P < 0.01). Binary logistic regression analyses revealed that having depressive symptoms was positively associated with more severe insomnia  and pain , and was negatively associated with other psychiatric diagnoses , while having anxiety symptoms was positively associated with severe physical diseases , poor adherence to treatment , and more severe insomnia  and pain . Having combined depression and anxiety symptoms was positively associated with poor adherence to treatment  and more severe insomnia  and pain , and was negatively associated with the diagnosis of schizophrenia  and others . Depressive and anxiety symptoms were common in clinically stable older patients with psychiatric disorders during the COVID-19 pandemic. Considering the negative impact of these symptoms on QOL, regular screening and appropriate treatment are recommended for this population.The impact of the COVID-19 pandemic on clinically stable older patients with psychiatric disorders is unclear. This study examined the prevalence of depressive and anxiety symptoms, and their associations with quality of life (QOL) in clinically stable older patients with psychiatric disorders during the COVID-19 pandemic. This was a multicenter, cross-sectional study. Depressive and anxiety symptoms, insomnia, pain, and QOL were assessed with standardized instruments. A total of 1063 patients were included. The prevalence of depressive and anxiety symptoms, and combined depressive and anxiety symptoms were 62.3% (95%CI = 59.4–65.2%), 52.4% (95%CI = 49.3–55.4%), and 45.9% (95%CI = 42.9–48.9%), respectively. Patients with depressive and anxiety symptoms had significantly lower QOL than those without ( Compared to other age groups, older adults are more vulnerable during the COVID-19 pandemic2. For instance, older patients with COVID-19 (>50 years) have considerably higher fatality rate3 and poorer treatment outcomes5, which could exacerbate fear and psychological distress due to COVID-19.As of late July 2020, the Coronavirus Disease 2019 (COVID-19) pandemic has caused ~1 million deaths out of >39 million confirmed cases7. To reduce the risk of disease transmission, some preventive measures, such as quarantine and travel restriction, could trigger or worsen mental health status in older persons with psychiatric problems7. For instance, clinically stable older patients with psychiatric disorders usually require long-term maintenance pharmacotherapy. Due to lack of primary mental health services in most areas of China, it is necessary for clinically stable patients to regularly attend psychiatric clinics in urban areas for follow up and medication prescriptions9. However, as a result of quarantine and travel restriction, patients had difficulties attending hospitals, which may trigger mental health problems, such as depression and anxiety. In addition, older psychiatric patients usually suffer from chronic physical diseases, such as cardiovascular diseases and metabolic disease, which also require long-term medical reviews. Limited access to health services could result in deterioration of their physical diseases and increase their risk of mental health problems.Of older adults, those with preexisting psychiatric disorders need greater attention due to the high risk of mental health problems during the COVID-19 pandemic10. These are frequent comorbidities12 that are associated with poor prognosis13, cognitive impairment15, physical distress17, and social disability12. Even though more attention should be given to depression and anxiety in older psychiatric patients during the COVID-19 pandemic, no relevant studies have been published to date.Depressive and anxiety symptoms (depression and anxiety hereafter) are common mental health problems in older psychiatric patientsA better understanding of the patterns of depression and anxiety is needed to develop appropriate preventive measures and effective treatments for older patients with psychiatric disorders during the COVID-19 pandemic. In addition, quality of life (QOL) is a comprehensive health outcome that reflects individuals’ subjective perception of their overall health status. However, the association of depression and anxiety with QOL in older patients with psychiatric disorders is not clear. Therefore, we conducted this study to examine the prevalence of depression and anxiety, and their associations with QOL among clinically stable older patients with psychiatric disorders during the COVID-19 pandemic. We hypothesized that depression and anxiety were common among clinically stable older patients with psychiatric disorders during the COVID-19 pandemic, and these would have a negative impact on patients’ QOL.18; (2) older adults aged 50 years and above20; and (3) clinically stable as assessed