Abies kawakamii is endemic to the island of Taiwan and has been listed as a threatened species in the Red List. In present study, we reported the complete chloroplast genome of A. kawakamii. The chloroplast genome is 121,290 bp in size. It was composed of 114 genes and they were 68 peptide-encoding genes, 35 tRNA genes, four rRNA genes, six open reading frames and one pseudogene. Loss of ndh genes was identified in the genome of A. kawakamii. Inverted repeat sequences include trnS–psaM–ycf12–trnG and trnG–ycf12–psaM–trnS were recognized in 52-kb inversion points. The phylogenetic analysis confirms that the Abies species are strongly supported as monophyletic. The complete plastome of A. kawakamii will provide potential genetic resources for further conservation and management strategies. Abies kawakamii (Hay.) Ito is endemic to the island of Taiwan and has been listed as a threatened species in the Red List   Liu . The Taiala) Liu . In the Abies kawakamii was sequenced by HiSeq4000 of Illumina. Totally 10.3 million high-quality clean reads (150 bp PE read length) were obtained. In total, ca. 10.1 million high-quality clean reads (150 bp PE read length) were generated with adaptors trimmed. The CLC de novo assembler , BLAST, GeSeq  was deposited at the herbarium of Institute of Botany, CAS (PE). Complete chloroplast (cp) genome of Abies kawakamii (GenBank: MH706726). The circle genome was comprised of a large single copy region , a small single copy region , and two inverted repeat regions (IR with 264 bp). The overall GC content of the A. kawakamii cp genome was 38.3%. It was composed of 114 genes and they were 68 peptide-encoding genes, 35 tRNA genes, four rRNA genes, six open reading frames and one pseudogene. All ndh genes have been lost in the genome of A. kawakamii. Short inverted repeat sequences were detected in 52-kb inversion points of the cp genome, which consist of trnS–psaM–ycf12–trnG and trnG–ycf12–psaM–trnS (1183 bp). Interestingly, such inverted repeats had been reported in several members of the genus Abies (A. koreana and A. ziyuanensis)  as the outgroup. These sequences were fully aligned with MAFFT v7.3  (Katoh and Standley Abies species (A. kawakamii and A. beshanenzuensis) were found to be a monophyletic group (To infer the phylogenetic position of ic group .


Atrial septal defects (ASDs) are common congenital heart defects (CHD). The clinical course in patients without closure of the ASD is associated with significant morbidity and mortality in advanced age. A small percentage of patients may develop pulmonary arterial hypertension (PAH) due to left to right shunting that impacts morbidity and mortality. Advances in prenatal screening and fetal echocardiography have allowed timely interventions. Nonetheless, some patients still may be diagnosed with ASD in adulthood as an incidental finding or presenting with clinical symptoms such as shortness of breath from right heart failure. We report a case of an adult female presenting with shortness of breath due to ASD causing PAH with Eisenmenger physiology. Atrial septal defects (ASDs) are the second most common congenital heart defects (CHD) . It accoA 44-year-old female with a history of heart murmur since age 15 and chronic dyspnea on exertion was admitted to the hospital with new-onset chest pain and shortness of breath. The pain was retrosternal, worse when lying flat, and improved with leaning forward. She was hypoxic on admission with an oxygen saturation of 86%. Physical examination revealed cyanosis, jugular venous distention, a right ventricular heave, and a loud pulmonic diastolic murmur. Blood work revealed a hemoglobin concentration of 14.2 g/dl, a normal troponin level < 0.012 ng/ml, serum creatinine of 0.51 mg/dl, negative antinuclear antibodies, negative HIV serology, and a negative pregnancy test. An electrocardiogram showed severe right ventricular hypertrophy .Echocardiography revealed severe right atrial and right ventricular enlargement, severe pulmonary hypertension with right ventricular systolic pressure (RSVP) of 70 mmHg, and suspicion for a large ASD .She underwent right heart catheterization (RHC) with a shunt run. This revealed 10% oxygen step-up from high superior vena cava to the right atrium, suggestive of ASD. Effective pulmonary blood flow to systemic blood flow (Qp/Qs) was 1, suggestive of equal bidirectional shunting and Eisenmenger physiology. RHC confirmed severe PAH (PVR = 8.7 Wood units) that did not respond to inhaled nitric oxide. The mean wedge pressure was 2 mmHg. She also underwent a computed tomography (CT) pulmonary angiogram that was negative for thromboembolic disease. A pulmonary function test (PFT) and diffusion lung capacity for carbon monoxide (DLCO) were normal.To better delineate the anatomy of the atrial septum, she underwent cardiac CT which revealed a large (2.5 × 3.5 cm) secundum-type defect .She had a six-minute walk test for prognostic purposes which revealed reduced walk distance of 300 meters or 50% of the predicted distance. She was classified as WHO class III functional status and started on combination therapy with Sildenafil 20 mg three times daily and Macitentan 10 mg once daily. She was also placed on two forms of contraception (barrier and nonestrogen contraceptives). Her shortness of breath and chest pain improved significantly, and she was scheduled for outpatient follow-up with a pulmonologist and cardiologist. At 30 days, the patient no longer felt short of breath with activities of daily living and her 6-minute walk test doubled to 600 meters.ASD is often encountered in the adult population, as many patients are symptom-free in the first few decades of life. Secundum-type ASDs are located at the fossa ovalis and represent about 70% of all ASDs . To detePAH is characterized by a pulmonary capillary wedge pressure ≤ 15 mmHg and a pulmonary vascular resistance (PVR) > 3 Wood units (WU). Cardiac output and PVR are often measured by thermodilution. However, this technique may be inaccurate in patients with intracardiac shunts, low cardiac output states, or significant tricuspid regurgitation. In such situations, the Fick principle may be preferable to calculate cardiac output and thus PVR .th decade of life (as it did with our patient) with dyspnea on exertion, chest pain, palpitations, and sometimes RHF [PAH in secundum-type ASD seems to be related to age, size of the defect, female sex, and nonclosed ASD status , 6. ASD Whether ASD ES is secondary to severe PAH due to the ASD shunt size alone or the ES is related to idiopathic PAH with a standby ASD is still a subject of debate. Therrien et al.  demonstrth decade with PAH ES and a large ASD (2.5 × 3.5 cm) suggesting that the magnitude of the ASD likely played a major hemodynamic role leading to shunt reversal and ES.In the study by Therrien et al. , patientIt is worth noting that other conditions can cause precapillary PH, with the most common being left heart diseases such as diastolic heart failure . Also, p2) is safe for ASD closure. Closure of the defect and pregnancy are not recommended if the PVR is >4.6 WU (PVRi > 8 WU/m2), even when an Eisenmenger-type phenomenon has not been reached. For patients with PVR between 2.3 and 4.6 WU, the decision to close the ASD is made on a case-by-case basis. Once the shunt has reversed from right to left (Qp : Qs < 1) or is bidirectional (Qp : Qs = 1), PAH is often irreversible and ASD closure is contraindicated due to worsening RHF [Secundum ASDs can be closed either surgically or percutaneously, and repair is indicated when there is evidence of RV compromise with or without symptoms . Left toU PVRi >  WU/m2, ening RHF , 10. Thening RHF , 11. HowPregnancy is contraindicated in all forms of PAH due to risk of cardiac, fetal, and obstetric complications , 12. WomASDs are not commonly associated with Eisenmenger physiology. The morbidity and mortality in ASD-related PAH are due to cardiac complications including heart failure and arrhythmias. Once ES develops, ASD closure is contraindicated. Medical management and avoidance of situations that can alter hemodynamic balance (such as pregnancy) to reduce right-sided pressures are paramount to the patient's survival.


