Metschnikowia. 28S rDNA- and ITS-based phylogenetic analysis showed that the isolates were divided into three clades, designated clade I, II, and III. Clade I contains two previously described Chrysopidae gut yeasts (M. picachoensis and M. pimensis) as well as a one of our new species named M. shishimaru. Clade II is a new clade, with at least two new species named M. kenjo and M. seizan. Clade III contains the previously described species M. noctiluminum, a Chrysopidae gut yeast, and one of our isolate (We have not described it as new species). However, the phylogenetic relationship between our isolate and M. noctiluminum was unclear. These results indicate that the Japanese Chrysopidae gut yeasts consist mainly of three undescribed species and that they are more unique than those found in previous surveys. The results of this study indicate that Chrysopidae gut yeasts are more diverse than previously thought and should be investigated in various geographical regions in the future.Family Chrysopidae is known to harbor specific gut yeasts. However, no studies have been conducted outside of a limited number of these green lacewing species, and the diversity of yeasts in the family as a whole is not known. Therefore, we collected 58 Chrysopidae adults  in Japan and isolated yeasts from all individuals. The results showed for the first time that not only subfamily Chrysopinae but also subfamily Apochrysinae have gut yeasts. We obtained 58 yeast isolates , all of which were of the genus The online version contains supplementary material available at 10.1007/s10482-023-01887-0. Wickerhamomyces anomalus is cultivated by scale insects as food  were filled with yeast cells. Since this green lacewing does not obtain amino acids directly from their diet, it was hypothesized that their gut yeast synthesizes essential amino acids . Since then, yeasts of the genus Metschnikowia have been isolated from four Chrysopidae: M. pimensis from Chrysoperla carnea, M. chrysoperlae from Ch. comanche, M. picachoensis from Ch. rufilabris, and M. noctiluminum from Ceraeochrysa lineaticornis  and 97% of the species in the family Chrysopidae belong to Chrysopinae  or gut contents (by picking up diverticula of the dissected digestive tracts) were taken, put on the surface of PDA plates , and streaked with a sterilized needle. When yeast colonies were detected on the agar plates, one yeast cell was isolated and established in culture. We established one culture per collected lacewing individual.Metschnikowia were obtained from NCBI GenBank with reference to Kurtzman et al. (DNA was extracted from yeast cells by using PrepMan Ultra kits (Thermos Fisher Scientific). All PCR reactions were performed by using KOD FX DNA polymerase . The sequence of the D1/D2 domains of the 28S rDNA region were amplified by PCR using the primers LROR and LR5  medium has been shown to induce asci formation in the Metschnikowia yeasts when several coexisting filamentous fungi (Cladosporium sp. etc.) were contaminated on the same agar plate. Based on this observation, when the isolates did not produce asci on the V8 juice agar, the following method was also used. Namely, Cladosporium sp. 1 (NBRC 115069) and Cladosporium sp. 2 (NBRC 115070), isolated from the surface of different individuals of Apertochrysa formosanus, were used as the two-member culture partners. In advance, these filamentous fungi were preincubated on MEA , then 5 mm squares of agar were cut and placed in the center of 2% water agar medium  and CMA , and incubated at 25 °C for 3 days. Yeasts were also preincubated on PDA medium at 25 °C for 3 days then suspended in sterile water with the turbidity adjusted to OD600 = 1. Then, 5 µl of the yeast suspensions were inoculated along the four sides of the inoculated agar blocks of the filamentous fungi and incubated at 15 °C.We often observed the formation of asci of nectar The morphological, physiological, and biochemical characteristics of yeast isolates were examined using standard protocols after Kurtzman et al. . The folWe collected 58 lacewing individuals that represented 9 species from 6 genera in 2 subfamilies of Chrysopidae Table . Yeasts We sequenced the 28S rDNA region from 58 isolates. The TIM2e+I+G4 base substitution model was selected as the most appropriate for the 28S rDNA region. In the phylogenetic tree based on the 28S rDNA sequences the isolates were divided into 3 clades which were tentatively called clade I, II, III Fig. .Fig. 1Ma M. pimensis and M. picachoensis described from North American lacewings .Seventeen isolates belonged to clade I. They were obtained from 3 species, 3 genera, and 1 subfamily of lacewings collected at 2 localities .Clade II consisted of 40 isolates from 9 species, 6 genera, and 2 subfamilies of lacewings from 6 localities Table . This clade Fig. . Clade IChrysoperla cf. nipponensis from one locality (Table M. noctiluminum) was described from lacewings (Ceraeochrysa lineaticornis), and two of which (Metschnikowia viticola and M. kofuensis) were described from grape berries. However, the phylogenetic analysis of the 28S rDNA region was not able to distinguish between the known species and our isolate.Only one isolate (YY-1–59 = NBRC 115081) from Metschnikowia shishimaru Yoshihashi and Degawa sp. nov.Mycobank No.: MB847823 : After 2 weeks asci was not observed. Chlamydospores are spherical.Fermentation and growth reactions for this species are given in Table S2.Chrysoperla cf. nipponensis) collected in Sugadaira-kogen, Ueda, Nagano, Japan on July 11, 2018 by Yuma Yoshihashi.Holotype: NBRC 115076 (YY-1–19 = JCM 35864 = CBS 18114), isolated from lacewing  collected in Sugadaira-kogen, Ueda, Nagano, Japan on July 11, 2018 by Yuma Yoshihashi.Other isolate examined: NBRC 115077 (YY-1–20), isolated from lacewing (Shishimaru” (Japanese) refers to the name of one of the three famous “biwa”  in “Genjo/Kenjo”, the title of a Japanese classical dance-drama (“Noh”)  asci formation was observed and matured after 1 week. Chlamydospores are subglobose to ellipsoid. Asci are needle-shaped, usually 13–24 µm in length. Pseudophyphae formation was observed around the asci only on V8 agar.Fermentation and growth reactions for this species are given in Table S2.Apertochrysa cf. prasina) collected in Sugadaira-kogen, Ueda, Nagano, Japan on July 3, 2018 by Yuma Yoshihashi.Holotype: NBRC 115071 (YY-1–01 = JCM 35862 = CBS 18359), isolated from the vomit of lacewing (Apertochrysa cf. prasina) collected in Sugadaira-kogen, Ueda, Nagano, Japan on July 3, 2018 by Yuma Yoshihashi.Other isolates examined: NBRC 115072 (YY-1–02) and NBRC 115073 (YY-1–04) were isolated from different individuals of lacewings (Kenjo” (Japanese) refers to the name of one of the three famous “biwa”  in “Genjo/Kenjo”, the title of a Japanese classical dance-drama (“Noh”) , asci formation was observed. Chlamydospores are spherical. Asci are sphaeropedunculate, usually 25–31 µm in length.Fermentation and growth reactions for this species are given in Table S2.Apochrysa matsumurae) collected in Institute for Nature Study, Shirokanedai, Minato-ku, Tokyo on July 6, 2018 by Yuma Yoshihashi.Holotype: NBRC 115074 (YY-1–11 = JCM 35863 = CBS 18360), isolated from lacewing (Apertochrysa cf. prasina) collected in Sugadaira-kogen, Ueda, Nagano, Japan on August 28, 2018 by Yuma Yoshihashi; NBRC 115080 (YY-1–58), isolated from lacewing (Apertochrysa astur) collected in Sugadaira-kogen, Ueda, Nagano, Japan on July 31, 2018 by Yuma Yoshihashi; YY-1–23, isolated from lacewing (Chrysoperla cf. nipponensis) collected in Sugadaira-kogen, Ueda, Nagano, Japan on July 18, 2018 by Yuma Yoshihashi.Other isolate examined: NBRC 115079 (YY-1–57), isolated from lacewing (Seizan” (Japanese) refers to the name of one of the three famous “biwa”  in “Genjo/Kenjo”, the title of a Japanese classical dance-drama (“Noh”)  were obtained from Chrysoperla cf. nipponensis (subfamily Chrysopinae); 1 was obtained from Kuwayamachrysa kichijoi (subfamily Chrysopinae); and 1 from Apertochrysa cf. prasina (subfamily Chrysopinae). Previous reports of the known species, Metschnikowia pimensis and M. picachoensis, were also obtained from Chrysoperla sp. . Therefore, it is suspected that clade I is mostly specific to the genus Chrysoperla.We detected 3 clades of yeasts isolated from the gut contents of 58 individuals of 9 species of Chrysopidae in Japan. Clade I included known species of M. kenjo and M. seizan), and its sister clade was M. corniflorae. Yeasts from this clade were the most common, as they were isolated from a taxonomically wide range of Chrysopidae species (across two subfamilies) and from all five sampling localities. These results indicate that this is the dominant clade of Chrysopidae gut yeasts in Japan. Neither host specificity nor geographic distributional bias were detected. One notable feature of the isolates in this clade is that they were also obtained from the subfamily Apochrysinae. Among the three subfamilies of Chrysopidae, Apochrysinae diverged from Chysopinae at an ancestral stage . The fact that isolates in clade II were obtained from two subfamilies suggests that Metshcnikowia gut yeasts may be present throughout the family Chrysopidae. Unfortunately, the third subfamily, Nothochrysinae, is not distributed in Japan and could not be studied. Further research on Nothochrysinae is needed.Clade II was a new clade consisting of only undescribed species Below is the link to the electronic supplementary material.


