimal discomfort to the animals. C57BL6/J and APP/PS1 mice  were obtained from Spife Biotechnology Co., Ltd. . The mice were kept in a regulated habitat  with free access to standard food and water. APP/PS1 mice were randomly allocated into the model group (n = 10) and ICA group (n = 12), whereas C57BL6/J mice were assigned to the control group (n = 10). The ICA group was administered ICA at 100 g/(kg*d) for 100 d, whilst the other two groups received the same quantity of sterile saline solution.The MWM test consists of spatial acquisition and spatial probe tests, which are used to assess spatial learning and memory abilities . The spaFollowing the MWM test, the mice were anesthetized and transcardially perfused with 300 mL of stroke-physiological saline solution to flush out their blood through the abdominal aorta. The blood samples were then stored at − 80 °C until further analysis. Thereafter, their brain tissues were collected, treated with a 4% paraformaldehyde solution, embedded in paraffin, and sectioned into 4–5 µm thick slices . The secA minimum of 5 fecal pellets were retrieved from the rectum of each mouse (100-d-old), placed in a sterile conical tube, and stored at − 80 °C until further analysis.16S rRNA gene sequencing of the fecal samples was carried out as reported previously . BrieflyThe detailed protocol for fecal and blood sample preparation for LC-MS analysis is provided in the Supplementary Materials and Methods.The UltiMate 3000 Ultra High-performance Liquid Chromatograph  and Thermo Q-Exactive Orbitrap Mass Spectrometer were used for ultrapure LC-MS/MS analysis (Thermo Fisher). Chromatographic separations were performed on Waters ACQUITY UPLC HSS T3 (100 mm × 2.1 mm × 1.8 μm). Thereafter, all the raw data were fed into Progenesis QI  and SIMCA-P14.0 , software for further analysis . The parFirstly, we identified the differential metabolites in the control, model, and ICA groups, which are engaged in important metabolic pathways, via correlation analysis. Thereafter, we identified the top 45 most abundant species in the intestinal flora in all three groups. Lastly, we used Spearman correlation analysis and heatmaps to assess the correlation between gut microbiota and metabolite content.https://pubchem.ncbi.nlm.nih.gov/) [http://www.lilab-ecust.cn/pharmmapper/), and Swiss Target Prediction (http://www.swisstargetprediction.ch/) databases, and all the targets were annotated as their official symbols using the UniProt Knowledgebase search function (http://www.uniprot.org/) in the Protein Database (UniProt). Thereafter, the GeneCards (https://www.genecards.org/) and Online Mendelian Inheritance in Man (OMIM) (https://omim.org/) [https://string-db.org/) for protein–protein interaction (PPI) network formation using Cytoscape 3.8.0. Thereafter, Gene Ontology (GO) enrichment and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses were conducted to further investigate the biological functions of the targets and their associated pathways. Lastly, the hub genes associated with important pathways were selected for subsequent molecular docking analysis by PyMOL 2.4.0 and Autodock software. Further information on the analytic processes is provided in the Supplementary Materials and Methods.The drug targets were predicted by PubChem (ih.gov/) , Pharm Mim.org/)  databaseData were presented as mean ± standard deviation (SD). The SPSS 20.0 software  was used to conduct statistical analyses. The escape latency was analyzed by separate repeated measures of two-way analysis of variance (ANOVA). Other data were evaluated by one-way ANOVA. P < 0.05 was considered statistically significant.p = 0.0148, Fig. p = 0.0263, Fig. p = 0.0173, Fig. The MWM test was used to detect and evaluate the spatial learning and memory capacities of APP/PS1 mice to examine the effects of ICA on their cognitive deficits. The escape latency data of navigation trials decreased significantly with daily practice. On day 5, the spatial probe test was administered and the time spent in the target quadrant and their frequency of crossing the target quadrant was recorded. The results of the MWM test demonstrated that the APP/PS1 mice had a regular and discrete swimming trajectory, a diminished number of platform crossings, and a longer escape latency compared to the control group  and Firmicutes (40–47%) were the leading phyla across the three groups  ratio in the model group (1.02) was upregulated compared to the control group (0.74) and downregulated compared to the ICA group (0.86). The presence of certain lipid metabolism-associated bacterial species, such as Akkermansia, Parabacteroides, and Alistipes is regarded as a health concern. Akkermansia is associated with blood lipid and blood glucose metabolism [Alistipes is associated with a higher-fat diet [Akkermansia increased  after ICA intervention. Meanwhile, the abundance of inflammation-associated bacteria, Mucispirillum [p = 0.04407). The linear discriminant analysis (LDA) effect size (LEfSe) was used to identify the key bacterial taxa in each group and all the validated sequences were analyzed , model (n = 10), and ICA (n = 12) groups. The Ace and Chao indexes revealed that ICA treatment could restore the abundance of intestinal flora in AD mice . Altogether, these results demonstrate that ICA mediates its anti-AD function by reversing the effects of AD on the sphingolipid metabolism in the gut.We further conducted fecal metabolomics on the control, model, and ICA groups to explore the anti-AD effects of ICA. PLS-DA and OPLS-DA  and sphingolipid metabolism (p = 0.017438 in the control group vs. the model group and p = 0.013173 in the ICA group vs. the model group) in the serum of APP/PS1 mice  in the serum and CerP 25:1 in the feces of the ICA group  and