A time-saving rapid equilibrium dialysis assay was used for the separation of unbound and bound VRC, following a high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) analysis method for drug concentration detection. Liver function and treatment details were collected from the electronic medical records of patients. Protein concentration was determined according to instructions. VRC plasma protein binding rate (PPB) in patient is significantly higher [69.5 ± 6.2%] than that in in-vitro samples, influenced by total drug concentration (Ct), plasma protein concentration, and protein type. The α1-acid glycogen (AAG) has the highest affinity with VRC. Relationship between total PPB of VRC with PPB of individual protein is not a simple addition, but a compressive combination. Unbound drug concentration (Cu) of VRC shows significant relationships with Ct, protein concentration, AST level, metabolism type of CYP2C19 and co-administration of high PPB medicines. Unbound plasma concentration of VRC shows a more sensitive relationship with ADRs than Ct.This study investigated voriconazole (VRC) unbound plasma concentration and its relationship with adverse drug reactions (ADRs) in patients with malignant hematologic disease. Plasma samples were collected from patients or spiked  Candida albicans infections, has a broader spectrum of activity than traditional triazole agents (fluconazole and itraconazole), and is metabolized mainly by cytochrome P450 2C19 (CYP2C19) (Voriconazole (VRC), a second generation triazole anti-fungal agent with a spectrum against invasive aspergillosis and CYP2C19) . As the t) and unbound concentration (Cu). Unbound fraction (fu) was 32.3 ± 5.5% in blank plasma spiked with VRC in vitro and about 22.95% in plasma of patient treated with VRC, respectively. PPB of VRC has been investigated more in detail by p < 0.001), indicating higher unbound voriconazole concentrations with decreasing albumin concentrations , and to explore the association of ADRs with unbound VRC plasma concentration.Although the plasma protein binding characteristics of VRC have been investigated by Vanstraelen et al. and Florent et al., results of these two studies are not consistent. C® that a loading dose of 6 mg/kg every 12 hours for two doses, followed by a maintenance dose of 4 mg/kg every 12 hours. Blood samples were collected from all 193 patients. A 5-ml Na-Heparin tube  was used for blood sample collection before  and 2 hours after  VRC administration (the endpoint of intravenous drip). After centrifugation , plasma was obtained from blood sample and was stored at −80°C until analysis.A non-controlled study (study A), approved by the Ethical Committee of Jiangsu Province Hospital (approved number: 2015-SR-206), was undertaken actively, carefully, and scientifically on the basis of Helsinki Declaration. Subjects were selected from patients treated in the hematology department of the First Affiliated Hospital of Nanjing Medical University/Jiangsu Province Hospital that with malignant blood diseases required VRC for treatment or prevention of invasive fungal infection. A total of 193 patients with signed informed consent participated in and completed this study. Detailed demographic information is shown in ® and previous literature  was conducted by Sangon Biotech . Only 124 patients were sequenced successfully, and were grouped into three different metabolic types  for further analysis.The DNAs of all patients were extracted by using Relax Gene Blood DNA System kit  and stored at −80℃ until the genotyping was performed. Sequencing of polymorphisms , provided by Sigma-Aldrich (USA), was used to prepare the IS working solution with acetonitrile (4.00 mg/L). Standard protein solutions were prepared in phosphate-buffered saline , with Behring® , α1-Acid Glycoprotein from human plasma  and Human Immunoglobulin (PH4) for Intravenous Injection . All solutions were freshly prepared at the moment of experiments.Voriconazole, provided by Tokyo Chemical Industry (Japan), was used to prepare a stock solution of 1.00 g/L in methanol . This stock solution was further diluted in acetonitrile or deionized pure water to a series of appropriate concentrations . Working solution A was used for HPLC-MS/MS analysis, and B was for in vitro studies (study B–F) were conducted for further investigation. Pooled blank lithium heparin plasma was collected from healthy volunteers. In study B, blank human plasma was spiked with VRC, resulting in four final concentrations . In study C, two concentrations of albumin (ALB) were spiked with two concentrations of VRC, resulting in four different ALB solution containing VRC . Study D was similar to study C with two different concentrations of α1-acid glycoprotein (AAG) spiked with VRC resulting in four types of samples . In study E, globulin (GLB) solutions were spiked with VRC resulting in four different final concentrations . Study F included samples in two mixtures made up of different human plasma protein concentration (40.01 g/L [30 g/L ALB+10 g/L GLB+0.01 g/L AAG] or 81 g/L [50 g/L ALB+30 g/L GLB+1 g/L AAG]) with two drug concentrations , resulting in four final mixtures .Five in vitro samples were separated using rapid equilibrium dialysis . In brie2) better than 0.997.After reaching equilibrium, VRC concentrations in both the plasma and the buffer compartment were determined using a validated HPLC-MS/MS method, with a LLOQ of 50.00 ng/ml, between-run precision, expressed as coefficient of variation, below 15%, and accuracy, expressed as a percentage of the theoretically added concentration, of between 88% and 107%. Linearity from 50.00 to 30,000 ng/ml was demonstrated, and a second order calibration model was employed which provided coefficients of determination (rin vitro sample). 100 μl of clear upper layer was diluted with 900 μl deionize water after centrifugation . After vortex, the mixture was injected into the HPLC system for separation and then the separated components are detected by MS and quantification was made through calibration curve.Plasma samples and the buffer compartment were prepared using a protein precipitation method. In short, 200 μl acetonitrile  were mixed with 50 μl plasma sample  with a tandem mass spectrometer Finnigan TM TSQ Quantum Discovery MAXTM , operated in positive-ion electrospray mode. The mobile phase consisted of 0.2% (v/v) formic acid and methanol . Column temperature was 35°C and run-time was set at 6.0 min. Compounds were detected via selected reaction monitoring (SRM) mode . Electrospray ionization (ESI) interface parameters were as follows: spray voltage 3500 V, sheath gas, and auxiliary gas (N2) 35 and 15 arbitrary units respectively, capillary heater temperature 350℃, collision energy , collision gas 1.5 mTorr. The volume of injection is 3 μl. The method was validated within the linear range 50.00 to 30,000 ng/ml.Concentrations were quantified by using a C18 reversed-phase chromatogram column HypersilVRC plasma protein bounding rate (PPB) was calculated according to the following formula:buffer and Cplasma represent the concentration of voriconazole at equilibrium in the buffer compartment and plasma compartment, respectively.CTreatment details (adverse effects and concomitant medication) and liver function tests  were collected from the electronic medical records of patients.Plasma total protein (TP), ALB, and AAG concentrations of all plasma samples from patients were determined by BCA protein quantification kit , bromocresol green albumin assay kit , and colorimetric sandwich ELISA kit  according to specifications, respectively.p value less than 0.05.Statistical analysis was performed by using SPSS 22.0 for Windows . One-way analysis of variance (ANOVA) and t-test were used to compare the difference in mean; Pearson correlation analysis was used to test the correlation between the factors (plasma protein concentration and VRC plasma concentration) and PPB of VRC in patient plasma samples. Data were described with mean ± standard deviations (SD). All the statistical tests were two-sided and considered as significant for a t) of VRC in 932 plasma samples from 193 patients collected on day 1, 4, 7, 10, 14  was shown in min and Cmax of VRC reached the steady state on day 4.Demographic information was shown in Protein binding rate of VRC in different sample type is significantly different, except that between study B and F, study C and D, and study C and E . Patients with a higher Ct  in group IV had a significantly higher PPB  were divided into four groups according to total drug concentration , 1,500 and 25,000 ng/ml (p=0.012), respectively.All of the blank plasma spiked with VRC in vitro (shown in t). ALB binding rate of samples with a higher concentration of VRC  was significantly higher in different protein groups . There was no similar result in AAG or GLB binding rate. Plasma protein mixtures spiked with a higher concentration of VRC  had a significantly higher binding rate than the lower concentration group (Ct=400 ng/ml) in both two different protein groups .PPBs of plasma protein solutions spiked with VRC in vitro were also grouped according to protein concentration  with higher protein concentration was significantly higher . AAG binding rate of samples with higher protein concentration had a significant higher PPB in both two Ct groups . GLB binding rate was without this characteristic in either lower Ct group or higher Ct group. Plasma protein mixtures spiked with a higher concentration of protein (Cp=81 g/L) had a significant higher PPB than the lower group (Cp=40.01 g/L) in both two different Ct groups .PPBs of plasma protein solutions spiked with VRC u characteristic of all in vitro samples were shown in t (400 ng/ml), Cu of a lower plasma protein concentration was significantly higher than sample with a higher plasma protein concentration . In a higher Ct , Cu of a lower AAG concentration was significantly higher than samples with higher AAG concentration . In a higher Ct , Cu of in vitro samples with a lower GLB concentration (10 g/L) was significantly higher than samples with higher GLB concentration .Ct, Cu, PPB, and plasma protein concentration, respectively.PPB was correlated positively with AAG , and ALB showed a positive correlation with TP  according to Pearson relationship analysis. There was no other significant correlation between Cmin of VRC on day 4 and day 10 .The total Cmin.The total Cmax in patients with AST in normal value  was significantly lower than those with abnormal AST  , respectively. There was no significant difference between patients with AST in normal value and those with abnormal AST  for VRC in this study was 16.6% (32 from 193 patients). Reversible visual changes  occurred in 13 patients (6.7%). Neurological abnormity or mental abnormity  occurred in 12 patients (6.2%). Abnormal liver function occurred in 5 patients (2.6%). Rash occurred in 3 patients (1.6%). Abnormal audition occurred in 3 patients (1.6%), and cyclosporine plasma concentration increasing occurred in one patient (0.5%) when co-administered with cyclosporine (shown in t (including Cmax and Cmin) in patients with and without ADRs  in combination than those without CYP450 inhibitor  shown in max in plasma samples from patients used high PPB medicine  in combination was significantly higher than those without high PPB medicine  in steady state of VRC reached therapeutic window   . However0 ng/ml) .t, which was consistent with the result from Florent et al. . ALT is mainly distributed in hepatocytes, so the variation of ALT may be influenced when used hepatoprotectants in combination. AST is mainly distributed in the cardiac, which may be influenced less by the liver function. These are different from the results reported from Apart from CYP2C19 metabolic types, the liver function also showed an impact on Cfunction . Data anu of voriconazole may also be affected by these combinations. In our study, Cu was significantly higher in patients administered with medicine of high protein binding rate  were significantly higher than those without ADRs, while there was no similar result in Ct, which indicated that Cu showed a more sensitive relationship with ADRs than Ct.Cin vitro samples, which was consistent with Florent et al.  that VRC was shown to bind preferably to ALB. It may be caused by the different device used for equilibrium dialysis. Therefore, AAG may play an important role in the protein binding characteristics of VRC when ALB is in an abnormally lower concentration.PPB was higher in sample with higher CAnother notable result was that the binding rate of the protein mixture is about 50%-60%, although the protein binding rate of VRC with three different plasma proteins was almost 30%-50% respectively. Thus, the relationship between total PPB and PPB of individual protein is not a simple addition, but a compressive combination.in vitro and in vivo to investigate the changing characteristics of Cu and PPB, in order to provide guidance for clinical medication. More cases should be taken into analysis in the future study.In this study, equilibrium dialysis (ED), the most common methods was used for investigating drug protein binding characteristics. ED is typically considered to be the gold standard , using at, plasma protein concentration, and protein type. The α1-acid glycogen has the highest affinity with VRC. Relationship between total PPB of VRC with PPB of individual protein is not a simple addition, but a compressive combination. Unbound drug concentration of VRC shows relationships with Ct, protein concentration, AST level, metabolism type of CYP2C19, co-administration of high PPB medicine. The relationship between unbound drug concentration and ADRs is more sensitive than that total plasma concentration do.VRC plasma protein binding rate in patient was significantly higher (69.5 ± 6.2%) than that in in-vitro samples, influenced by CThe datasets generated for this study are available on request to the corresponding authors.The studies involving human participants were reviewed and approved by the Ethical Committee of Jiangsu Province Hospital. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.Y-QW, X-YZ, LM, and X-HZ designed the clinical trial. Z-Q-YY, L-NS, Z-CY, and YQ performed the drug concentration analyses. QC and LY performed the genetic analyze. Z-Q-YY performed the statistical analyses. All authors were involved in drafting or reviewing the manuscript and approved the final version.This project was sponsored by the grants from the Priority Academic Program Development of Jiangsu Higher Education Institutions, National Natural Sciences Foundation of China , Natural Science Foundation of Jiangsu Province (BK20161591), Six Talent Peaks Project in Jiangsu Province (2014-YY-001), Jiangsu Provincial Medical Youth Talent (QNRC2016215), Suzhou science and education Youth Project (KJXW2016067), and Suzhou industrial technology innovation (SYSD2016046).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.