Insulin resistance (IR) is a major pathogenesis of nonalcoholic fatty liver disease (NAFLD). The triglyceride-glucose (TyG) index has recently gained popularity to assess IR and NAFLD due to its simplicity and low cost. The aim of the current study was to evaluate the relationship between the TyG index and aminotransferase.A serial cross-sectional study was conducted among 232,235 Royal Thai Army (RTA) personnel aged 35–60 years from 2017–2021. Elevated aminotransferase was defined as ≥ 40 U/L and ≥ 35 U/L among males and females, respectively. A linear regression analysis between the TyG index and log-transformed aminotransferase was performed. High- and low-TyG index groups were divided according to Youden’s index cut point for predicting elevated aminotransferase. Multivariable logistic analysis was also utilized to investigate the association between the TyG index and elevated aminotransferase.P < 0.001 for both). In the fourth TyG quartile, the prevalence of elevated ALT was 47.8% and 40.2% in the participants aged 35–44 and male participants, respectively.The TyG index revealed a dose‒response relationship with log-transformed aminotransferase in both sexes and all age groups. The TyG index was positively associated with the prevalence of elevated aminotransferases. In comparison with the first TyG quartile (< 8.37), participants in the fourth quartile (> 9.23) had a higher chance for elevated ALT (AOR: 2.81, 95% CI: 2.71–2.90 for males and AOR: 4.01, 95% CI: 3.50–4.60 for females, A high TyG index is a novel risk factor for elevated aminotransferase among RTA personnel. Those with a high TyG index should be screened for elevated aminotransferase, particularly males aged 35–44 years.The online version contains supplementary material available at 10.1186/s12944-023-01811-5. Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease, resulting in cirrhosis and hepatocellular cancer . In 2020Insulin resistance (IR) is known to be the primary mechanism of NAFLD . HoweverRecently, Sakboonyarat et al. revealed that metabolic syndrome was a common health issue among RTA personnel over 35 years old. Moreover, rising trends in obesity prevalence were also observed in the population , 12. SomFrom 2017 to 2021, a serial cross-sectional study was carried out. The data set was extracted from the RTA personnel annual health examination database with permission from RTAMED in Bangkok, Thailand . AnnuallThe Army Institute of Pathology, the Armed Forces Research Institute of Medical Sciences, and 37 RTA hospitals conduct annual health examinations for RTA personnel. A self-report guide was utilized to collect demographic characteristics and behavioral risk factors, including age, sex, health insurance schemes, regular exercise, alcohol use, and smoking status. Anthropometric measurements of systolic blood pressure (SBP) and diastolic blood pressure (DBP) were taken. Moreover, bodyweight and height were measured to calculate body mass index (BMI).Cardiometabolic risk factors include high FPG, SBP, DBP, and serum uric levels. FPG was categorized as under 126 mg/dL and 126 mg/dL or more (hyperglycemia). High blood pressure was defined as an SBP of 140 mmHg or more or a DBP of 90 mmHg or more. High serum uric level was defined as 7 mg/dL or more , 18. EleP value less than 0.05 was considered statistically significant. All analyses were performed using StataCorp, 2021, Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC.The frequency distribution of demographic characteristics was performed to describe the study subjects. Categorical data are presented as percentages. Regarding continuous variables, the mean and standard deviation (SD) are presented in the case of a normal distribution, and the median and interquartile range (IQR) are presented in the case of a nonnormal distribution. Log transformation was performed on AST and ALT due to their nonnormal distribution, and the linear assumption was violated. The Breusch–Pagan test was utilized to assess homoscedasticity. Linear regression analysis was used to identify the linear association between the TyG index and log-transformed AST and ALT. Youden’s J statistics of the ROC curve were utilized to determine the TyG cutoff point in predicting elevated AST and ALT. Then, an area under the ROC curve (AUC) was calculated. Logistic regression analysis was used to determine the association between elevated aminotransferase and the TyG index. Furthermore, multivariable analysis was employed to estimate the adjusted odds ratio (OR) and 95% confidence interval (CI). All statistical tests were two-sided, and a Table P < 0.001) in comparison with AST . Finally, Table The median for ALT was 20, 24, 28, and 34 for TyG index quartiles 1 to 4, respectively. The median AST increased from 23 to 27 for the first and fourth TyG index quartiles . A dose‒response relationship was observed between elevated aminotransferases and TyG index quartiles. After using the cut point of the ROC curve analysis to determine the high TyG index (> 8.93 for AST and > 8.84 for ALT) and low TyG index for AST and ALT, a high TyG index was associated with elevated AST and ALT . A high TyG index was also associated with elevated AST and ALT in all sexes and age groups, as shown in Table P < 0.001 for both).Table Supplementary Fig. In the present study, 232,235 RTA personnel aged 35–60 were enrolled nationwide. Previously, some studies in China demonstrated the association between the TyG index and liver function parameters among a healthy obese population , 14. HowThe TyG index was found to reveal a dose‒response relationship with aminotransferases, particularly ALT. Similar to our study, a study in China identified a linear dose‒response relationship between the TyG index and ALT of 1.22 IU for every 1-unit increase in the TyG index . The relSeveral cardiometabolic risk factors and insulin resistance were also found to be associated with aminotransferases –20. TherIn the current study, TyG index thresholds of 8.89 and 8.57 for males and females, respectively, were developed to identify individuals with elevated ALT. The cut points and ability to predict elevated ALT were similar to those in another related Chinese study. However, their cut points for males were lower than those for females: 8.69 for males (sensitivity 70.2% and specificity 56.2%) and 8.96 for females (sensitivity 52.9% and specificity 70.1%) . Their cSex discrepancies were observed in the present study. A higher dose‒response relationship between the TyG index and ALT was observed among females than among males. The sex-related difference in fat distribution might explain the relationship. While females had higher total body fat compared to males, males had higher values for waist girth and visceral adipose tissue , 30. MorDifferences in the relationship between the TyG index and aminotransferase were also observed between the different age groups. The prevalence of elevated ALT was shown to decrease in the higher age group. The reduction in prevalence in older age groups may be due to a reduction in ALT as we age . A few pSeveral cohort studies among the Chinese also indicated a strong association between the TyG index and NAFLD in those aged < 40 years, in both the diabetes and nondiabetes populations , 38. In Elevated aminotransferases are associated with NAFLD and insulin resistance , 42, 43.The present study encompassed a substantial number of strengths, enrolling a large, representative sample of RTA personnel nationwide. The study provided valuable insights into the relationship between the TyG index and aminotransferase as well as the prevalence of elevated aminotransferase in each TyG index quartile in Thailand. Furthermore, future strategies for the primary prevention of NAFLD and elevated aminotransferases may benefit from these findings.Our research encountered several limitations. First, the study employed a serial cross-sectional design in which the TyG index and aminotransferase were measured concurrently. Consequently, a causal relationship between the TyG index and elevated aminotransferase was not established. Second, the present study was conducted among RTA personnel, with a higher percentage of male participants (roughly 90%). Nevertheless, the results reflected an actual scenario in the study population. Third, due to the observational study using previously collected data from the health examination database, behavioral risk variables were collected very crudely. For instance, the total number of alcoholic drinks, the total number of cigarettes, and exercise intensity were not recorded. Finally, the data on infections such as viral hepatitis B and the drug usage of participants, which could alter the aminotransferase, were limited. Further adjustments for additional confounders and a meta-analysis are required to determine whether the TyG index can be utilized as a simple screening tool in medical practice.Our data revealed that elevated aminotransferases are a common health concern, particularly among males, participants aged 35–44, and those with a high TyG index. We also indicated the association between the TyG index and aminotransferase, showing that the TyG index is a novel risk factor for elevated aminotransferase in the RTA population.Additional file 1: Figure S1. ROC analysis of the triglyceride-glucose (TyG) index for predicting elevated alanine aminotransferase (ALT): a) overall; b) males; c) females; d) age group 35–44 years; e) age group 45–54 years; f) age group 55–60 years. Figure S2. Overall ROC analysis of the triglyceride-glucose (TyG) index for predicting elevated aspartate aminotransferase (AST).


Elevated serum uric acid (SUA) is regarded as a risk factor for the development of cardiovascular diseases. Triglyceride-glucose (TyG) index, a novel surrogate for insulin resistance (IR), has been proven to be an independent predictor for adverse cardiac events. However, no study has specifically focused on the interaction between the two metabolic risk factors. Whether combining the TyG index and SUA could achieve more accurate prognostic prediction in patients undergoing coronary artery bypass grafting (CABG) remains unknown.2 likelihood ratio test.This was a multicenter, retrospective cohort study. A total of 1225 patients who underwent CABG were included in the final analysis. The patients were grouped based on the cut-off value of the TyG index and the sex-specific criteria of hyperuricemia (HUA). Cox regression analysis was conducted. The interaction between the TyG index and SUA was estimated using relative excess risk due to interaction (RERI), attributable proportion (AP), and synergy index (SI). The improvement of model performance yielded by the inclusion of the TyG index and SUA was examined by C-statistics, net reclassification improvement (NRI) and integrated discrimination improvement (IDI). The goodness-of-fit of models was evaluated using the Akaike information criterion (AIC), Bayesian information criterion (BIC) and χP < 0.001; Cox regression: HR = 4.10; 95% CI 2.80–6.00, P < 0.001). A significant synergistic interaction was found between the TyG index and SUA . The addition of the TyG index and SUA yielded a significant improvement in prognostic prediction and model fit [change in C-statistic: 0.038, P < 0.001; continuous NRI (95% CI): 0.336 (0.201–0.471), P < 0.001; IDI (95% CI): 0.031 (0.019–0.044), P < 0.001; AIC: 3534.29; BIC: 3616.45; likelihood ratio test: P < 0.001).During follow-up, 263 patients developed major adverse cardiovascular events (MACE). The independent and joint associations of the TyG index and SUA with adverse events were significant. Patients with higher TyG index and HUA were at higher risk of MACE (Kaplan–Meier analysis: log-rank The TyG index interacts synergistically with SUA to increase the risk of MACE in patients undergoing CABG, which emphasizes the need to use both measures concurrently when assessing cardiovascular risk.The online version contains supplementary material available at 10.1186/s12933-023-01838-z. Coronary heart disease (CHD) is