Cer(d18:0/15:0) and negatively correlated with glycerophospholipids PC (3:0/3:0) and PS (16:0/18:0). Interestingly, Verrucomicrobiota, the phylum of Akkermansia, showed the same correlation with Akkermansia. These findings revealed that the reduced abundance of Akkermansia and increased abundance of Alistipes were associated with the increased levels of ceramides in the APP/PS1 mice. Moreover, the ceramide levels in APP/PS1 mice decreased when the abundances of Akkermansia and Alistipes were altered by ICA intervention. Altogether, these results indicate that the therapeutic effect of ICA may be strongly associated with sphingolipid metabolism and that Akkermansia and Alistipes may play a crucial role in this process, thus indicating that ICA mediates its anti-AD effect via the microbiome–metabolites–brain axis.Spearman analysis was performed between the gut microbiota and fecal/serum metabolites to further examine the anti-AD effects of ICA on the gut microbiota and metabolism. We found that the F/B ratio was significantly reduced in the ICA group compared to the model group and that the abundances of erd18:0/1:0 in theerd18:0/1:0 in theerd18:0/1:0 in theNP analysis was performed to determine the anti-AD mechanism of ICA. Firstly, 184 drug targets were identified through PubChem, Pharm Mapper, and Swiss Target Prediction databases. Additionally, 3630 AD-related genes were obtained from the OMIM and GeneCards databases, among which 115 prospective ICA targets were selected for further analysis  revealed that a total of 119 KEGG pathways, including the PI3K-Akt signaling pathway, sphingolipid signaling pathway, and NF-κB signaling pathway, were significantly enriched by the 115 target genes  and Muc effects ) increasc status ) was sigAkkermansia regulates the gut–brain axis by maintaining the intestinal mucosal barrier and regulating lipid metabolism [The gut microbiome significantly influences the host's metabolism. For instance, tabolism , 29. Thetabolism  and γ-setabolism  activititabolism . Furthertabolism . In our Bacteroidetes is a dominant phylum of the gut microbiome and that it is associated with sphingolipid production [Bacteroides. Consistently, in our study, correlation analysis showed that the abundance of Bacteroidetes was significantly correlated with sphingolipid metabolism. Furthermore, Akkermansia and Alistipes were correlated with at least 5 metabolites, in both the serum and fecal samples and may be the primary gut microbial species to interact with the host’s metabolites. Alistipes, a comparatively novel sub-branch of the Bacteroidetes phylum, is often linked with persistent intestinal inflammation and sphingolipid production [Akkermansia is associated with anti-inflammatory function in the intestines, reduction in obesity, and lipid metabolism regulation [Akkermansia has been reported to promote Aβ40-42 reduction and improve intestinal barrier dysfunction and dyslipidemia in APP/PS1 mice [Akkermansia abundance and a decrease in Alistipes abundance. Collectively, our findings underscored the significance of the microbiome–metabolite–brain axis in mediating the anti-AD effects of ICA.Previous studies revealed that oduction , suggestoduction –36, consoduction . In contgulation . AkkermaPS1 mice . In the TP53, plays a crucial role in sphingolipid-induced cell apoptosis [Finally, NP was used to investigate the association between ICA and AD treatment based on system networks. The results revealed that the therapeutic effect of ICA on AD may be mediated via a variety of signaling pathways, including the PI3K-Akt signaling pathway, sphingolipid signaling pathway, and NF-κB signaling pathway, consistent with previous studies . ICA haspoptosis . MoleculSome of the limitations of this study need to be acknowledged. Firstly, we used a single analytical method to detect the fecal and serum metabolites, which may limit the scope of our study; therefore, multiple analytical methods should be used in future studies to identify more metabolic pathways associated with the ICA-mediated treatment of AD. Secondly, we only explored the metabolomic changes in the fecal and serum samples before and after cognitive impairment in APP/PS1 mice; however, combined multi-site and multi-omics studies can more accurately determine the regulatory networks associated with the development of cognitive decline. Lastly, we used a single animal model and single drug dose in this study, and further studies should be conducted using different animal models, such as 5XFAD mice and 3xTg-AD mice, and under different drug doses, to further validate our results.Alistipes and Akkermansia) and sphingolipid metabolism, which might be key factors contributing to the therapeutic effect of ICA on AD. Furthermore, NP analysis revealed the potential mechanisms underlying the ICA-mediated treatment of AD that might affect the sphingolipid signaling pathway via the PRKCA/TNF/TP53/AKT1/RELA/NFKB1 axis. Altogether, our results indicate that ICA may serve as a potential therapeutic compound for preventing AD development via the microbiome–metabolite–brain axis. However, further studies, specifically multi-omics, spatial transcriptomics, and spatial metabolomics analyses are required to further explore the exact mechanism by which ICA mediates its therapeutic effect on AD.This is the first study to explore the underlying mechanisms associated with the anti-AD function of ICA by integrated 16 s rRNA sequencing, multi-metabolomics, and NP analyses. Our results revealed that ICA can effectively improve AD-induced cognitive impairment and pathologic changes. In addition, ICA ameliorated AD-induced gut microbiome dysbiosis and metabolic disorder in APP/PS1 mice. Interestingly, we found an association between gut microbiota .