Salmonella isolated at a Veterinary Medical Teaching Hospital microbiology laboratory, examine trends in presence of these resistance genes, and to explore the correlation between phenotypic resistance and presence of specific genes. The presence of ESBL, ACBL, and PMQR genes were detected using a single, novel multiplex qPCR. Only the genes blaCMY–2 and blaTEM were detected in the 110 Salmonella isolates tested. PMQR genes were not detected in isolates screened. Of 94 third-generation cephalosporin resistant isolates, representing eight serotypes, 48% (n = 45) were positive for blaCMY–2 only and 50% (n = 47) were simultaneously positive for blaCMY–2 and blaTEM. Two third-generation cephalosporin resistant isolates were tested negative for all β-lactamase genes in our qPCR assay and likely house ESBL genes not screened for by our qPCR assay. A logistic regression model revealed that for serotype Dublin isolates (n = 38) the odds ratio for testing positive for blaTEM when compared to all other serotypes was 51.6 . For serotype Typhimurium (n = 9) the odds ratio for testing positive for blaTEM when compared to all other serotypes was 43.3 . Overall, our results suggest that the prevalence of resistance to cephalosporins and fluoroquinolones due to ESBLs, ACBLs, and PMQR genes present in bovine nontyphoidal Salmonella enterica isolates has remained relatively constant in the isolates screened over a 14-year period.The objectives of this study were to evaluate the prevalence of extended spectrum β-lactamase (ESBL) genes, AmpC-type β-lactamase (ACBL) genes, and plasmid mediated quinolone resistance (PMQR) genes in  Salmonella enterica (NTS)  . In the ca (NTS) . In humatriaxone . With 3%triaxone . As resiKlebsiella pneumoniae and Escherichia coli. Worldwide, the most common ESBLs are the SHV, TEM, and CTX-M types. AmpC-type β-lactamase (ACBL) genes also encode for enzymes capable of degrading β-lactam antibiotics, including: extended spectrum cephalosporins (excluding cefepime and cefpirome), cephamycins, and ceftriaxone  genes encode for enzymes which are able to cleave the β-lactam ring of a wide range of β-lactam antimicrobials  . They cotriaxone . blaCMY–globally .qnr genes protect DNA gyrase, the aac(6′)-lb-cr gene acetylates ciprofloxacin, norfloxacin, and certain other quinolones, and oqxAB and qepA genes produce efflux pumps  microbiology laboratory during a 14-year interval using a single, novel multiplex qPCR method.While there are multiplex PCR methods available for the detection of either ESBL, ACBL, or PMQR genes, there are few published multiplex PCR methods available for the combined detection of ESBL, ACBL, and PMQR genes relevant to NTS treatment . The goaSalmonella isolates were selected for qPCR analysis from a collection of 242 Salmonella isolates recovered from 9162 bovine fecal samples submitted to the University of California, Davis William R. Pritchard VMTH microbiology laboratory between January 1, 2002 and December 31, 2016 as detailed previously  program. All isolates with phenotypic resistance to at least one of the following drugs, nalidixic acid, ceftiofur, and/or ceftriaxone, were included in the study  (For each year a pan-susceptible (n = 16) . For two(n = 16) . These i® (Thermo Fisher) and minimum inhibitory concentrations (MIC) were interpreted using NARMS breakpoints . Two hundred microliter of DNA was eluted for each isolate into a sterile 2 ml micro centrifuge tube. The DNA samples were then stored at −80°C until further downstream processing.blaTEM, blaCTX–M, and blaCMY–2) and for presence of plasmid mediated quinolone resistance (PMQR) genes -Ib-cr). qnrA was not included in the qPCR assay because it has been rarely identified in Salmonella isolates with phenotypic resistance to fluoroquinolones. Cattle studies screening for qnr genes have more frequently detected qnrB and qnrS  qPCR assays were developed to facilitate rapid and sensitive analysis of samples. Isolates were analyzed for the presence of β-lactamase encoding genes (and qnrS . FurtherrA genes . Other rand qnrS .blaTEM (LT985387), blaCTX–M (CP025146), blaCMY–2 (KY612500), oqxA (CP019074), oqxB (CP019074), qnrS (CP026578), qnrB (KP012539), and aac(6′)-Ib-cr (NG_056043)) were aligned using Sequence Analysis and Molecular Biology Data Management software Vector NTI AdvanceTM11 . The alignment was used to design primers specific to target for singleplex and multiplex qPCRs assays -Ib-cr all used the fluorescent probe 6-carboxy-fluorescein (FAM); oqxA, blaCMY–2, and qnrB used the VIC probe; whereas, qnrS and oqxB used tetrachlorofluorescein (TET). All the probes utilized a 3′ minor groove binding quencher  (Thermo Fisher Scientific) for singleplex or Gene Expression Master Mix (Qiagen) for multiplex, and 5 μl of the DNA in a final volume of 12 μl.The singleplex and multiplex qPCR for each target contained 0.42 μl water, 0.58 μl primer/probe mix , 6 μl of commercially available TaqManCq was defined as the cycle in which there was a significant increase in reporter signal of the amount of PCR product detected during the exponential phase, above the threshold.All samples were placed in a 384-well plate and amplified in a 7900HT FAST Real-time PCR system (Thermo Fisher Scientific) using the manufacturer’s standard amplification conditions . Fluorescent signals were collected during annealing and quantitative cycle (Cq) was calculated and exported with a threshold of 0.15 and a baseline of 3–10 for FAM labeled assays, 0.20 and a baseline of 3–10 for VIC assays, and 0.10 and a baseline of 3–15 for TET assays. The qnrS), only one target positive control was conducted using a nucleic acid template of known copy number. In multiplex qPCR mixtures, each of the two -Ib-cr, and qnrB) or three  target positive controls was combined in a single amplification tube. Standard curves were generated for each set of 10-fold serial dilutions of target. We calculated the amplification efficiency (E) of all assays from the slope (S) of the standard curves, using the formula E = 101/–s - 1 . To evaluate the reproducibility of Cq measurements and their associated error of the mean, a histogram was generated to visually evaluate the data  for the effect of explanatory variables sex, serotype, submission type (IDC vs. Suspect), and year group  on the risk of detecting an isolate positive for the gene blaTEM. Three models were constructed that differed by the presence of a binomial variable that allowed the evaluation of the effect of each of these three serotypes: S. Dublin, S. Typhimurium, and S. Newport when compared against any other serotype. This was a binomial variable that compared one of the three serotypes to all other serotypes combined . These three serotypes were selected because they represented the top three serotypes for isolates selected . Year group (2002–2009 vs. 2010–2016) when isolates were collected was included and maintained in all models as an independent variable to evaluate temporal changes on antimicrobial resistance. These two multi-year periods were chosen because they represent two halves of the time period evaluated. Additionally, these time periods were selected because of legislation related to antimicrobial use that occurred after 2009, such as changes on how ceftiofur could be used in an extra-label manner in livestock  and 26.4 (99% CI: 24.9–27.7) were determined for blaCMY–2 and blaTEM, respectively. Cq value distribution for blaCMY–2, indicates that isolates below the cut-off of 23 were phenotypically resistant to ceftriaxone  were phenotypically resistant to at least one 3GC. Of these 94 3GC resistant isolates, 48% (n = 45) were positive for blaCMY–2 only and 50% (n = 47) were simultaneously positive for both blaCMY–2 and blaTEM. Two third-generation cephalosporin resistant isolates, which were negative for both blaCMY–2 and blaTEM, likely house ESBL genes not screened for by our qPCR assay.Isolates categorized as resistant to at least one third-generation cephalosporin (3GC) via MIC testing and were positive for either  by year . Out of blaCMY–2–positive, ceftriaxone resistant isolate positive for blaTEM  reported 100% of third-generation cephalosporin (3GC) resistant isolates . For serotype Typhimurium, which accounted for 9% of all isolates, the odds ratio for testing positive for blaTEM when compared to all other serotypes was 43.3 . For serotype Newport, which accounted for 42% of all isolates, the odds ratio for testing positive for blaTEM when compared to all other serotypes was 0.96 . For isolates in year group 2002–2009  the odds ratio of carrying blaTEM was 0.88 when compared to Salmonella isolated between 2010 and 2016  . Although not significant, the odds ratio of having blaTEM for isolates collected from animals suspected of salmonellosis  was 2.09 when compared to isolates collected as part of an infectious disease control protocol  .A logistic regression model revealed that certain serotypes of r blaTEM . A similWhile the three serotypes previously mentioned accounted for a majority of the 93 3GC resistant isolates, five other serotypes were also detected . These sblaCTX–M was not detected in any of the 110 NTS isolates screened. Additionally, none of the 110 NTS isolates, including two isolates phenotypically resistant to nalidixic acid, were positive for the PMQR genes screened in our assay -lb-cr). It should be noted that the methods used in our study did not allow for the delineation between aac(6′)-lb-cr and other highly similar variants like aac(6′)-lb. Likewise, the methods used in our study did not allow for differentiation between blaCTX–M groups.The ESBL gene n = 94) were phenotypically resistant to a 3GC and 98% (n = 92) and 50% (n = 47) of these resistant isolates were PCR-positive for blaCMY–2 and blaTEM, respectively (blaCMY–2 encoding the AmpC-type β-lactamase (ACBL) CMY-2  CMY-2 . The higblaCMY–2 . More reisolates . AnalysiblaTEM was present in 50% (n = 47) of 3GC resistant NTS isolates in our study and which were also simultaneously positive for blaCMY–2. TEM-1, discovered in 1965, is one of the most ubiquitous β-lactamases among Enterobacteriales  expressed ESBL-type TEM-52  ceftriaxone resistant strains were positive for blaTEM. It should be noted that a limitation of our study was that all isolates positive for blaTEM were also positive for blaCMY–2 and that the methods used in our study did not allow for the delineation between the β-lactamase gene blaTEM–1 and other highly similar ESBL variants like blaTEM–52.The β-lactamase encoding gene teriales . TEM-1 iteriales . With TEteriales . A 2012 e TEM-52 . In the e TEM-52 . The 201Enterobacteriales carrying blaCTX–M in dairy cattle was an E. coli strain in a study by Salmonella isolates screened in our study were positive for blaCTX–M.In the U.S., the