the leading cause of death, constituting an increasing public health burden worldwide , 2. CoroPrevious studies have shown that patients with diabetes mellitus (DM) derive more benefit from CABG than those without DM –9, and aThe triglyceride-glucose (TyG) index has recently been regarded as a reliable indicator of IR, which is more economical and convenient than traditional assessment methods and shows a high degree of consistency with the hyperinsulinemic-euglycemic clamp –15. AmonSerum uric acid (SUA) homeostasis depends on its production, excretion and reabsorption . MultiplHowever, the prognostic value of the TyG index and SUA in patients after CABG remains unclear so far. Moreover, no study has focused on the synergistic effect of the TyG index and SUA on the prediction of adverse cardiovascular events after CABG. In the present study, we sought to investigate the prognostic value of the TyG index and SUA in patients undergoing CABG and further evaluated the synergistic effect of the two indicators.The study was approved by the Ethics Review Committee of Shandong Provincial Hospital, The Second Hospital of Shandong University and Qilu Hospital of Shandong University and was carried out in compliance with the Helsinki Declaration. The patients provided verbal informed consent allowing the retrospective use of their anonymized data for health-related research, which was allowed by the Ethics Committee.This multicenter retrospective cohort study included past-CABG patients from 3 tertiary public hospitals . From June 2014 to June 2018, 1665 consecutive patients who underwent CABG were screened. Among them, 270 were excluded due to concomitant surgery , 3 were excluded because of the history of CABG, 3 were excluded because of taking urate-lowering drugs, 11 were excluded because of suspected familial hypertriglyceridemia (triglyceride ≥ 5.65 mmol/L), and 13 were excluded due to missing data of SUA or data for TyG index calculation. A total of 1365 patients met all inclusion criteria and were followed up by telephone from July 2022 to November 2022. Finally, 1225 (89.7%) patients completed the telephone survey and were enrolled for the final analysis  = 175 × SCr (mg/dL)−1.234 × age (year)−0.179 × 0.79    .2 likelihood ratio test was performed.To investigate the joint predictive value of the TyG index and SUA on MACE, we divided the patients into four groups: Group 1: TyG ≤ 8.87 and Non-HUA, Group 2: TyG > 8.87 and Non-HUA, Group 3: TyG ≤ 8.87 and HUA, and Group 4: TyG > 8.87 and HUA. Corresponding Kaplan–Meier curves were generated followed by the log-rank test. The joint predictive value was further analyzed via the fully adjusted Cox regression model. To test the interaction between the TyG index and SUA, we calculated relative excess risk due to interaction (RERI), attributable proportion (AP), and synergy index (SI), as previously documented –33. The The ROC curve analysis showed that the optimal cut-off value of the TyG index for predicting MACE was 8.87, based on the maximum value of the Youden Index . Meanwhile, compared to patients without HUA, those with HUA exhibited a higher MACE risk .In our study cohort , MACE occurred in 263 (21.5%) patients . The first occurrence of MACE included 82 (6.7%) all-cause death [53 died from cardiac causes and 29 died from other causes], 70 (5.7%) non-fatal MI, 66 (5.4%) non-fatal stroke and 45 (3.7%) repeat revascularization. Kaplan–Meier survival curves were drawn according to the cut-off value of the TyG index and HUA .Patients were divided into four groups according to the cut-off value of the TyG index and the sex-specific criteria of HUA. Kaplan–Meier analysis was performed to compare the risk of MACE among the four groups Fig. . ResultsP < 0.001). The result remained significant in multivariable-adjusted analysis. The adjusted HR for MACE was 4.10 (95% CI 2.80–6.00) in patients with TyG index above the cut-off value and HUA, compared to individuals in Group 1  of cardiac death: 6.07 (2.66–13.85), P < 0.001)]  of all-cause death: 5.10 (2.66–9.79), Sensitivity analysis was performed after exclusion of patients with renal insufficiency or individuals receiving lipid-lowering or hypoglycemic treatment at admission, which showed that our results were robust : 0.195 (0.134–0.257), P < 0.001] : 0.141 0.021–0.260), 0, P = 0.As shown in Table Based on our analysis, we have the following main findings: (1) Both the TyG index and SUA were independent prognostic factors for post-CABG patients. (2) Patients who had concurrent high TyG index and HUA had the greatest risk of MACE compared to those with neither risk factor elevated. (3) The TyG index and SUA synergistically increased the risk of incident MACE in patients after CABG.Several studies have investigated the relationship between IR and adverse cardiovascular events after revascularization –36. In tWhether the SUA is an independent risk factor for adverse cardiovascular events is still controversial . StudiesTo the best of our knowledge, the current study provided the first proof of the synergistic effect between the TyG index and SUA in increasing the risk of MACE. We use the additive model to perform interaction analysis, which is suitable for biological and etiological investigations , 48. DesThe ability of the TyG index to improve model performance was found in previous studies , 59, butTo rule out the influence of lipid-lowering or hypoglycemic treatment on the calculation of the TyG index, data were reanalyzed after excluding patients taking lipid-lowering or hypoglycemic drugs. We further excluded individuals with renal insufficiency, which can substantially influence the SUA level. We also explored the joint association of the TyG index and SUA with MACE among different subgroups. The results did not change significantly in sensitivity analysis and subgroup analysis, indicating that the predictive value of the TyG index and SUA for MACE was applicable to almost all populations.This study has several limitations. First, although this is a multicenter cohort study, the retrospective design and its inherent limitations cannot be avoided. Second, several variables associated with post-CABG adverse events were not included in the regression model, such as admission type, clinical syndrome, pre-operative co-morbidity and pre-operative risk. In addition, although multiple variables associated with the progression of atherosclerosis were adjusted, we did not adjust for several variables affecting graft failure and further driving the occurrence of repeat revascularization. Therefore, no statement can be made whether the association of the TyG index and SUA with MACE was independent of these risk factors. Third, repeat revascularization was difficult to assess though it was explicitly defined and confirmed by carefully reviewing the corresponding medical records. Fourth, the HbA1c levels were not measured and data for the Society of Thoracic Surgeons (STS) risk score and Syntax score calculation were not available in most patients. Finally, our study population had a low rate of therapeutic intervention for uric acid and diabetes, which limited the generalization of results to other populations. Further prospective studies among populations with a higher therapeutic intervention rate could address the limitations of this study and confirm our findings.In conclusion, the results emerging from our study revealed the prognostic value of the TyG index and SUA in patients who underwent CABG. Furthermore, our data provided novel information on the synergistic interaction between the TyG index and SUA. The combination of the TyG index and SUA could be proposed as a useful prognostic indicator in post-CABG patients.Additional file 1: Table S1. ROC curve analysis determined optimal cut-off value of the TyG index for predicting MACE. Table S2. Univariate Cox regression analysis for MACE. Table S3. HR for variables in the multivariate Cox regression analysis. Table S4. Joint association of TyG index and SUA with all-cause death and cardiac death. Table S5. Sensitivity analysis for the joint association of the TyG index and SUA with MACE. Table S6. Synergistic interaction between the TyG index and SUA in patients with and without DM/obesity.


Soil salinization poses a worldwide challenge that hampers agricultural productivity.Employing high-throughput sequencing technology, we conducted an investigation to examine the impact of compost on the diversity of bacterial communities in saline soils. Our study focused on exploring the diversity of bacterial communities in the inter-root soil of plants following composting and the subsequent addition of compost to saline soils.Flavobacterium, Saccharomonospora, Luteimonas and Streptomyces. Proteobacteria, Firmicutes, and Actinobacteria were the dominant phyla in the soil after the addition of compost. The application of compost has increased the abundance of Actinobacteria and Chloroflexi by 7.6 and 6.6%, respectively, but decreased the abundance of Firmicutes from 25.12 to 18.77%. Redundancy analysis revealed that soil factors pH, solid urease, organic matter, and total nitrogen were closely related to bacterial communities.Compared to the initial composting stage, Alpha diversity results showed a greater diversity of bacteria during the rot stage. The germination index reaches 90% and the compost reaches maturity. The main bacterial genera in compost maturation stage are The addition of compost effectively reduced soil pH and increased soil enzyme activity and organic matter content. An analysis of this study provides theoretical support for compost’s use as a saline soil amendment. Saline land refers to soil with high levels of salinity and alkalinity, which are harmful to plant growth and agricultural production . Soil saComposting is an effective biological method to improve soil texture and crop yields . Waste iAs a key component of soil ecosystems, microorganisms are widely considered important indicators of soil quality . Soil miThe utilization of high-throughput sequencing (HTS) technology has proven to be an efficient method for detecting alterations within microbial communities. This technology is extensively employed in the examination of intricate microbial communities inhabiting soil across various habitats. Therefore, in this study, we performed composting and potting experiments and hypothesized that compost addition could improve saline soils by changing the soil microenvironment. The aim of this study was to examine the influence of different levels of saline-alkali soil on bacterial communities throughout the composting process, employing high-throughput sequencing. Moreover, the primary objective of this study was to evaluate the efficacy of compost application in augmenting plant growth and ameliorating soil quality. Additionally, the study aimed to investigate the impact of compost application on the composition of bacterial communities in saline soils, along with their correlation with environmental factors.