first reported Our multiplex qPCR assay, while originally developed for use in an epidemiological or microbiological research setting, has potential advantages over traditional phenotypic testing common in a clinical setting. While research PCR assays tend to be low throughput and prioritize the ability to detect the lowest number of gene target copies, clinical PCR assays have additional requirements including high throughput and minimizing the chance of either false positive or negative results . FrequenblaCMY–2-positive, ceftriaxone resistant isolate also positive for blaTEM, namely Dublin and Typhimurium (blaCMY–2 (blaTEM or blaCMY–2 gene (the latter being the most probable). A previous study conducted on colostrum fed to dairy calves screened cephalosporin resistant E. coli for β-lactamase resistance genes and observed, similarly to our study, that none of the isolates were positive for blaCTX–M; they also observed that 45% and 35% of these isolates were positive for blaCMY–2 and blaTEM, respectively  resistance, and the driver of resistance is most probably being driven by another antimicrobial gene  for isolating a multidrug resistant Salmonella from suspect clinical salmonellosis cases when compared to isolates originating from the VMTH IDC protocol sampling  were resistant to at least one 3GC. Of these 3GC resistant isolates, 98% (n = 92) were positive for blaCMY–2 and 50% (n = 47) were positive for blaTEM and blaCMY–2. The consistently high prevalence of blaCMY–2 over time in isolates resistant to ceftriaxone suggests this gene may be a potential target for rapid molecular screening to identify isolates resistant to 3GC when compared to culture-based methods. The lack of isolates positive for blaCTX–M or PMQR genes screened suggest that the cattle population evaluated continued to be low risk group for carrier of these important resistance genes. There was also no significant association between the odds ratio of isolating a blaCMY–2-positive, ceftriaxone resistant isolate also positive for blaTEM and the year or year-group the isolates were collected. The higher odds for NTS serotype Dublin, ceftriaxone resistant isolate being positive for blaTEM highlight the need for continued monitoring of this important cattle host-adapted strain. Overall, our study suggests that the prevalence of resistance to cephalosporins due to ESBL and ACBL genes present in bovine NTS isolates has remained relatively constant in this hospital population in Northern California from 2002 to 2016.Out of 242 The original contributions presented in the study are included in the article/CB, BB, EE, EH, and RP conducted laboratory testing of samples. CB, BB, and RP performed data analysis and wrote the manuscript. CB, BB, AP, MC, and RP designed the study. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Individuals with bipolar disorder (BD) often possess maladaptive traits and present with various difficulties in psychosocial functioning. However, little is known about the intimate partners of adults with bipolar disorder (BD) and how mental illnesses other than BD within couples may further complicate the picture. Such knowledge is needed to inform both couple and family interventions.Participants were parents whose children were enrolled in a prospective study: 55 with BD and their partners, and 47 healthy control couples. All completed diagnostic interviews, and questionnaires describing personality traits, negative life events, coping skills, social support, marital adjustment and inter-partner verbal aggression. Parents with BD and healthy control parents were compared, as were the intimate partners. A series of exploratory analyses focused on the average measures within couples, with and without BD, and took account of comorbid personality disorders among those with BD and major depressive disorder among their partners.Intimate partners of adults with BD, relative to healthy control partners, presented with more mental disorders, higher neuroticism, lower extraversion, more emotion-focused coping, smaller social networks, less satisfaction with their social networks, and little, satisfying social contact. Additionally, they reported less consensus and satisfaction in their marital relationships, and engaged in more verbal aggression towards their partners. Participants with BD showed similar, more extreme, characteristics. Marital distress and verbal aggression were greatest among couples with an adult having BD and a comorbid personality disorder or a partner with major depressive disorder.both parents with BD and their intimate partners exhibit high levels of mental illness, maladaptive personality traits and psychosocial difficulties, thus limiting their partners’ ability to provide support and stability in the these high risk families. Moreover, mental illnesses other than BD may contribute to marital problems within couples. Some statistical analyses, particularly those involving comorbid conditions, were under-powered in this study. As clinical implications, the current study suggests that both individuals with BD and their partners could benefit from interventions aimed at lowering emotionality and verbal aggression, and increasing social support and effective coping skills.This study contributes to the literature by demonstrating that  Bipolar disorder (BD), a chronic and debilitating condition, is ranked among the top ten leading causes of disability worldwide  having a parent with BD or parents with no mental disorder. The study included a comprehensive assessment of families  and 102 intimate partners (59 BD and 43 control) from 204 parents participating in a prospective study comparing the development of children of parents with BD and children of healthy control parents (Ellenbogen and Hodgins SD = 5.35), 39.41 (SD = 5.06), 38.15 (SD = 5.24) and 38.28 (SD = 4.18) years respectively. Parent education level (number of years), used as a proxy of socioeconomic status, was 13.87 (SD = 2.96), 13.86 (SD = 3.39), 15.98 (SD = 2.88) and 15.35 (SD = 2.65) for index parents with BD, their intimate partners, index control parents, and their intimate partners respectively.Fifty-eight parents with BD and their 62 intimate partners from were recruited from psychiatric outpatient clinics and support groups in the province of Québec (Canada). Using community advertisements, healthy control parents (52 index parents and 48 spouses/intimate partners), who were free of any past mental illness and personality disorders: 6 (13%) drug abuse/dependence, 2 (4%) anxiety disorders, 1 (2%) avoidant PD, 1 (2%) obsessive–compulsive PD and 1 (2%) PD NOS. For inclusion, all parents were required to have at least one biological child between 4 to 14 years of age, be fluent in English or French, and have been raised and educated in Canada. Parents who presented with a chronic medical condition, physical handicap, or below-average intelligence quotient (IQ < 70) were excluded. Parents were mostly Caucasian, middle-class, and French Canadian.Diagnoses were confirmed using a semi-structured diagnostic assessment (see below) and psychiatric records. Some healthy control parents did meet criteria for The SCID-I, a valid and reliable diagnostic instrument, was used to assess parents’ mental health  to 5 (strongly agree). Studies have demonstrated high internal consistency (Chronbach’s α = .89 to .95), convergent and discriminant validity, as well as temporal stability of the NEO PI-R , affectional expression , satisfaction (satisfaction with the relationship and commitment to its continuance), and cohesion (common interests and activities). Participants respond to each item using a Likert scale, with higher values indicating greater relationship quality. The DAS has adequate internal consistency (Chronbach’s α = .70 to .95). The DAS has been validated for its use in both English and French  and the adequacy of social support (satisfaction). Internal consistency (Chronbach’s α = 0.74 − 0.78) for the ASSIS are adequate Barrera .The PERI Life Events Scale measures participants’ self-reported experiences of positive and negative life events which are coded as being dependent (e.g. divorce) or independent (e.g. a death in the family) of the participant’s own behaviour. Only negative dependent and independent life events were utilized due to their associations with mental illness  to 5 (Very Much). Standardized T scores for three primary styles of coping  were obtained. High internal consistency (Chronbach’s α = .78 − .88) and temporal stability have been reported for the CISS .2 = .15, R2 increment of .06 to .07). Therefore, a sample size of 92 was estimated to be sufficient to detect group differences in the aforementioned MANOVA analyses with power 0.80 and an alpha level of 0.05.Data were screened and corrected for outliers  and distributional anomalies that violated statistical assumptions. A series of Multivariate Analysis of Covariance (MANCOVA) tests were conducted to examine differences in personality traits, negative life events, coping skills, social support, marital adjustment and verbal aggression between BD and healthy control index parents, and the partners of parents with BD and healthy control partners. MANCOVAs were also conducted to explore differences between couples with a parent having BD and a comorbid PD, couples having a parent with BD and no comorbid PD and healthy control couples. Similar analyses were conducted to examine the effects of having an intimate partner with a history of MDD in couples with a parent having BD. Due to the issue of non-independence and to obtain a global estimate of couple functioning, the latter analyses used mean scores across all available parents when there was more than one parent in a family. For the measure of verbal aggression at the couple level, we averaged the mean levels of verbal aggression towards and from partners . Education, a proxy for socio-economic status, was used as a covariate for all analyses. For all analyses, we focus on contrast analyses comparing groups across dependent variables of interest rather than multivariate omnibus tests, as the latter was not of interest in the present study Kline . From thη2 = .15). Parents with BD also reported less effective coping strategies compared to index healthy controls. In particular, 10 and 13% of the residual variance in emotion-focused and avoidance-oriented coping, respectively, was explained by group membership. Index parents with BD reported low social support, including smaller networks, less satisfaction, and fewer contacts, relative to index healthy controls. Group differences were largest  for satisfaction with social network. Index parents with BD displayed less affection to their partner, were less satisfied with their relationship and perceived it as less cohesive, than index healthy control parents. Group membership explained between 6–8% of the residual variance in each of these areas of marital adjustment. Finally, parents with BD reported elevated levels of verbal aggression from their partner relative to healthy controls. `Of the index parents with BD, 15 (27%) also presented with PDs. As presented in Table The intimate partners of parents with BD and healthy control partners also differed. Among the intimate partners of parents with BD, 18 (31%) presented past or current major depression, 9 (15%) past or current alcohol abuse/dependence, 6 (10%) past or current drug abuse/dependence, 6 (10%) past or current anxiety disorders, 5 (8%) past or present eating disorders, 1 (2%) borderline PD, 1 (2%) avoidant PD, 1 (2%) narcissistic PD, 1 (2%) schizotypal PD, and 2 (3%) passive aggressive PD. As presented in Table Intimate partners of parents with BD also reported smaller social networks, less satisfaction with their social networks, and less satisfying social contact than the partners of healthy control parents. Similar to parents with BD, group differences were largest  for satisfaction with social network. Additionally, they reported less consensus  and satisfaction  in their marital relationships, and engaged in more verbal aggression towards their partners . Low couple satisfaction reported by the intimate partners of parents with BD, given the large effect size, was particularly robust.In sum, index parents with BD differed from healthy control index parents as to high levels of maladaptive personality traits, dependent negative life events, ineffective coping skills, low levels of social support, unsatisfying marriages, and verbal abuse from their spouse. Their intimate partners differed from the healthy control partners to a lesser extent, but significantly as to the same personality traits, the use of emotion-focused coping skills, low levels of social support, as well as unsatisfactory marital relationships and verbally abusing their spouse.The next series of analyses compared mean scores of couples with and without a partner with BD. As presented in Table all couples with a parent having BD vs. controls  by comorbid PDs and or a having a partner with MDD. Thus, the present findings indicate that couple and family therapy are also warranted. Many of the suggested intervention might improve family functioning and by extension the health of their children. Indeed, strong social support systems in parents with BD during middle childhood were found to act as a protective factor against the future development of substance use symptoms in OBD in early adulthood .In conclusion, adults with BD appear to select intimate partners with similar maladaptive personality traits, ineffective coping skills and who demonstrate high levels of verbal aggression. Moreover, both adults with BD and their intimate partners report a paucity of social support. These findings indicate that the intimate partners, as well as the partners with BD, could


Atypical clinical symptoms of juvenile hereditary hemochromatosis (JHH) often leads to misdiagnosis and underdiagnosis bringing ominous outcomes, even death.HAMP, OMIM: 606464).The whole exome was sequenced and interpreted. A literature review assisted to analyze and verify the phenotype–genotype relationships. We revealed the entire process of diagnosis, treatments, and outcome of two diabetic onset of JHH families to provide new insights for genotype–phenotype relation with novel compound heterozygous mutations in the hepcidin antimicrobial peptide (HAMP caused type 1 diabetic‐onset JHH. The two patients accessed irregular phlebotomy treatments, and then, experienced poor prognosis. We summarized the process of overall clinical management of reported 26 cases comparing to our novel atypical diabetic onsets Juvenile Hereditary Hemochromatosis cases.Two probands were diagnosed and treated as type 1 diabetes initially because of specific symptoms and positive islet autoantibodies. Poor control of hyperglycemia and progressive symptoms occurred. Sequencing informed that the compound heterozygous and homozygous mutations c.166C>G and c.223C>T in HAMP, of which the atypical JHH should be differentially diagnosed with type 1 diabetes at the onset. Early administration of phlebotomy and vital organs protection and surveillance might be important for the treatment of atypical JHH.It was first reported that positive pancreatic islet autoantibodies diabetes onset of JHH resulted from loss‐of‐function mutations of  It reported the positive pancreatic islet autoantibody diabetes onset JHH case. A novel compound heterozygosity mutation in HAMP was found. Early administration of phlebotomy and vital organs protection are important. The concentration of pancreatic autoimmune antibody was detected by radioligand binding assay (RLA)  software. Reads were mapped to the human reference genome sequence (assembly GRCh37/hg19) using the Burrows‐Wheeler Alignment Tool. Single nucleotide variants, insertion, or deletion were detected using the Genome Analysis Toolkit.www.mutationtaster.org), PolyPhen‐2 (genetics.bwh.harvard.edu/pph2), and SIFT (sift.bii.a‐star.edu.sg). The structure of protein was predicted by PSIPRED (http://bioinf.cs.ucl.ac.uk/psipred) and Phyre2 (www.sbg.bio.ic.ac.uk/phyre2). Conservation of amino acid change was analyzed by Clustal Omega sequence alignment tool and calculated by means of the WebLogo service. The HAMP (NM_021175) variates from probands and their relatives were amplified by PCR and sequenced by TsingKe Biological Technology  with Sanger sequencing.The variants sites, types, frequencies, and other information were obtained through databases and transcript annotation databases, such as 1000 Genome, Human Gene Mutation Database (HGMD), dbSNP, the Exome Aggregation Consortium (ExAC), Ensembl, UCSC, RefSeq, and Consensus CDS. The impacts on protein structure and function of variants were predicted using different mutation predictor software like Mutation Taster . Duel energy X‐ray showed osteoporosis because of low Z‐score of total hips (−3.3). In May 2015, 2‐II‐1 suffered impaired liver function, including elevated alanine aminotransferase 98 U/L, aspartate aminotransferase 63 U/L, alkaline phosphatase 179 U/L, and γ‐glutamyl transpeptidase 162 U/L. She was also diagnosed as hypothyroidism because of high TSH 25.51 uIU/ml and low FT4. The ultrasound showed increased thyroid volume and uneven echogenicity. Besides, physical examination revealed bruises, slight focal pigmentation  is a known mechanism of hemochromatosis (PVS1), absent in population data bases (PM2), recessive disorder detected in trans (PM3), computational evidence showed deleterious effect (PP3), and highly specific disease phenotype (JHH) with single gene (HAMP) (PP4). The c.166C>G of HAMP are “likely pathogenic” as it is absent in population data bases (PM2), recessive disorder detected in trans (PM3), computational evidence showed deleterious effect (PP3), and highly specific disease phenotype (JHH) with single gene (HAMP) (PP4).Thus, according to ACMG the two missense mutations of HAMP has at least two moderate and two supportive evidences of pathogenicity, fulfilled the criteria of ACMG for “pathogenic” or “likely pathogenic” variant. From the clinical, biological, genetic, and imaging data . The PolyPhen‐2 predicted missense mutation probably changing the protein secondary structure Figure  with a sBrissot, , the two3.3Following the diagnosis of hemochromatosis, 1‐III‐1 was treated with deferoxamine, an iron chelation treatment, from day 60 and phlebotomy once on day 67 Figure . Consequ2‐II‐1 received treatment of insulin for diabetes, levothyroxine for hypothyroidism, and polyene phosphatidyl choline for hepatic protection. But she got poor blood glucose control. After we made a clinical diagnosis of hemochromatosis, she received deferoxamine for iron chelation and refused phlebotomy. Her prognosis was also poor. Finally, she died of liver failure.3.4HAMP‐JHH with or without HFE, TFR2 mutations. The main clinical manifestations of HAMP‐JHH are hepatic involvement, hypogonadism, skin pigmentation, hyperglycemia, cardiomyopathy, arthropathy, osteoporosis, splenomegaly, primary hematological abnormality, and hearing loss. Hepatic involvement and hypogonadism are hallmark features of HAMP‐JHH as the frequency of them are 75% and 61%, respectively . Interestingly, all patients with mere HAMP mutations, whether intronic or exonic, have an onset age of less than 30 years. HAMP with HFE or TFR2 mutations (complex mutations) patients have a later onset age. The characteristics and distribution of onset symptoms in the two groups were also inconsistent, and the onset of symptoms in the mere HAMP mutations group seemed to have a more tendency of severity, which needed to be supported by more data  mutation from his father and a heterozygous c.223C>T (p. R75X) mutation from his mother, 2‐II‐1 owned homozygous c.166 C>G (p. R56G) mutation from her parents. We made an in silico prediction of the secondary structure of p. R75X and p. R56G and the 3D structure of p. R75X D Jones,  and PhyrD Jones,   (Hershko et al., HAMP gene. It is first time that the positive pancreatic islet autoantibodies featured type 1 diabetic‐onset hemochromatosis. Through the review of two Chinese cases and worldwide published patients with pathogenic HAMP mutations, we attached the importance that the early differential diagnosis, evaluation, surveillance, and protection of crucial organs from iron deposition and proper phlebotomy at the early stage are crucial for the good prognosis in HAMP‐JHH patients.In this study, we explored and reported the overall clinical management, including early stage of misdiagnosis, exact clinical and genetic diagnosis, treatment, and prognosis, of two novel atypical diabetic onsets JHH cases with novel compound heterozygous and homozygous mutation in the The authors declare that there is no conflict of interests regarding the publication of this paper.All authors participated sufficiently in the work to take public responsibility for the appropriateness of the collection, analysis, interpretation of the data, and editing the paper. HX Wu, JY Liu, DW Yan, and HD Zhou, designed the study protocol, contributed to the diagnosis and discussion of the study. HX Wu and HD Zhou wrote the manuscript. XH Zhuang, JY Liu, DW Yan, HX Wu, and HY Li provided and concluded clinical information. L Li performed the sequence analysis. DW Yan, HY Li, and ZG Zhou contributed to reviewing and editing the manuscript. HD Zhou is the guarantor and supervisor of this work. All authors read and approved the final version of the manuscript.Fig S1‐Table S1‐S2Click here for additional data file.