−1, total carbon: 7.02 g kg−1, SOM: 2.84 g kg−1, pH: 10.74, and electrical conductivity (EC): 1.36 dS m−1 , were prepared by Jiangsu Guoxin Xielian Energy Co. Using a 2-mm sieve, the saline soils were mixed evenly after air-drying. The experimental crop was radish (Fengguang Generation), and the experiment began in the laboratory in January 2022. Sheep manure and corn straw were purchased separately from the market. Saline soils had the following initial properties: total nitrogen (TN): 1.39 g kg6 dS m−1 .The reactor for composting was a 75-cm × 55-cm × 60-cm polypropylene plastic box with a total reactor volume of 247.5 L. During composting, porous sieve plates were placed 10 cm from the bottom of the plastic box. Aeration was maintained throughout the composting process at 0.2 L/(L min). Three different proportions of saline soil were used in the composting process  mixed mechanically with straw and sheep manure. The total mass and volume of saline soil, sheep manure and straw in each reactor were 32 kg and 240 L. We mixed sheep manure with corn straw in a ratio of 1:2 by dry weight, with a C/N of approximately 25. Composting was adjusted at 60% soil moisture content SMC; . The matPot experiments were conducted using control (CK) and three treatments , with four replicates per treatment, obtaining a total of 16 pots. Each pot, measuring 19 cm in diameter and 17 cm in depth, was filled with 0.8 kg of substrate and subsequently planted with a total of 20 radishes. The substrate consisted of saline soil and compost . For CK, no compost was added to the saline soil; for AP, MA compost product was added; for BP, MB compost product was added; and for CP, MC compost product was added. The pots were irrigated by hand until they reached 60% of their water holding capacity. In addition, roots are collected from potted plants, soil is stripped, and ~1 mm of soil is left around the roots. Subsequently, ~1 mm of soil was washed away in the PBS buffer, and 4 composite samples were prepared from each group of treated soil. The collected soil samples were subsequently partitioned into two segments: one segment was preserved at a temperature of 4°C for physicochemical analysis, while the other segment was preserved at a temperature of −80°C for microbial analysis.The pH of all fresh soil samples was determined by air-drying, grinding, and passing them through a 2-mm sieve; temperature (T); EC; and SMC, TN, sodium (Na), solid catalase (SCAT), and SOM contents. A fully automatic Kjeldahl nitrogen tester  was used to determine the TN content of the soil. The pH and electrical conductivity (EC) were determined by employing a pH electrode  and an EC indicator , respectively. The measurement of SOM content was conducted through the utilization of the muffle furnace scorch method, while the determination of soil potassium (K) and sodium (Na) contents was carried out using a flame photometer FP640; . Soil enThe Power Soil DNA extraction kit  was employed to extract the complete genetic DNA from compost and potted soil samples. Compost and potting soil samples in triplicate and then combined. The quality and quantity of extracted DNA was assessed using the NanoDrop 1000 spectrophotometer . The polymerase chain reaction (PCR) was conducted using TransGen AP221-02: TransStart Fastpfu DNA polymerase (20 μL) along with 0.8 μL (5 μM) of both forward and reverse primers, 10 ng of template, 4 μL of buffer (5×), 2 μL of deoxynucleoside triphosphates (2.5 mM), 0.4 μL of polymerase, and 0.2 μL of bovine serum albumin. After detection on 2% (w/v) agarose gel, the final amplicon was quantified using the AxyPrep DNA gel extraction kit . Using the Yili MiSeq platform, the same amount of purified amplicon was collected at Alway Gene  for follow-up sequencing. The region of the bacterial 16S rRNA gene, specifically 338F_806R, was amplified using primers 338F (5-ACTCCTACGGGAGGCAGCAG-3) and 806R  splicing. This involved initially conducting QC procedures and subsequently filtering the double-ended reads based on sequencing quality. Additionally, the splicing process was carried out by considering the overlapping relationship between the double-ended reads. The optimized data underwent processing utilizing sequence noise reduction techniques, such as DADA2/Deblur, in order to acquire representative sequences and abundance information for amplicon sequence variants (ASVs). Using ASV representative sequences and abundance information, various statistical and visual analyses can be conducted, encompassing species taxonomy, community diversity, species dissimilarity, correlation, phylogenetic, and functional prediction analyses.For the multivariate statistical analysis , SPSS version 19.0 was used. A significance threshold of 0.05 was used to determine statistical significance. Data were collected in four replicates and subjected to analysis of variance (ANOVA). Principal component analysis (PCA) was employed to evaluate variations in bacterial and fungal communities, as well as their transformations throughout the composting process. The application of redundancy analysis (RDA) unveiled the correlation between environmental factors and the manifold alterations in bacterial community composition . The R hThe temperature, pH, soil moisture content (SMC), and germination rates of the compost were assessed at various time points. It was observed that temperature played a crucial role in influencing the decomposition of organic matter and microbial activity throughout the composting process. SMC was also monitored at different times. MA had the highest average SMC of 69%, followed by MB with 62%, and the overall SMC reached >50% . In the Cellvibrio, Pedobacter, Devosia, Planococcus, Planococcus, and Microbacterium were the dominant genera. The findings of this study align with the outcomes of a prior investigation pertaining to the fluctuations in bacterial community dynamics throughout the composting process of distilled grain waste , there was a significant increase in the abundance of the Pedobacter genus, which emerged as the predominant genera, constituting 25.2, 22, and 17.56%, respectively, of the overall bacterial community  were compared. ANOVA revealed significant changes in bacterial alpha-diversity at different stages of composting ,D,F. TheThe diversity of bacterial communities is of utmost importance in soil ecosystems, as it is crucial for understanding the structural characteristics of microbial communities . The curThe effects of different proportions of compost products mixed with saline–alkali soil on microbial community diversity in plant rhizosphere soil were studied via PCA based on the bacterial level . The finCanonical correspondence analysis (CCA) was employed to investigate the correlation between the diversity of bacterial communities and the physicochemical characteristics of soil in the inter-rhizosphere soil of plants subsequent to the application of compost products in saline soils refer to Soil enzymes play a crucial role in assessing soil fertility and are actively engaged in the cycling and transformation of soil nutrients, thereby serving as indirect indicators of microbial activity . The impThis study showed that composting with different proportions of raw materials produced mature end-products and altered the bacterial community succession. This study additionally examined the impacts of incorporating compost as a soil amendment on the fertility and microbial diversity of saline soils. The findings from 16S RNA amplicon sequencing revealed that Proteobacteria, Firmicutes, Actinobacteria, and Chloroflexi were the prevailing bacterial taxa in saline soils. RDA results indicated that pH, TN, organic matter, and soil enzymes were the key parameters affecting the bacterial community. These findings may provide new ideas for compost as a bioamendment for saline soils.The Illumina sequences were deposited in the NCBI Sequence Read Archive (accession numbers SRR24001333–SRR24001347 for the rhizosphere soil bacteria of potted 16S rRNA gene data and SRR24031951– SRR24031993 for the compost rhizosphere soil 16S rRNA gene data).DX: Writing – original draft. XY: Methodology, Writing – review & editing. JinC: Methodology, Visualization, Writing – review & editing. XL: Formal analysis, Methodology, Software, Writing – review & editing. JiaC: Conceptualization, Supervision, Writing – review & editing. JL: Conceptualization, Supervision, Writing – review & editing.


Bleeding is one of the common adverse events of endoscopic retrograde cholangiopancreatography (ERCP), which is mainly caused by endoscopic sphincterotomy (EST). At present, it remains unclear whether proton pump inhibitor (PPI) should be used to prevent post-EST bleeding. Therefore, we performed a randomized controlled trial to investigate whether PPI is effective in the prevention of post-EST delayed bleeding.Consecutive eligible patients were randomly assigned (1:1) to experimental group (PPI group) or control group . The patients in PPI group received intravenous esomeprazole 40  mg and normal saline 100  mL every 12  h for 2  days after ERCP immediately, and followed by oral esomeprazole (Nexium) 20  mg once a day for 7  days. Correspondingly, patients in the control group received intravenous normal saline 100  mL and did not take PPIs or any acid-suppressing drugs during hospitalization and after discharge. All patients were followed up for 30  days after ERCP. The primary endpoint was the incidence and severity of post-EST delayed bleeding.n = 146) or NS group (n = 144). 5 patients from each group were excluded from the final analysis. There were 6 patients with post-EST delayed bleeding, with an incidence rate of 2.14%. The median time of delayed bleeding was 2.5  days after ERCP. 3 cases  occurred in the PPI group, with 1 case of mild and 2 cases of moderate bleeding. 3 cases  occurred in the NS group, with 2 cases of mild and 1 case of moderate bleeding. There was no significant difference in the incidence and the severity of post-EST delayed bleeding between the two groups (p = 1.000).Between July 2020 and July 2022, 290 patients were randomly assigned to PPI group (Prophylactic use of PPI after EST does not reduce the incidence and severity of post-EST delayed bleeding in patients.https://www.chictr.org.cn/searchproj.aspx, identifier ChiCTR2000034697. Since first described in 1974, endoscopic sphincterotomy (EST) has become a standard procedure of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and was widely used in the treatment of pancreaticobiliary diseases. Previous literature has pointed out that bleeding is a severe adverse event after ERCP, and usually occurs after EST . DelayedAt present, the role of PPI in preventing post-EST bleeding remains unclear. Therefore, this prospective randomized controlled trial aimed to investigate the effect of PPI in the prevention of post-EST bleeding, and to determine whether patients need to use PPI to prevent post-EST bleeding.The patients who underwent ERCP procedure for the first time in the First Affiliated Hospital of Nanchang University between July 2020 and July 2022 were immediately recruited, and evaluated for clinical trial inclusion. Inclusion criteria: (1) patients who signed informed consent, (2) patients aged between 18 from 80 years, and (3) EST was performed during ERCP. If immediate bleeding occurs during ERCP, complete intraoperative hemostasis is performed so that there is no active bleeding after operation until enrollment. Exclusion criteria: (1) patients with severe hepatic insufficiency (Child-Pugh class B or C), (2) patients with severe renal insufficiency: endogenous creatinine clearance <50 mL/min, (3) patients with coagulation disorders: platelets <100 × 10^9/L, prothrombin time (PT) prolonged by more than 3 s, international normalized ratio (INR) >1.5, activated partial thromboplastin time (APTT) >1.5 times the upper limit of normal, (4) patients with peptic ulcer bleeding or gastrointestinal bleeding caused by the following causes: esophageal varices, reflux esophagitis, Mallory-Weiss syndrome, Dieulafoy disease, colon disease, small intestine disease or distal gastric ulcer after gastrectomy, (5) patients with acute pancreatitis before ERCP, (6) patients requiring anticoagulation and antiplatelet agents within 7 days before the study, (7) patients with active cardiovascular and cerebrovascular disease, (8) pregnant or breastfeeding women, (9) known or suspected allergy to any PPI, (10) patients enrolled in any study involving an investigational agent within 30 days prior to this study, and (11) patients using acid suppressive agents within 24 h before enrollment. Termination test criteria: (1) patients have adverse drug events and (2) patients request to withdraw from the trial. This study has been approved by the Ethics Committee of the First Affiliated Hospital of Nanchang University, and registered at the Clinical Trials Registration site in China (No. ChiCTR2000034697).This study is a prospective, randomized, controlled clinical trial study, and two groups were established, namely the experimental group (PPI