Studies have indicated that underdiagnosis and diagnostic delay are common in celiac disease. Therefore, it is important to increase our knowledge of what symptoms and biomarkers could identify undiagnosed cases of celiac disease.We screened for celiac disease antibodies in stored blood samples from 16,776 participants in eight population-based studies examined during 1976–2012. Undiagnosed celiac seropositivity was defined as celiac disease antibody positivity (IgG-deamidated gliadin peptide above 10.0 U/mL and/or IgA-tissue transglutaminase (TTG) or IgG-TTG above 7.0 U/mL) without a known diagnosis of celiac disease in the National Patient Register. In all studies general health symptoms were recorded by participant-completed questionnaire, including self-perceived health, tiredness, headache and gastrointestinal symptoms. Furthermore, blood samples were drawn for analyses of biomarkers e.g. hemoglobin, blood glucose, cholesterol, liver parameters and vitamins. The participants with undiagnosed celiac seropositivity were matched by sex, age and study with four controls among the celiac disease antibody negative participants.We excluded, five participants with known celiac disease, resulting in a population of 16,771 participants. In this population 1%  had undiagnosed celiac seropositivity. There were no statistically significant differences in symptoms between cases and controls. Undiagnosed celiac seropositivity was associated with low blood cholesterol (< 5 mmol/L) and low hemoglobin (< 7.3 mmol/L for women and < 8.3 mmol/L for men).In this general population study, undiagnosed cases of celiac seropositivity did not have more symptoms than controls, confirming the diagnostic difficulties of celiac disease and the low prognostic value of symptoms for a diagnosis of celiac disease. Furthermore, decreased levels of cholesterol and/or hemoglobin in the blood were associated with undiagnosed celiac seropositivity.The online version contains supplementary material available at 10.1186/s12876-021-01667-y. Celiac disease (CD) is a lifelong autoimmune disease caused by an abnormal immune response triggered by the ingestion of gluten-containing grains  in genetically susceptible individuals . CD is aIn Denmark, the prevalence of diagnosed CD is lower than in other European countries, despite recent increases in prevalence of CD recorded in national registries , 13. Fur. The screening for CD has been described elsewhere [, 16,776 participants with available serum were screened for CD antibodies by the EliA™ Celikey® TTG anti-IgA and anti-IgG assay, and DGP anti-IgG assays, and 169 participants were identified with undiagnosed celiac seropositivity , sex and study to four controls, antibody negative participants. The 169 participants with undiagnosed celiac seropositivity were matched with four antibody negative participants, giving 676 controls. We compared the cases and controls on general characteristics  not including 1.0 and p values < 0.05 (two-sided) were considered as significant. Statistical analyses were performed with software package SAS 9.4 and SAS Enterprise Guide 7.1 .Conditional logistic regression was performed in comparisons of cases and controls, to account for homogeneity among matched participants. General characteristics were compared between cases and controls using; Wilcoxon test and Independent samples A total of 16,776 individuals was screened for CD antibodies. Among these, five participants had a diagnosis of CD in The National Patient Register and were therefore excluded, resulting in a study population of 16,771 individuals; 9515 women and 7256 men. The five participants with a diagnosis of CD in the register were all CD antibody negative. The prevalence of undiagnosed celiac seropositivity, defined by CD antibody positivity (IgG-DGP ≥ 10.0 U/mL and/or IgA-TTG or IgG-TTG ≥ 7.0 U/mL) without a known diagnosis of CD, was 1% . The 169 participants with undiagnosed celiac seropositivity were matched with four antibody negative participants, giving 676 controls.Table p = 0.011). We found no significant association for liver parameters and undiagnosed celiac seropositivity, nor for fasting blood sugar, serum 25-hydroxy Vitamin D or serum Vitamin B12.We compared levels of biomarkers between cases and controls, in Table In this study the 169 participants (1%) with undiagnosed celiac seropositivity were matched with four controls among the CD antibody negative participants. The cases and controls were compared regarding general symptoms, abdominal symptoms and biomarkers. Our results showed no significant differences in symptoms, but for low serum cholesterol measurements (< 5 mmol/L) and low blood hemoglobin (< 7.3 mmol/L for women and < 8.3 mmol/L for men) we found a significant association with undiagnosed celiac seropositivity. Thus, this study confirms the diagnostic difficulties of CD and the low prognostic value of symptoms for a diagnosis of CD.p = 0.011). Indicating that for very low levels of serum ferritin, there might be an association with undiagnosed CD. It is however important to note the possibility of low iron, normal ferritin iron deficiency anemia, as ferritin is affected by other factors and can be in normal range fx. in patients with chronic disease.This study confirm our previous findings  of no maIn the present study we confirm the low prevalence of diagnosed CD; in this cohort 5 of the 16,776 screened individuals had a known diagnosis of CD in the National Patient Register (0.03%). This is consistent with a Danish register study showing the prevalence of diagnosed CD in adults increasing from 0.08% in 2006 to 0.18% in 2016 . When weThe population-based design is a strength of our study, since it may reflect a relevant non-clinical setting for screening of a wider population. Furthermore, the availability of stored blood samples for CD antibody measurements and linkage to nation-wide registries to exclude diagnosed cases of CD offered a unique opportunity to carry out this study. However, selection and response bias might be a limitation. Furthermore, our study might be limited by the slight uncertainty of the diagnosis of CD in the biobank analyses as clinical diagnosis and biopsies were not possible. Nevertheless, we know from our earlier study  that theIn this population-based study comprising 16,771 individuals 1% had undiagnosed celiac seropositivity, defined by CD antibody positivity with no known diagnosis of CD. Individuals with undiagnosed celiac seropositivity were compared with CD antibody negative matched controls, and we found no significant differences in general or abdominal symptoms, confirming the diagnostic difficulties of CD and the low prognostic value of symptoms for a diagnosis of CD. However, decreased levels of serum cholesterol as well as low blood hemoglobin was associated with undiagnosed celiac seropositivity.Additional file 1. Additional Material (Description of the population-based studies included), Additional Table 1 (Numbers of answers on symptoms for each symptom in the different cohorts), Additional Table 2 (Numbers and presence of biomarkers for each biomarker in the different cohorts) and Additional Table 3 (Questions from the questionnaires from the different cohorts translated to English).


Phase III clinical trials of the tumour necrosis factor inhibitors SB4, SB2, and SB5  have demonstrated efficacy in moderate-to-severe rheumatoid arthritis (RA). Data from these trials were used to identify baseline characteristics associated with radiographic progression and to build a matrix risk model for its prediction.Patients with radiographic progression and baseline demographic and disease characteristic data were pooled across the 3 phase III studies of each biosimilar and its reference product. Baseline demographics and disease characteristics were evaluated for their relationship with radiographic progression (1-year mean change in mTSS > 0); 3 factors were selected based on strongest Pearson’s correlation coefficient with the change in modified Total Sharp Score. Univariate logistic regression was performed to assess the association between each baseline factor and the rate of radiographic progression, with subsequent matrix model development performed using multivariate logistic regression.P < 0.001).A total of 1371 patients were included in the analysis, with a radiographic progression rate of 27.4%. The 3 baseline predictors of radiographic progression, based on Pearson’s correlation coefficient, were 28 swollen joint count (SJC28), C-reactive protein (CRP), and physician global assessment (PhGA). A matrix model showed that the predicted risk of radiographic progression was higher with the increased level of SJC28, CRP, and PhGA  associated with radiographic progression were similar to those described in prior studies. Even though radiographic progression was minimal, a small number of patients who have increased SJC28, CRP, and PhGA at baseline should be closely monitored and follow treat-to-target approach.https://www.clinicaltrialsregister.eu/ctr-search/trial/2012-005026-30/resultsEudraCT 2012-005026-30. Registered 30 April 2013, https://www.clinicaltrialsregister.eu/ctr-search/trial/2012-005733-37/resultsEudraCT 2012-005733-37. Registered 10 July 2013, https://www.clinicaltrialsregister.eu/ctr-search/trial/2013-005013-13/resultsEudraCT 2013-005013-13. Registered 01 April 2014,  Rheumatoid arthritis (RA) is a chronic, systemic disorder that causes clinical symptoms as well as structural joint damage leading to functional disability, poor quality of life, decreased work productivity, and substantial societal cost in terms of both direct and indirect costs –5. AchieResearch efforts have identified baseline factors that are predictive of radiographic progression and provide clinical value for identifying patients who require intensive treatment and monitoring from the time of diagnosis. Prior studies of nonbiologic and bDMARDs have revealed certain baseline factors associated with radiographic progression, including baseline swollen joint count (SJC), C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), rheumatoid factor (RF) and anti-citrullinated peptide antibody (ACPA) status, and the presence of erosions –29. DiseRisk factors for rapid radiographic progression have been identified in terms of a matrix risk model more than a decade ago  and sincSeveral previous studies showed a blunted relationship between the progression of joint damage and clinical disease activity during the course of treatment with bDMARDs , 31–36, This is a pooled analysis of 3 phase III studies that compared the efficacy and safety of each biosimilar TNF inhibitor  with its associated reference product  –41. All The methodologies of each of the 3 studies have been published in detail elsewhere –41. The Since the effects of all 3 TNF inhibitors on radiographic progression were similar and were also shown to be similar between originator and biosimilar TNF blockers –44, the Structural joint damage was assessed from x-rays of both hands and feet. Radiographs were scored at week 0 and the final study week  using the modified Total Sharp Score (mTSS), the sum of the joint erosion score and the joint space narrowing score , 46. X-rPatients with radiographic data, baseline demographics, and disease characteristics available from each study were pooled and analysed. The 3 individual baseline factors most associated with radiographic progression were identified based on those having the strongest Pearson’s correlation coefficient with the change in mTSS. Various demographic  and disease characteristics  were analysed  by CDAI, SDAI, and DAS28 at week 24/30. Separate matrices were built on joint space narrowing and joint erosion score, subcomponents of mTSS, and for the proportion of patients with joint erosion score > 0 and joint space narrowing > 0 in trichotomised cutoffs of each baseline factor.P values < 0.05  of whom experienced radiographic progression (> 0) with a mean change in mTSS of 0.41 . Of note, while on TNF inhibitor therapy, 121 (8.8%) patients had progression of mTSS ≥ 3. Baseline characteristics for all patients are displayed in Table P = 0.002), it did not significantly correlate with the numerical change in mTSS, which was the measurement used to extract individual baseline factors that were most associated based on Pearson’s correlation coefficient (P = 0.7261).Although RF status (positive [> 14 kIU/L] vs negative) significantly correlated with the presence of radiographic changes (yes/no) . The predicted proportion of patients with radiographic progression tended to increase as the matrix moved from the lower to the higher range of each risk factor. As an example, the proportion of radiographic progressors (patients with the 1-year change in mTSS > 0) in the group with the highest cutoff value of SJC28, CRP, and PhGA was 40.7% , whereas the proportion of radiographic progressors in the lowest cutoff value of SJC28, CRP, and PhGA was 15.5% . In the matrix, CRP had a significant association with radiographic progression (P < 0.0001). P values for SJC28 and the PhGA were 0.139 and 0.140, respectively.Development of the matrix risk model on radiographic progression Fig.  showed tIn the exploratory analysis, the matrix for the subcomponents of mTSS score was developed, and it showed that the predicted probability of patients with joint erosion score > 0 or joint space narrowing > 0 increased as each baseline factor worsened  and predicted probability of patients with radiographic progression (yes/no) based on SDAI and CDAI  confirmed these data by identifying baseline CRP level, RF/ACPA status, and in addition erosion score as independent factors for predicting rapid radiographic progression, defined as an increase in Sharp-van der Heijde score ≥ 