group) and the control group . According to previous literatures, the incidence of post-EST bleeding is ranged from 0.3 to 2.0% , 7. It iERCP was performed using the JF260V or TJF260V electronic duodenoscope and related accessories manufactured by OLYMPUS Company, Japan. For patients who were considered to be at high risk for PEP, we administered 100 mg rectal diclofenac suppositories immediately before the procedure. The patients were placed in the prone position during the operation, deeply anesthetized with propofol. During the procedure, oxygen inhalation and ECG monitoring were given. All the patients received EST treatment and were observed after EST to determine whether there was immediate bleeding. Those with minor bleeding that stopped spontaneously within a few minutes of observation need no special treatment. Patients with severe bleeding which could not ceased spontaneously were treated with ice saline rinsing, endoscopic spraying of 1:10000 ice norepinephrine saline, balloon compression or titanium clip closure according to the situation until there was no bleeding. All patients were operated by experienced endoscopists and were given routine post-ERCP care such as fasting for 24 h, rehydration, electrolytes and energy supplement, monitoring vital signs, etc. 3 h after ERCP, blood amylase was test and 24 h after ERCP, blood routine, liver function, blood amylase, coagulation function and other laboratory tests were reviewed. Symptoms such as abdominal pain, fever, hematemesis, melena, etc. were observed. If relevant symptoms appeared, whether it was an adverse event after ERCP was determined, and the patient was treated accordingly. If post-EST delayed bleeding was suspected, secondary endoscopic examination was performed to confirm the diagnosis, and appropriate hemostatic treatment such as fluid resuscitation, endoscopic hemostasis or blood transfusion was given according to the bleeding situation. All patients were followed up by outpatient service or telephone call at 1 week, 2 weeks and 1 month after discharge to ask whether they had any manifestation of gastrointestinal bleeding, and if delayed bleeding was suspected in discharged patients, they were re-admitted to the hospital for endoscopic examination to confirm the diagnosis.(1) Post-EST bleeding: Patients with any one of ABC plus D can be diagnosed. A: Hematemesis or blood from nasobiliary tube drainage, or bloody stool or melena after normal stool; B: hemoglobin decreased >20 g/L within 24 h (or hematocrit >6%), or blood transfusion ≥2 units within 24 h, but hemoglobin increased <10 g/L (or hematocrit <3%); C: circulatory instability, systolic blood pressure ≤ 90 mmHg or pulse ≥110 beats per minute (reappears after circulatory stability); D: Endoscopy is clearly defined as bleeding after EST , (2) ClaThe primary endpoint is the incidence of post-EST delayed bleeding within 30 days. The secondary endpoints include (1) severity of post-EST delayed bleeding within 30 days, (2) percentage of patients requiring interventional or surgical treatment within 30 days, and (3) percentage of patients requiring blood transfusion within 30 days. Other indicators are adverse events except bleeding, mainly including PEP, biliary tract infection, perforation and death.(1) Patients’ basic conditions, past history, personal history, clinical symptoms and preoperative diagnosis, (2) laboratory test results before and after ERCP, (3) endoscopic findings and endoscopic procedures performed during ERCP, (4) the incidence and severity of post-EST delayed bleeding, and (5) other adverse events after ERCP.t test or nonparametric test. p < 0.05 was considered statistically significant.The statistical analysis was performed using SPSS 25.0 software. Categorical variables data were presented as percentages (%), and the Chi-square test or Fisher exact test was used for analysis. Continuous variables data were expressed as mean ± standard deviation or median (25th–75th percentiles) where appropriate, and compared by student A total of 290 patients who met the criteria were randomly assigned according to the random number method. 146 patients were assigned to PPI group, of which 5 patients were excluded due to loss of follow-up, and finally a total of 141 patients in PPI group were included in the analysis. 144 patients were assigned to NS group, of which 2 patients were diagnosed with gastric ulcers during ERCP and required acid-suppressive medication so they were withdrawn from the clinical trial, and 3 patients were excluded because of loss of follow-up. Finally, a total of 139 patients in NS group were included in the analysis . In thisp = 0.043). There were no significant differences in other laboratory tests such as blood routine examination, liver and kidney function between the two groups both before and after ERCP (p > 0.05) (The pre-ERCP laboratory test results of the two groups were compared. Prothrombin time (PT) in the two groups was within the normal range, although the PPI group had a shorter PT than the NS group ( > 0.05) .p > 0.05). All the immediate bleeding was stopped after successful endoscopic treatment before the end of ERCP. There were no significant differences between the two groups in terms of stone numbers, maximum diameter of stones, stone extraction methods, size of sphincterotomy incision, precut sphincterotomy, biliary duct dilatation method, the type of stent and so on (p > 0.05)  had immediate bleeding during the EST procedure, and 5 cases (3.6%) in the normal saline group, with no statistical difference between the two groups ( > 0.05) .p = 1.000). All the bleeding were stopped after endoscopic treatment, and no patients underwent vascular embolization or surgical treatment, and no deaths occurred. We followed up all patients in this study by telephone or outpatient visit at the 1st week, 2nd week and 1st month after ERCP, and no patient presented with upper gastrointestinal bleeding such as hematemesis or melena.Among all 280 patients eventually enrolled, a total of 6 patients had post-EST delayed bleeding, with the incidence of 2.14%, and the median occurrence time of delayed bleeding was 2.5 days after EST. Among them, 3 cases of delayed bleeding  were from the PPI group, of which one case had mild bleeding, manifested as melena within 24 h after ERCP, and the hemoglobin decreased by more than 3 g/dL compared with the pre-ERCP period, with no indication for blood transfusion. Another 2 cases had moderate bleeding, of which one patient vomited blood within 72 h after ERCP, and the other patient had melena on the 5th day after ERCP. Neither of them had the indication for blood transfusion. Another 3 cases of delayed bleeding  were from the NS group, of which 2 cases were mild, and one case was moderate, all of which were manifested as melena within 72 h after ERCP. All the patients with post-EST delayed bleeding had successful endoscopic treatment , and theAmong the 280 patients, the total incidence of post-ERCP adverse events rate was 11.79% (33/280), with no statistical difference between the PPI group  and the NS group . Besides post-EST bleeding, there were 22 cases of PEP (1.43%), 4 cases of biliary infection (1.43%), and 1 case of gastrointestinal perforation (0.36%) occurred. There was no significant difference in the incidence of adverse events between the two groups. There were no deaths in either group . In thisWith the development of ERCP technology, EST has been continuously improved since it was introduced in 1974. At present, bleeding is still one of the serious adverse events of EST that cannot be ignored. It is well known that proton pump inhibitor (PPI) plays a significant role in the prevention and treatment of upper gastrointestinal bleeding , 16. HowIn our study, the overall incidence of post-EST bleeding was 2.14% (6/280), of which 5 cases (83.3%) of bleeding occurred within 72 h after ERCP, the other one occurred on the 5th day after ERCP, and the median time of delayed bleeding was 2.5 days after EST, which was consistent with previous reports . Bleedinp = 1.000), which indicated that PPI has no significant effect on preventing post-EST delayed bleeding. It is well known that the mechanism of PPI in the prevention and treatment of upper gastrointestinal bleeding is to inhibit the secretion of gastric acid and increasing the intragastric pH level so as to prevent the dissolution of blood clots, and promote platelet aggregation and plasma coagulation so that the hemostatic effect works  with post-EST delayed bleeding in this study required blood transfusion. The remaining bleeding patients did not meet the indications for blood transfusion. There was no significant difference in the incidence and severity of post-EST delayed bleeding between the two groups . All the immediate bleeding were also completely stopped during ERCP. Therefore, the potential contribution of post-EST immediate bleeding on delayed bleeding was equally distributed between the two groups. Second, in the research of Leung , the project of the Jiangxi Department of Science and Technology (No. 20202BBGL73109), the project of the Health and Family Planning Commission of Jiangxi Province (No. 202310285), and Jiangxi Postgraduate Innovation Special Fund Project (YC2021-S192).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Borrelia burgdorferi s.l. from ticks to humans. Climate affects tick abundance, and climate change is projected to promote shifts in abundance in Europe, potentially increasing human exposure. We analyzed serum samples collected between the years 2014–2019 from German National Cohort (NAKO) participants at four study sites  for immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies using an enzyme‐linked immunosorbent assay (ELISA) and line blot immunoassay as confirmatory test for positive and equivocal ELISA samples. We reported crude and weighted seropositivity proportions for local estimates. We used mixed model analysis to investigate associated factors, such as age, sex, migration background, or animal contacts. We determined the serostatus of 14,207 participants. The weighted seropositivity proportions were 3.4% (IgG) and 0.4% (IgM) in Augsburg, 4.1% (IgG) and 0.6% (IgM) in northern Berlin, 3.0% (IgG) and 0.9% (IgM) in Hanover, and 2.7% (IgG) and 0.6% (IgM) in Münster. We found higher odds for IgG seropositivity with advancing age (p < 0.001), among males compared to females (p < 0.001) and reduced odds among participants with migration background compared to those without (p = 0.001). We did not find evidence for an association between serostatus and depression, children within the household, or animal contact, respectively. We found low seropositivity proportions and indications of differences across the study locations, although between-group comparisons did not yield significant results. Comparisons to earlier research are subject to important limitations; however, our results indicate no major increases in seropositivity over time. Nevertheless, monitoring of seropositivity remains critical in light of potential climate-related Borrelia exposure.Lyme borreliosis (LB) is caused by the transmission of  Borrelia burgdorferi sensu lato (B. burgdorferi s.l.). Climatic factors affect the geographical spread of Ixodes ricinus (I. ricinus), the primary vector of B. burgdorferi s.l. in Europe1. Due to climate change-related temperature increases and humidity alterations, I. ricinus expanded its territory while also showing prolonged seasonal activity2, implying an increased potential risk for human exposure to ticks.In Europe, Lyme borreliosis (LB) is the most frequent tick-borne disease caused by 3. However, LB is a notifiable disease in selected, but not all European countries4. In Germany, LB is partially notifiable in nine of sixteen federal states; notification data from these states indicate a varying but steady incidence by region for the years 2013–2017, ranging from 26 to 41 cases per 100,000 persons5, while nation-wide health insurance data from 2019 indicated an incidence of 179 cases of LB