5 after 1 year .Thus, matrix modelling demonstrated risk reduction with initial combination therapy that included infliximab or prednisone relative to MTX monotherapy, establishing treatment choice as a main determinant of rapid radiographic progression. However, in contrast to these prior risk models that determined risk by treatment arm, the current analysis did not compare radiographic progression by product or between biosimilars and reference products.The goal of our study was to determine if one could discern patients at risk for progression of joint damage while on TNF inhibitors, since joint damage is generally a sign of aggressive disease and high inflammatory propensity, especially if cumulative over time.Therefore, we did not examine rapid radiographic progression, since it is primarily observed upon administration of conventional synthetic DMARDs or placebo. However, since the matrix model shows that TNF inhibitors cannot prevent progression in patients at high risk, such patients may have to receive another treatment than a TNF-blocker, given their significant progression on these drugs. The predicted model also showed that patients with high levels of SJC28, CRP, and PhGA at baseline also showed slightly increased risk of higher disease activity by CDAI at week 24/30. Based on this, one can infer that baseline characteristics have a relationship with radiographic progression and disease activity. This further supports the importance of the treat-to-target approach; if the treatment target of LDA is not met between weeks 12 to 24, advancing to the next line of therapy is recommended . We alsoThis analysis has several limitations. Most notably, the lack of a placebo or MTX monotherapy group in the phase III studies precludes prediction of radiographic progression in reference to no biologic treatment. Another limitation is that ACPA status was not obtained in the study. Additionally, although the phase III studies had similar designs, patient demographics, and disease characteristics, they were not primarily designed to be combined.To identify baseline factors for patients on anti-TNFs, a more stringent definition of radiographic progression compared to previous matrix models , 29 was Our analysis of phase III clinical trials of biosimilars and reference products for RA identified baseline factors that were consistent with those identified for rapid radiographic progression in previous studies of csDMARD therapy in RA. This signifies that even though radiographic progression is minimal while on anti-TNF, a small proportion of patients still has significant progression, and clinicians should closely monitor patients who have high SJC28, CRP, and PhGA before treatment start whether they are started on csDMARDs or anti-TNFs.Additional file 1 : Table S1. Disease activity cut-off values. Fig. S1A. Predicted probability (with 95% confidence limits) of patients with radiographic progression (yes/no) based on CDAI. B. Predicted probability (with 95% confidence limits) of patients with radiographic progression (yes/no) based on SDAI. Fig. S2A. Matrix model of the proportion of patients with joint erosion score > 0 based on SJC28, CRP, and PhGA. Data are presented as % . Predicted probability of patients represented by shading: green, < 20.0%; yellow, 20.0–25.0%; red, > 25.0%. B. Matrix model of the proportion of patients with joint space narrowing > 0 based on SJC28, CRP, and PhGA. Data are presented as % . Predicted probability of patients represented by shading: green, < 15.0%; yellow, 15.0–21.0%; red, > 21.0%. Fig. S3A. Matrix model of the proportion of patients in remission or low disease activity by SDAI at week 24/30 based on SJC28, CRP, and PhGA. Data are presented as % . Predicted probability of patients in remission with low disease activity represented by shading: green, > 47.0%; yellow, 40.0–47.0%; red, < 40.0%. B. Matrix model of the proportion of patients in remission or with low disease activity by DAS28 at week 24/30 based on SJC28, CRP, and PhGA. Data are presented as % . Predicted probability of patients in remission with low disease activity represented by shading: green > 32.0%; yellow, 27.0–32.0%; red, < 27.0%. Fig. S4. Number of patients corresponding to each tertile of the 3 baseline factors.


Current guidelines for the treatment of anaplastic astrocytoma (AA) recommend maximal safe resection followed by radiotherapy and chemotherapy. Despite this multimodal treatment approach, patients have a limited life expectancy. In the present study, we identified variables associated with overall survival (OS) and constructed a model score to predict the OS of patients with AA at the time of their primary diagnosis.We retrospectively evaluated 108 patients with newly diagnosed AA. The patient and tumor characteristics were analyzed for their impact on OS. Variables significantly associated with OS on multivariable analysis were included in our score. The final algorithm was based on the 36-month survival rates corresponding to each characteristic.On univariate analysis, age, Karnofsky performance status, isocitrate dehydrogenase status, and extent of resection were significantly associated with OS. On multivariable analysis all four variables remained significant and were consequently incorporated in the score. The total score ranges from 20 to 33 points. We designated three prognostic groups: A (20–25), B (26–29), and C (30–33 points) with 36-month OS rates of 23%, 71%, and 100%, respectively. The OS rate at 5 years was 8% in group A, 61% in group B and 88% in group C.Our model score predicts the OS of patients newly diagnosed with AA and distinguishes patients with a poor survival prognosis from those with a greater life expectancy. Independent and prospective validation is needed. The upcoming changes of the WHO classification of brain tumors as well as the practice changing results from the CATNON trial will most likely require adaption of the score. Anaplastic astrocytoma (AA) is a diffusely infiltrating, malignant primary brain tumor. An update of the World Health Organization (WHO) classification in 2016 established new diagnostic groups based on histological phenotypes and genotypes, which are linked to unique biological behaviors and treatment responses [6-methylguanine-DNA-methyltransferase (MGMT) promoter methylation with better progression-free survival (PFS) and overall survival (OS). Together with a young age, a high initial Karnofsky Performance Status (KPS) and the presence of oligodendroglial histological characteristics are generally the most important factors associated with better outcomes of WHO grade III gliomas [As our knowledge of molecular markers has rapidly evolved, studies performed before the 2016 WHO classification update did not distinguish between the separate entities, as we currently do. Key research in the past decade lacked a clear distinction between AA and oligodendroglioma. In the NOA-04 study, molecular subgroup analysis of a mixed cohort of patients with WHO grade III tumors demonstrated associations of IDH mutations, 1p/19q-codeletion, and OIdeal treatments for the different subgroups as defined by the genotype remain uncertain. Radiotherapy (RT), chemotherapy (CTx), and a combination of both have all proven to be effective measures in primary and secondary treatment for different subgroups of diffuse glioma –4. CurrePrognostic scores for the heterogeneous entity “glioma” are well established, especially for recurrent disease. One of the earliest prognostic scores for re-irradiation of recurring glioma was published by Combs and colleagues in 2013 . It was This was a single-center, retrospective, observational study. Ethical approval was obtained from the Charité Review Board (EA2/150/20). The patient database of Charité Universitätsmedizin Berlin was searched for patients with AA who had received treatment between January 2010 and January 2020. We researched each patient’s medical record to assess the following eligibility criteria: age ≥ 18 years, primary histopathological diagnosis of a WHO grade III tumor, absence of 1p/19q-codeletion, and primary treatment received at Charité Universitätsmedizin Berlin. Treatment decisions at our center are made by a multidisciplinary tumor board and reflect the individual patient’s wishes. As part of a narrow follow-up schedule, all patients receive consultations and contrast-enhanced magnetic resonance imaging (MRI) controls every 3 months. Overall, 108 eligible cases were included. We then reviewed the respective medical records to retrieve information including basic patient characteristics , histopathology of primary diagnosis , primary therapy , disease progression, secondary therapy, last contact, and death.Six characteristics were analyzed for their potential association with OS: sex , age at the time of surgery , KPS , IDH status (mutant vs. wildtype), MGMT promoter methylation status (methylated vs. non-methylated), and resection status after primary surgery . The KPS was determined postoperatively. IDH mutation was determined by immunostaining. If IDH R132H was negative, additional pyrosequencing for IDH1/2 was performed. The extent of resection was defined based on postoperative contrast-enhanced MRI.p value < 0.05 was considered significant. Univariate analysis (UVA) was performed using the log-rank test. Variables that proved to be significant in UVA were included in a multivariable Cox regression analysis (MVA). We included characteristics that were independent predictors of OS in MVA in our scoring system. To generate a subscore for each variable, the 36-month survival rate for each characteristic was divided by 10. The subscores of all significant parameters were totaled to result in the score for each patient. This methodological approach has been demonstrated in other studies [Statistical analysis was performed using IBM SPSS Statistics for Mac OS, version 26.0 . A  studies , 13.2 daily. Standard adjuvant chemotherapy with TMZ included 150 or 200 mg/m2/d TMZ administered on 5 consecutive days as part of a 28-day cycle. Most patients received 12 cycles. If interruption or termination occurred at any point of treatment, we attempted to document the duration and reason. When comparing the different treatment arms of our cohort, patients receiving CTx only  showed significantly better survival (p 0.001) than those who received any kind of combined radiochemotherapy . This can be explained by substantial differences in the frequency of IDH-wildtype tumors: Of those 34 patients receiving RCTx, 7 (20.6%) had IDH-wildtype tumors. In contrast, there were only 2 (4.2%) IDH-wildtype tumors in the 49 patients strong CTx only group. This distribution is in line with the general recommendation for IDH-wildtype tumors to receive combination therapy.An overview of the patient and tumor characteristics most relevant for the construction of a prognostic score is presented in Table Median follow-up to last contact or death was 29.5 months. Forty patients underwent salvage therapy for recurrent disease. Salvage treatment regimens were quite heterogeneous. Nine patients received trimodal therapy with re-resection followed by RCTx. Eight patients had re-resection followed by either radiotherapy or systemic therapy. Six patients underwent re-resection without adjuvant treatment. Seven patients received RCTx without re-resection. Five patients received systemic monotherapy and another five patients received only radiotherapy without re-resection.p < 0.001), KPS (p < 0.001), IDH status (p 0.006), and extent of resection (p < 0.001) were significantly associated with OS. Sex and MGMT promoter status failed to show significance (Table p 0.011), KPS (p 0.033), IDH status (p 0.042), and extent of resection (p < 0.001) all remained significant (Table p = 0.021) and the RCTx group (p < 0.001).Age . For IDH-mutant astrocytic gliomas, homozygous deletion of the CDKN2A gene has recently been shown to be a powerful predictor of poor outcome . CDKN2A The second limitation of our study is related to the rapid changes in molecular testing and classification of astrocytoma in the past few years. The current 2016 WHO classification is already considered insufficient for grading and for forming prognostic groups, and an update is expected to be released by the end of 2020 [Thirdly, postoperative treatment in our cohort is very heterogenous. This illustrates the lack of suitable AA specific treatment guidelines until recently. Several historic studies have failed to demonstrate a universally superior postoperative treatment approach , 5, 21. Fourthly, all data were acquired retrospectively and therefore were not recorded in accordance with a predefined study protocol. The KPS was not documented in some patients, and in general, the number of patients with a good KPS was relatively high in our cohort. Finally, it must be mentioned that at this point, our analysis and the score we constructed lack validation in an independent cohort.We presented a model for a score that predicts the OS of patients newly diagnosed with AA. The scoring system requires four basic characteristics that are available at the time of histopathological confirmation of diagnosis: age, KPS, IDH status and extent of resection. None of the variables require additional diagnostic workup. The retrospective design of the results presented here should be considered. A validation of the score in an independent cohort is needed. In addition, future research must be in line with our growing understanding of molecular parameters, the changing treatment approaches, and the conclusions drawn in the upcoming revision of the WHO classification. A future version meeting these criteria could serve as a simple and useful tool in the choice of treatment regimen and patient consultations.