per 100,000 insured persons in Germany6.Especially in central and northern Europe, reported LB cases have increased within the past two decades7, and in Bonn in Western Germany (2018–2020)8, respectively, found no increases in seropositivity proportions compared to earlier investigations 9, despite increases in tick density in at least one German region (Siebengebirge near Bonn). The data for Hanover is included in this work with a different research focus.Two recent local serological surveys conducted in Hanover, Northern Germany (2014–2018)B. burgdorferi s.l. among the general population of four different regions in Germany based on a nation-wide population-based cohort study  with—for the first time—high accuracy due to large sample size; (2) to compare seropositivity using identical age- and sex population weights; and (3) to investigate risk factors for seropositivity across regions. The data create a base for future comparisons regarding potentially increasing human B. burgdorferi s.l. exposure and enable investigations of seroconversion and –reversion within a large and ongoing cohort.Our work aims (1) to estimate the local seropositivity proportion of antibodies against 10. All potential NAKO-participants were randomly drawn from population registries. Subjects were eligible for participation when aged between 20 and 69 years at sampling date, provided written informed consent, had their primary residence within a regionally limited catchment area corresponding to the responsible NAKO study site, and were of sufficient health for study participation on site. Participants aged 40 years and above were oversampled. Detailed information is provided by Peters et al.10. All participants provided written informed consent. In our investigation, we randomly selected baseline serological samples from the urbanized sites Augsburg, Berlin North, Münster, and used all eligible samples from Hanover. The Hanover data were reported before7 with a different research focus. We performed stratified random sampling for the three other study sites after restricting to those with: available data for risk factor evaluation (if possible), focusing on a target distribution of 50% males and a distribution of age groups corresponding to the original NAKO recruitment, i.e., an oversampling of the age groups ≥ 40 years.The German National Cohort (NAKO) is a prospective population-based cohort study with 205,415 baseline participants examined across 18 study sitesB. burgdorferi s.l. antibodies using an enzyme‐linked immunosorbent assay (ELISA). Positive and equivocal ELISA samples underwent line blot immunoassay for confirmation  screened all samples for immunoglobulin G (IgG) and immunoglobulin M (IgM) 9. We classified each sample for IgG and IgM serostatus based on these two schemes. To estimate general population seropositivity, we weighted our sample with the respective local age and sex distribution based on the 2020 update of the 2011 census (www.destatis.de). For comparison with earlier estimates, we additionally weighted by the age- and sex distributions of the underlying study populations of the German National Health Interview and Examination Survey 1998  and the German Health Interview and Examination Survey for Adults 9. Due to low total number of IgM-positive samples, we restricted further analyses to IgG antibodies. We used the χ2-test for trend in proportions to investigate a potential seropositivity trend with age, and with increasing education level. Then, we used the χ2-test (two-sided) to test for differences in German standard-population-weighted (2020 update of the 2011 census) seropositivity proportions between the study sites, and used post-hoc pairwise comparisons between the individual centers using the Fisher’s exact test (two-sided) with Bonferroni correction.In the primary analysis, we considered a sample with positive or equivocal ELISA and positive line blot result as a seropositive . For the secondary analysis to allow comparability with two previous studies, we considered a positive ELISA sample with subsequent positive or equivocal line blot or an equivocal ELISA with a positive line blot as positive 8. Due to the indication of a potential association of seropositivity with depressive symptomatology 7, we also added depression as control variable to obtain further insight. To provide insights into potentially altered tick exposure with children living in the same household, e.g., by altered outdoor activities8, we added this variable to our models as control variable.To evaluate potential risk factors for seropositivity, we used logistic mixed model analysis, with study centers as the clusters. We constructed models to estimate odds ratios (OR) for IgG seropositivity; in model 1, as a function of sex, age, education level, migration background, depression , children within the household; in model 2, as a function of all variables from model 1 and additionally animal-related variables (having a particular pet vs. no pet) due to their restricted availability by NAKO design. We controlled for education level and migration background in our models to add additional evidence to recent conflicting findings concerning the role of socioeconomic factors concerning seropositivityWe considered a significance level of 5% to determine statistical significance. All analysis and visualization was conducted in R version 4.1.2. We used the package “survey” to apply weights, “gtsummary” to support table creation, “ggplot” for visualization, and the glmer-function from “lme4” to fit the mixed model. Finally, we used the “DHARMa”-package for further inspection of the model, e.g., residual analysis.The Bavarian Medical Association (“Bayerische Landesärztekammer”) approved all NAKO-related human examinations as the central ethics committee . Local medical associations additionally approved the examinations. Our study respects all national laws and the 1975 Declaration of Helsinki in the current version.Blood samples of 14,207 participants were available for our analysis. The participants were aged 20–74 years, with a median age of 50; 50.0% were male, 55.6% reported high education according to ISCED97, and 18.0% had a migration background. The overall crude IgG-seropositivity proportion was 3.4%.p < 0.001); however, differences were only significant when comparing the older age group 60–69  4.5–5.9%) to the younger age group 20–29  . The pairwise comparisons with Fisher's exact test did not yield significant results at the 95% significance level. Table 9.Local population-weighted point seropositivity varied by location Fig. . ParticiFrom logistic mixed-model analysis, we found that every 10-year increase in age was associated with 1.26-fold (95%-CI 1.16–1.38) the odds for IgG-seropositivity  and 2.7% in Münster (95%-CI 2.1–3.4).We conducted the largest-ever German multi-center serological survey for 9 and weighting them by age and sex for comparability to two earlier studies9 based on BGS98 and DEGS, we did not find any indication for relevant increases in seropositivity. Seropositivity in Augsburg was lower in our study when compared to BGS98  and DEGS estimates  for Bavaria. Seropositivity for Hanover was comparable with Lower-Saxony estimates in BGS98 , but lower when compared to DEGS . For northern Berlin, seropositivity was comparable to BGS98 jointly reported estimates for Brandenburg, Mecklenburg-Vorpommern, and Saxony-Anhalt . Similarly, seropositivity was comparable when comparing northern Berlin seropositivity estimates to DEGS estimates . When considering the seropositivity proportions for Münster, we found a similar seropositivity proportion compared to earlier BGS98-estimates for North Rhine-Westphalia . However, seropositivity was lower than DEGS estimates .The comparison of our findings to earlier studies is subject to critical limitations due to differences in the sampling methodology. We could not account for factors such as the degree of rurality or other living conditions. However, when classifying our samples like in11, potentially due to higher exposure to green-space areas and, therefore, ticks. Notification data from Bavaria and Berlin supports this by showing that, compared to the surrounding region, Berlin and Augsburg had lower incidences5.All four study sites recruited participants from predominantly urban areas, which may have resulted in reduced seropositivity proportion compared to earlier investigations, which included a higher proportion of rural participants. Within DEGS, participants living in municipalities with less than 5000 inhabitants had twice the chance for being seropositive compared with those with more than 100,000 inhabitants12. We did not find conclusive evidence for an association between educational level, current depression (PHQ-9 score ≥ 10), or previous or current animal contact with serostatus, respectively. Our results from multivariable modelling concerning educational level are in line with previous studies, which also found no association between socio-economic status and serostatus9, but opposes recent findings from a population-based cohort in central Bonn, in which highly educated individuals had higher chances for positive serostatus compared to individuals with medium-level education8. The conflicting findings might be explainable by the availability or use of different outdoor spare time activities in different urban regions. Additional investigations including higher proportions of participants with lower and intermediate education are required to complement this discussion. In contrast to a previous study using the original PHQ-9-scores as a proxy for depression diagnosis7, we did not find evidence for an association between serostatus and depression on a binary scale.Our results confirm advancing age and male sex as risk factors for positive antibody detection. As found in earlier studies, adults with a migration background were less likely to be seropositive11, but contrasts a previous finding12, which found higher chances for seropositivity among children living in households with any pet vs. no pet or with a cat vs. no cat, respectively.Our findings did not support an association between animal contacts and seropositivity, which is in line with earlier findings among adultsBorrelia strains between the studies hamper the comparability of seropositivity proportions of our study with previous analyses. A long-term cohort like NAKO can overcome this in the future by providing the basis for a harmonized longitudinal seropositivity analysis. The small number of seropositive individuals in the low education group and the groups of individuals with animals in the household may have resulted in low statistical power and, thus, the inability to identify a potential association in the regression models.Our work has several limitations. Most samples considered in our regression analysis originate from the study center in Hanover. Hence, our analysis is predominantly driven by this single-site data. Furthermore, the use of test kits with differing specificity, sensitivity, and considered Borrelia exposure.In conclusion, we found low seropositivity across four study locations across Germany, with minor indications of differences between sites. Our seropositivity estimates of the years 2014–2019 for four predominantly urban regions correspond to previous estimates for 1997–1999 and 2008–2011, respectively, indicating no considerable increases of seropositivity over time. However, comparisons to earlier estimates suffer from limitations. Even in urbanized regions, potential climate-change-related shifts in tick exposure may increase infections and, therefore, non-urgent follow-up may be conducted in future waves of the NAKO cohort study. Our findings underpin previously suggested risk factors for seropositivity, with advancing age and male sex as the most critical risk factors. Migration status appears as an additional factor of lower seropositivity since many persons migrating to Germany may come from countries with little or no Supplementary Information.


Multiple organ dysfunction syndrome (MODS) is common in patients with sepsistic admitted to an intensive care unit (ICU) and greatly increases mortality. Pancreatic stone protein/regenerating protein (PSP/Reg) is a type of C-type lectin protein that is overexpressed during sepsis. This study aimed to evaluate the potential involvement of PSP/Reg in MODS development in patients with sepsis.The relationship between circulating PSP/Reg levels, patient prognosis, and progression to MODS was analyzed in patients with sepsis admitted to the ICU of a general tertiary hospital. Furthermore, to examine the potential involvement of PSP/Reg in sepsis-induced MODS, a septic mouse model was established per the cecal ligation and puncture procedure, randomized into three groups, and subjected to a caudal vein injection of recombinant PSP/Reg at two different doses and phosphate-buffered saline. Survival analyses and disease severity scoring were performed to evaluate the survival status of the mice; enzyme-linked immunosorbent assays were performed to detect the levels of inflammatory factors and organ-damage markers in murine peripheral blood; terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining was performed to measure apoptosis levels in lung, heart, liver, and kidney tissue sections and to visualize the degree of organ damage in the mouse model; myeloperoxidase activity assay, immunofluorescence staining, and flow cytometry were performed to detect neutrophil infiltration levels in vital murine organs and the activation indexes of neutrophils.in vivo and in vitro, which is characterized by the increased levels of intercellular adhesion molecule 1 and CD29.Our findings indicated that Circulating PSP/Reg levels were correlated with patient prognosis and sequential organ failure assessment scores. Furthermore, PSP/Reg administration increased disease severity scores, shortened survival time, increased the TUNEL-positive staining rate, and increased the levels of inflammatory factors, organ-damage markers, and neutrophil infiltration in the organs. Neutrophils can be activated by PSP/Reg to an inflammatory state, both Patient prognosis and progression to MODS can be visualized by monitoring PSP/Reg levels upon ICU admission. Additionally, PSP/Reg administration in animal models exacerbates the inflammatory response and severity of multiorgan damage, which may be accomplished by promoting the inflammatory state of neutrophils. Sepsis was initially considered a systemic inflammatory response syndrome mediated by the release of massive amounts of inflammatory mediators; however, subsequent clinical trials targeting inflammatory suppression failed to reduce the mortality associated with sepsis . This fag, 15 min) within 30 min of the collection to get the serum, which was then stored at −80°C for subsequent analysis. The study endpoints were mortality 28 days after admission and progression to MODS 48–72 h after admission. MODS was identified when the Sequential Organ Failure Assessment (SOFA) score was ≥5 points.In the current prospective study, adult patients with sepsis admitted to the ICU of the First Affiliated Hospital of Nanchang University from September 2021 to October 2022 were included, and some patients with potential bias were excluded . ClinicaThis study was approved by the Ethics Committee of the First Affiliated Hospital of Nanchang University , and each patient signed an informed consent form prior to participation.C57BL/6 male mice aged 8–10 weeks and weighing 20–24 g were purchased from Vital River Lab Rotary  and housed under specific pathogen-free conditions. All the experiments were performed in accordance with the regulations of the Experimental Animal Welfare and Ethics Committee of the First Affiliated Hospital of Nanchang University. Prior to the experiment, the mice were acclimated to a controlled indoor environment for over 1 week without food or water restrictions, followed by cecal ligation and puncture (CLP) for sepsis induction . Recombinant pancreatic stone protein/regenerating protein (PSP/Reg)  was dissolved in PBS of 100 μL, and the solution was injected into the caudal vein 30 min after CLP at 40 and 400 ng/kg. Mice injected with low-dose PSP/Reg corresponded to patients with systemic infections, whereas high-dose PSP/Reg was the median amount in patients with sepsis  (control), PSP-40, and PSP-400 groups (h sepsis . Controln = 10), PSP/Reg (400 ng/kg) (n = 10), or an equivalent volume of PBS (n = 6) in the caudal vein. Over the subsequent 7 days, the survival rate was assessed every 2 h.To evaluate the effect of PSP/Reg in a septic mouse model, 26 mice were randomized into three groups 30 min after CLP and injected with PSP/Reg (40 ng/kg)  according to the manufacturer’s protocol. The laboratory technicians who performed the assays were blinded to the clinical information. The levels of cytokines  and organ-damage markers  were quantified using ELISA assay kits from R&D Systems and BD Life Science, respectively, following the manufacturer’s instructions.Tissue samples were fixed in 4% paraformaldehyde, embedded into the optimal-cutting-temperature compound, and cut into 5-μm sections. The sections were then incubated in a blocking solution  for 30 min, followed by overnight co-incubation at 4°C with the anti-LY6G antibody (Abcam). After washing, the sections were incubated with the fluorescein isothiocyanate-conjugated secondary antibody (Proteintech) for 2 h, and the cell nuclei were labeled with 4′,6-diamidino-2-phenylindole (Bioss).The TUNEL assay was performed using One-Step TUNEL Apoptosis Assay Kit (Beyotime Biotechnology) following the manufacturer’s instructions. Tissue sections were fixed in 4% paraformaldehyde, permeabilized with 0.1% Triton X-100 for 10 min, and incubated with the TUNEL reaction mixture for 1 h at 37°C in the dark. Cell nuclei were visualized with 4′,6-diamidino-2-phenylindole. Images were captured using an Olympus IX71 microscope and quantified using the ImageJ software.MPO activity in murine lungs, hearts, livers, and kidneys was evaluated by performing a tissue MPO activity assay (Elabscience Biotechnology Co. Ltd.) according to the manufacturer’s instructions. MPO activity was expressed as the optical density at 460 nm per mg of protein.Fresh lung tissue was placed on sterile gauze and weighed to obtain the wet weight. The tissue was then placed in an oven at 60°C for 72 h to obtain the dry weight, which was measured three times. The wet/dry ratio was calculated as the ratio of the wet weight to the dry weight.A mouse bone marrow neutrophil isolation kit (Solarbio) was used to isolate neutrophils from the mouse bone marrow. The specific steps are as follows. The mouse thigh bone was first rinsed with 75% ethanol and PBS and then with the 10% fetal bovine serum-supplemented Roswell Park Memorial Institute 1,640 medium after both ends of the thigh bone were sheared to obtain bone cells. Next, density gradient centrifugation was performed according to the manufacturer’s instructions after erythrocyte lysis to obtain neutrophils, the morphology of which was observed by performing Wright-Giemsa staining. Flow cytometry (FCM) analysis revealed that the purity of the neutrophils was >90%. Subsequently, the isolated neutrophils were cultured in the complete Roswell Park Memorial Institute medium , and equivalent amounts of 40 ng/mL or 400 ng/ml PSP/Reg or PBS for 24 h of stimulation. The next day the Neutrophils were collected for further analysis.Phycoerythrin-conjugated anti-intercellular adhesion molecule 1 (ICAM-1) (BD Biosciences) and fluorescein isothiocyanate-conjugated anti-CD29 antibodies (BD Biosciences) were used to detect the levels of surface antigens on neutrophils. After co-incubation at room temperature for 30 min, the cells were washed thrice with PBS containing 2% bovine serum albumin. FCM analysis was performed using an LSRFortessa cell analyzer (BD Biosciences), and the samples were analyzed using the FlowJo software.in vitro and in vivo experiments were normally distributed and are described as the mean ± standard error of the mean. Statistical significance was assessed using Student’s t-test or one- or two-way analysis of variance, as appropriate, to identify any differences within the groups. Kaplan–Meier survival curves were used to compare survival times, and the log-rank test was performed to compare differences between the groups.Continuous variables in the clinical data were non-parametrically distributed and are, therefore, represented as the median (interquartile range [IQR]) or number (percentage). The Mann–Whitney U test was performed to compare differences in the median values of continuous clinical variables between the two groups, and the Kruskal–Wallis test was performed to compare PSP/Reg levels among the groups according to the SOFA score. The Spearman rank correlation test was performed to analyze the correlation between circulating PSP/Reg levels and organ support therapy using human data. Logistic regression and receiver operating characteristic (ROC) analyses were performed to assess whether circulating PSP/Reg was a predictive factor for MODS development (48–72 h after ICU admission) and 28-day mortality. Continuous variables in the To determine the clinical relevance of circulating PSP/Reg levels, 141 adult patients with sepsis who were admitted to the ICU were prospectively recruited. The patients’ clinical characteristics are presented in p < 0.001) (p < 0.001)  . In addi< 0.001) .r = 0.496; p < 0.001) and those who needed the long-term administration of vasopressors , mechanical ventilation , or renal replacement therapy .The Spearman rank correlation test showed a strong correlation between circulating PSP/Reg levels and dependence on organ support therapies among patients with a high demand for vasopressors at admission (p = 0.001) (p < 0.001) (Patients with MODS (SOFA scores ≥5) exhibited higher circulating PSP/Reg levels compared with patients without MODS  . Similar< 0.001) .Performing the Kaplan–Meier analysis of PSP/Reg values stratified by quartiles revealed that PSP/Reg plasma levels at admission exhibited a strong correlation with the 28-day mortality rate. Furthermore, the survival rate of patients with PSP/Reg levels exceeding the third quartile (246.73 ng/mL) sharply declined during the second week of sepsis . These fp = 0.005; odds ratio: 1.006 , p < 0.001). The ROC analysis also revealed that it was a predictor of progression to MODS  (p < 0.001)   and 28-d< 0.001) .Furtherm< 0.001)  and S2.p < 0.01), suggesting that PSP/Reg increased the disease severity score of the mice in a dose-depended manner (p < 0.01), and PSP-400 mice showed the shortest median survival time   .Levels of inflammatory factors reflect the level of systemic inflammation. In this study, compared with PBS mice, PSP-40 mice exhibited significantly increased levels of the inflammatory factors tumor necrosis factor-α, IL-6, and Il-1β. High-dose PSP further increased tumor necrosis factor-α and IL-6 levels but did not further exacerbate IL-1β levels –E.Key parameters reflecting multiorgan damage were also measured. It was found that the plasma levels of lactate dehydrogenase (1781 ± 105.4 U/L), troponin I (29.65 ± 1.01 ng/mL), and creatinine (1.82 ± 0.02 mg/dL) in PSP-40 mice were indicative of tissue damage in the liver, heart, and kidney, respectively, compared with those in PBS mice , and that organ damage was further exacerbated among PSP-400 mice –H. AdditAn independent analysis measuring tissue damage was performed on the TUNEL-stained lung, heart, liver, and kidney tissue sections. The lung, heart, liver, and kidney tissues collected from mice injected with PSP/Reg showed a higher TUNEL-positive staining rate than those collected from PBS-treated mice –D.p < 0.01). After immunofluorescence staining, neutrophil tissue infiltration was observed in the lungs, kidneys, hearts, and livers of PBS mice, whereas PSP/Reg administration markedly increased PMN tissue infiltration, which was more pronounced in mice injected with a higher dose of PSP/Reg  and kidneys (0.88 ± 0.02 U/g vs. 1.8 ± 0.16 U/g) increased by over two-fold in PSP-40 mice compared with those in PBS mice, and a similar trend was also observed in the heart (0.81 ± 0.05 U/g vs. 1.22 ± 0.07 U/g) and liver (1.21 ± 0.09 U/g vs. 1.84 ± 0.42 U/g) –D. Simil PSP/Reg –H. Thesein vitro, and injected with equivalent amounts of PSP/Reg (40 or 400 ng/mL) or PBS. PSP/Reg stimulation resulted in increased levels of ICAM-1 and CD29  ,B. To fuand CD29 ,D, consiMODS is a devastating complication in critically ill patients that frequently leads to increased morbidity and mortality in the ICU. Despite the severe effect of MODS on patient outcomes, factors that drive its development into sepsis remain poorly understood. Further in-depth investigations are warranted to gain a better understanding of the mechanisms underlying this condition. Therefore, we designed a prospective clinical study to explore the potential correlation between PSP/Reg and the development of sepsis-induced multiple organ dysfunction. In this study, we established a mouse model of CLP-induced sepsis to investigate the possible