Relevant studies were identified through systemic searches of PubMed, Embase, Cochrane Library, Ovid, CNKI, and Wanfang database up to 28 February 2019. Changes in central retinal thickness (CRT) in μm and best-corrected visual acuity (BCVA) in logMAR equivalents at 1, 3, and 6 months after initial treatment were performed by pooled analysis. Adverse events (AEs) were evaluated. p=0.029) in patients with DME. IVC was superior to IVR in reducing central retinal thickness (CRT at 1 mo (p < 0.0001), 3 mo (p=0.025), and 6 mo (p=0.019)) from baseline with statistical significance. For AEs, the pooled results showed that no significant difference in the risk of intraocular pressure increased  or conjunctival hemorrhage  between two groups.  Eight articles involving 588 patients with DME were identified for this meta-analysis. The results showed that IVC significantly improved BCVA compared with IVR at 6 mo (SMD = −0.74 95% CI: −1.28 to −0.2;  This meta-analysis showed that IVC trended to be more effective than IVR in terms of functional and anatomic outcomes for treating DME. As a common manifestation of diabetic retinopathy (DR), diabetic macular edema (DME) is the foremost cause of central vision loss, and even blindness, which greatly influences patients' life quality . For DR Laser has been the gold standard treatment for DME since laser could result in a 50% reduction in severe vision loss . Neverthp < 0.05) [Ranibizumab , the first anti-VEGF agent approved by the FDA, is a humanized monoclonal antibody fragment, which could bind all active forms of VEGF-A . The mos < 0.05) . The occ < 0.05) .Although anti–vascular endothelial growth factor (VEGF) agents are mostly chosen as a first-line treatment, there is an important role for steroids in the treatment algorithm for DME. The potential role of intravitreal steroids in disease modification here has a significant rationale. Corticosteroids reduce not only leukostasis and inflammatory cytokine production, but also VEGF expression . SeveralTo date, no systematic review has discussed the therapeutic effect and safety of IVC versus IVR in DME. Therefore, we performed this meta-analysis to quantify the effect and safety of conbercept and ranibizumab in the treatment of DME.A systematic search was performed in electronic databases, including Wanfang, CNKI, PubMed, Embase, Ovid, and Cochrane library. The search terms were as follows: “conbercept,” “Ranibizumab,” “diabetic macular edema,” and their synonyms or similar words (from their inception to February 2019) with the search formula of (Conbercept) AND (Ranibizumab) AND (“DME” OR “diabetic macular edema”). The reference lists of included articles and relevant reviews were searched manually to find other potentially eligible studies.For inclusion, articles were selected on the basis of the following criteria: (1) the study population included patients with DME; (2) the IVC was included as an intervention; (3) randomized controlled trials (RCTs), retrospective or prospective cohort study, and observational study; and (4) reported best-corrected visual acuity (BCVA) or central retinal thickness (CRT).Studies were excluded if (1) combined with other diseases; (2) they were performed in pediatric patients (≤18 years old) and pregnant women; and (3) no full texts, full texts without raw data, review articles, and duplicate publications.Data collection and analysis were performed according to a standard Cochrane protocol . Two autData of BCVA and CRT were showed in terms of mean ± standard deviation (SD), in condition that the value of mean or SD was not provided in the article, we used Get Data software to estimate the mean and the SD from the reported graph. The Cochrane Collaboration's tool was applied to evaluate the risk of bias of each included study.I square test. If I2 exceed 50% (p < 0.01), heterogeneity was considered statistically significant, and random-effects model was applied. When no heterogeneity was detected or the heterogeneity was relatively small, fixed-effects model was used for the meta-analysis. Sensitivity analysis was performed to evaluate the influence of a single study on the overall estimate.STATA version 12.0  was used for the meta-analysis. For the outcomes of dichotomous data (frequency of adverse events (AEs)), odds ratio (OR) with 95% confidence interval (CI) was calculated, whereas continuous data (BCVA and CRT), standardized mean difference (SMD), and 95% CI were calculated. Between-study heterogeneity was assessed by n = 72) and screening of abstracts (n = 118), 10 potential articles were assessed for eligibility. However, 2 studies were excluded because of inconsistency data. Ultimately, 8 articles [A total of 200 studies were initially identified according to the index words. After removal of duplicates . No significant difference was found in BCVA between the IVC and IVR groups  . A random-effect model was used, and no significant difference was found in BCVA between the IVC and IVR groups at 3 mo  . The pooled results revealed that IVC significantly improved BCVA compared with IVR at 6 mo   vision. The pooled analysis of the mean change in BCVA from baseline to 1, 3, and 6 mo after treatment were displayed in a forest plot . Three sp=0.855) . Four stp=0.261) . Three sp=0.029) .I2 = 40.6%, p=0.135), and a fixed-effect model was used. Both interventions resulted in decreased CMT, and IVC was significantly more effective at 1 mo compared with IVR  . The random-effect model was used, and the pooled results revealed that IVC significantly reduced CMT compared with IVR at 3 mo  (p=0.019)  . Six andp=0.025)  and 6 mop=0.019) .I2 = 0%, p=0.792). Analysis using a fixed-effects model demonstrated no statistically significant difference between the IVC and IVR groups  (p=0.65) .Four studies demonstrated intraocular pressure increased after injection of conbercept and no heterogeneity among studies (p=0.352) . Similar(p=0.65) , with noIn the sensitivity analysis, we found that the removal of Guo et al.  decreaseThere is strong relationship between VEGF levels in both the anterior and vitreous chambers and DME severity , 35. TheRanibizumab, a recombinant humanized antibody fragment that binds vascular endothelial growth factor (VEGF), was the first drug approved for the treatment of DME . Conbercp=0.029), as well as reduction in CMT at 1 mo , 3 mo , and 6 mo  compared with the treatment of IVR. Previous study included four retrospective studies and five RCTs with a total of 609 patients, suggesting that both IVC and IVR are effective in the therapy of diabetic macular edema and affirm that IVC presents superiority over IVR therapy in regard of CMT in patients with diabetic macular edema, but no statistically significant difference with regard to visual improvement [In our study, we evaluated the efficacies and safety of IVC versus IVR in the treatment of DME based on eight studies including 588 patients. The results demonstrated that IVC could acquire significant improvement in BCVA at 6 mo  and 3 mo (p=0.261) after the initial treatment. But, IVC could acquire significant improvement in BCVA at 6 mo (p=0.029). The results showed that with the increase of time, BCVA improvement in the conbercept group was better than that in the ranibizumab group. DME resulted in dysfunction of central and sharp vision. Our meta-analysis showed that there was no significant difference in the degree of visual acuity improvement between the two drugs during short-term treatment. As the disease progress, conbercept has a significant visual improvement in the treatment of 6 mo, which may be associated with more VEGF-binding sites than ranibizumab [BCVA, a primary measure of treatment efficacy, is an exceedingly important function outcome. In this meta-analysis, we found the improvements in BCVA did not vary significant between the IVC and IVR groups at 1 mo . Our meta-analysis was restricted to publications in English and Chinese language, without some potential eligible studies in other language included, which probably led to bias. (2) The results of this meta-analysis were based on studies with relatively small sample size and, therefore, should be interpreted cautiously. More well-designed and large-scale trials should be conducted to verify our results. (3) Some of the studies analysed have not be published in impact factor journals. More authoritative articles should be included in further study.This meta-analysis is the first study to review the current evidences of published data regarding the use of conbercept versus ranibizumab in DME. Despite some limitations, the results of this meta-analysis are clinically useful and can offer some valuable, preliminary data on the clinical practice. However, the results of current literatures were uncompleted in all follow-up points, with the outcomes at 6 mo in most trials. Hence, more clinical studies in all follow-up phases should be required.