involvement of PSP/Reg in the progression of sepsis-induced multiple organ dysfunction via neutrophil activation.Initially, PSP/Reg was named PSP because it was found to inhibit the precipitation of calcium carbonate crystals in the pancreatic juice within the pancreatic stones of patients with chronic calcific pancreatitis . SubsequIn sepsis, it is difficult for neutrophils to be recruited to the site of infection , which mTo further verify the regulatory effect of PSP/Reg on PMN tissue infiltration, we detected the surface activation indicators of bone-marrow PMNs in mice administered with PSP/Reg and discovered that PSP/Reg stimulation increased the levels of the adhesion molecules ICAM-1 and CD29 on the surface of PMNs. The activation and tissue infiltration of neutrophils are strictly regulated by adhesion molecules . During Among the 141 patients with sepsis admitted to the ICU in our study, those with septic shock exhibited significantly higher levels of circulating PSP/Reg. There was a strong correlation between circulating PSP/Reg levels and 7-day survivors requiring organ support, indicating that disease severity was an independent risk factor for progression to MODS 48–72 h after admission and 28-day mortality. Moreover, this study showed that the intravenous injection of PSP/Reg aggravated multiorgan damage in the CLP mouse models and shortened their survival time. At the cellular level, we confirmed that PSP/Reg induced the inflammatory activation of murine neutrophils, further supporting its role in promoting inflammation during sepsis. This indicated that PSP/Reg might facilitate the activation and infiltration of neutrophils in distal organs to intensify the CLP-induced inflammatory cascade, thereby exacerbating multiorgan damage in sepsis.Sepsis and MODS are multifaceted conditions with highly intricate pathogeneses involving a dynamic and complex immune response that may involve both proinflammatory and anti-inflammatory mechanisms. The effect of PMNs on multiorgan damage in early and late sepsis is not yet fully understood, and further studies are needed to investigate the underlying mechanisms that regulate the immune response during these phases of sepsis. Our study has shed new light on the potential role of PSP/Reg in exacerbating sepsis-induced multiple organ dysfunction by facilitating the activation and infiltration of neutrophils; the underlying regulatory mechanisms involved in this process are likely to be highly complex and multifactorial. Thus, it is necessary to explore these mechanisms in greater detail to identify potential therapeutic targets for the prevention and treatment of sepsis and MODS.List of abbreviations: PSP/Reg, Pancreatic stone protein/regenerating protein; MODS, multiple organ dysfunction syndrome; ICU, intensive care unit; CLP, cecal ligation and puncture; PBS, phosphate-buffered saline; TUNEL, terminal deoxynucleotidyl transferase dUTP nick end labeling; MPO, myeloperoxidase; SOFA, sequential organ failure assessment; ICAM-1, intercellular adhesion molecule 1; FCM, flow cytometry; IL, interleukin; IQR, interquartile range; ROC curve, receiver operating characteristic curve; CI, confidence interval.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Nanchang University , and each patient had signed the informed consent form prior to participation. The patients/participants provided their written informed consent to participate in this study. The animal study was reviewed and approved by Experimental Animal Welfare and Ethics Committee of the First Affiliated Hospital of Nanchang University. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.PH contributed to the experimentation, analysis, and manuscript preparation. FL contributed to the research concept and oversaw the study. QS and WD contributed to the performance of experiments. LW and WXZ contributed to the immunological evaluation through sample measurements. KQ contributed to the revision of the manuscript. YL contributed to the article by making important revisions and additions. QL contributed to the article by providing assistance with further subgroup analysis of the data. NZ contributed to the article by helping to guide the statistical analysis.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Data on risk factors predicting uveitis development in spondyloarthritis (SpA) is scarce. Our aim was to examine associations between demographic, clinical and/or laboratory characteristics of SpA with the occurrence and the course of uveitis, including ocular damage and recurrence rate.Characteristics (at disease diagnosis and ever-present) from axSpA and Psoriatic arthritis (PsA) patients followed in 3 tertiary rheumatology-clinics were retrospectively recorded. Comparisons were made between patients with and without uveitis, as well as between those with uveitis-rate [episodes/year] above the median uveitis-rate in the whole cohort (“recurrent”-uveitis) and the remaining uveitis patients (“non-recurrent uveitis”). In multivariable models, age, gender and variables significantly different in univariate analyses were included.p = 0.028) and ever-present peripheral arthritis . In contrast, uveitis in PsA occurred only in 2.7% of patients and was associated with SpA family-history (OR = 6.35 (1.29–31.27), p = 0.023) axial disease at diagnosis  and disease duration . Median uveitis recurrence rate was comparable between axSpA and PsA . No associations were found between recurrent uveitis and demographic/clinical/laboratory characteristics. Ocular damage (e.g. synechiae) was seen in 16.1% of axSpA and 30% of PsA patients, all of them with recurrent uveitis.264 axSpA and 369 PsA patients were enrolled. In axSpA, uveitis occurred in 11.7% and was associated with HLA-B27 (OR = 4.15, 95%CI 1.16–14.80, Uveitis occurred more commonly in axSpA than in PsA patients, while uveitis recurrence rate was similar. Permanent ocular damage may occur more often in PsA than axSpA.The online version contains supplementary material available at 10.1007/s00296-023-05424-0. The term spondyloarthropathy (SpA) encompasses a group of chronic inflammatory disorders of the joints, including psoriatic arthritis (PsA), peripheral SpA, enteropathic arthritis and axial SpA (axSpA) which incorporates non-radiographic axial SpA (nraxSpA) and ankylosing spondylitis (AS) . The sacUp to one-third of individuals with SpA experience uveitis, which is usually anterior and unilateral and represents the most common extra-articular feature , 5. The The clinical course of uveitis varies, and inadequate or inappropriate treatment can lead to accumulating damage and possibly vision loss . AccordiIn this retrospective study we aimed to examine possible associations between demographic, clinical and laboratory characteristics and the occurrence and the course (including recurrence and ocular damage) of uveitis, in SpA patients. In this context, we also estimated the recurrence rate of uveitis in our real-world SpA cohort.We screened medical records from 3 tertiary centers in Greece, of all axSpA (fulfilling the ASAS classification criteria for axSpA ) andPsA For both axSpA and PsA, clinical, laboratory and demographic features were compared between patients with and without uveitis. Moreover, patients were considered to have “recurrent uveitis” when their rate of uveitis episodes was above the median uveitis episodes rate of the entire cohort (separately for axSpA and PsA). Characteristics of patients with “recurrent uveitis” were compared to those without (“non-recurrent uveitis”). An additional analysis was also performed, comparing characteristics of patients who displayed only one episode of uveitis to those with more than one episode.The current study was conducted according to the Declaration of Helsinki. The study was approved by the Scientific councils of “Laiko” , “NIMTS”  and “Ippokratio” . All patients provided written informed consent.Statistics.p-values less than 0.05. Regarding sample size calculation, this was not performed a priori in our study, as we included all patients that were actively followed-up in our departments. However, using the Daniel formula with confidence intervals 95% and margin of error 5%, adequate number was calculated to be 246 patients for axSpA (estimated uveitis rate: 20%) and 59 patients for PsA (estimated uveitis rate: 4%) . Of note, when we ran another model in which disease duration  was included, results did not change .In patients with axSpA, uveitis occurred in 31 of 264 (11.7%) at a mean (SD) 6.2 (4.3) years after the diagnosis of the index disease. Of them, 21 were already on treatment with bDMARDs  at the time of first episode. Uveitis was always affecting the anterior chamber and was unilateral in half  of the cases. Uveitis occurrence was associated with HLA-B27 positivity (p = 0.008), axial disease at diagnosis of index disease (p = 0.004), disease duration (p = 0.012), as well as with the ever-occurrence of dactylitis (p = 0.045), enthesitis (p = 0.033) and bowel involvement (p = 0.009)  = 5.61 (1.01–28.69), p = 0.038] and disease duration  remained statistically significant.In patients with PsA, uveitis occurred in only 10/369 (2.7%) of patients after a mean (SD) 4.8 (5.5) years after the diagnosis of the index disease. In 4 of them, uveitis occurred despite they were already on treatment with bDMARDs . Anterior uveitis was unilateral in most  of the cases. Uveitis occurrence was associated with a family history of SpA, (In axSpA patients 12/31 (38.7%) had only one episode, while the rest 19/31 (61.3%) displayed more than one episode. Median uveitis episodes rate was 0.205 episodes/year. In PsA, only 2/10 (20%) patients had only one episode, while the other eight patients exhibited more than one uveitis episode and the median uveitis episodes was 0.285 episodes/year.p = 0.018). This remained significant after adjustment for disease duration . In a sensitivity analysis, we compared axSpA and PsA patients with one episode of uveitis, versus those who exhibited more episodes. In axSpA subgroup, patients with more than one uveitis episodes (compared to those who had only one uveitis episode) displayed more common peripheral arthritis at diagnosis of index disease  in these patients, this was seen less commonly in axSpA than in PsA [5/31 (16.1%) versus 3/10 (30%), In this retrospective study, we found that uveitis is associated with positivity for HLA-B27 and with ever-present peripheral arthritis in axSpA, and with axial disease at diagnosis, disease duration and family history of SpA in patients with PsA. We also found that in a real world-setting, the median recurrence rate of uveitis is 0.205 (episode/year) for axSpA and 0.285 for PsA.Uveitis is not uncommon in the setting of SpA. Traditionally it is estimated to occur in about 20–30% of SpA patients throughout the disease course , 14–17 wUveitis has a considerable clinical burden affecting the quality of life and functional ability of patients . In SpA,Various risk factors have been suggested to associate with uveitis in SpA, with HLA-B27 positivity being the most well established in axSpA , 17, 24,p = 0.059). Besides the role of HLA-B27 in PsA remains elusive, it has been reported that HLA-B27 positive axial-PsA patients show similarities with axSpA and perhaps also higher uveitis rates, [. Along these lines, it has to be noted that although axSpA and PsA are both classified under the umbrella of SpA and share a lot of clinical manifestations, the extra-articular features as well as the comorbidities occur in different frequencies in these two entities [For PsA, Delmás et al. have found an association between uveitis and HLA-B27, while they also report that PsA patients with uveitis have more frequently sacroiliitis on MRI compared to those without, implying that uveitis might be more often encountered in axial-PsA . It has s rates, . It is nentities . In termentities .Despite effective treatments for uveitis, recurrent episodes can recur. The concept of “recurrence” is also used as phrasing in the recent EULAR recommendations for axSpA . RelevanAnterior uveitis can lead to unfavorable outcomes including synechiae and cataract . This coWe acknowledge that our study has certain limitations. Due to the retrospective design of our study, the frequency of uveitis was obtained mainly through medical files in outpatient rheumatology clinics. Second, the study was not designed to detect possible associations between bDMARD treatment received and episodes of uveitis. This has already been addressed by other SpA-studies which have shown that monoclonal antibodies against TNF are more effective compared to IL-17 inhibitors and etanercept . Of noteIn conclusion, uveitis is more frequent by more than fourfold in axSpA than PsA. Its occurrence associates with specific characteristics like HLA-B27, peripheral arthritis and family history of SpA in axSpA and PsA patients, respectively. Ocular inflammation resulted in ocular damage in about 15–30% of our patients, all of them with recurrent uveitis, underlying the importance of early identification and treatment of these patients.Supplementary file1 (DOCX 32 KB)Below is the link to the electronic supplementary material.