by their treating psychiatrists, and able to understand the purpose and procedures of the assessments. Following previous studies22, “clinically stable patients” were defined as those who had changes in their dose of psychotropic medications of <50% in the past 3 months. This definition was also consistent with the clinical practice in the participating hospitals. Older patients and their guardians (if available) who regularly attended the outpatient clinics for maintenance therapy in each participating hospital were invited by a research psychiatrist with the approval from their treating psychiatrists to participate in this study. After providing their written informed consent on site in the outpatient department of the participating hospitals, they subsequently completed the online assessment using their smartphone. The study protocol was approved by the ethical committees of the participating hospitals.This was a cross-sectional study conducted between May 22 and July 15, 2020, in four major tertiary psychiatric hospitals in the eastern (Jiangsu province), southern (Fujian province), western (Gansu province), and northern (Beijing) China, which could represent a wide range of clinical settings in China. Older psychiatric patients receiving maintenance treatments in the outpatient departments of the four hospitals were consecutively invited to participate in the survey, if they met the following criteria: (1) diagnosed with psychiatric disorders according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10)23: N = (Zα2 × P × (1–P))/d2. The confidence level (Z) is equals to 1.96 at significance level of α = 0.05, P was the estimated proportion, and d is the tolerated margin of error and was calculated with 0.1 × P. A previous study has found that the prevalence of depression and anxiety were 27.9% and 31.6%, respectively, in the general population24. In order to achieve sufficient statistical power, we used P = 0.279 to calculate the sample size. Assuming 10% of patients who would refuse the invitation, 1000 patients were needed in this study.The sample size was calculated with the following formula27, data were collected using the WeChat-based “Questionnaire Star” program. The WeChat is a social communication program in smartphone with >1 billion users in China. As part of the process of receiving treatments at the participating hospitals, all patients (and/or their guardians) receiving maintenance treatments in the participating outpatient departments were WeChat users. For patients who had difficulties in use of smartphone, the research psychiatrists assisted them to complete the assessment using patients’ or their guardians’ smartphone.Due to the potential risk of transmission and logistical reasons during the COVID-19 pandemic, face-to-face interviews could not be performed. Following other studiesThe basic sociodemographic and clinical data  were collected. Questions with a “yes/no” option were used to collect COVID-19-related data, i.e., “whether or not they were concerned about the COVID-19 pandemic-related information”, “whether or not they frequently used mass media for COVID-19-related information”, “whether or not they had difficulty accessing their psychiatrists during the COVID-19 pandemic”, “whether or not they were adherent to psychiatric treatment during the COVID-19 pandemic”, and “whether or not they had difficulty attending psychiatric hospitals due to the COVID-19 pandemic restrictions”.29, which has been widely used in clinical research with a total score ranging from 0 to 2730. A PHQ-9 total score of ≥5 was considered as “having depression”, and ≥10 was considered as “having moderate to severe depression”31. The severity of anxiety was assessed using the generalized anxiety disorder (GAD-7)33, with the total score ranging from 0 to 21. A GAD-7 total score of ≥5 was considered as “having anxiety”, and ≥10 was considered as “having moderate to severe anxiety”32. Patients with both PHQ-9 total score of ≥5 and GAD-7 total score of ≥5 were considered as “having combined depression and anxiety”.Depression was evaluated using the validated Chinese version of the nine-item Patient Health Questionnaire (PHQ-9)34, which has been translated and validated in Chinese populations35. The ISI total score ranges from 0 to 28 with a higher total score indicating more severe insomnia. Those with an ISI total score ≥8 were considered “having insomnia symptoms”36. The severity of pain was evaluated using the “0–10” numeric rating scale on pain38, with “0” representing “no pain at all” and “10” representing “unbearable pain”39. The overall QOL was measured using the sum of the first two item scores of the World Health Organization Quality of Life-brief version (WHOQOL-BREF)42, with a higher score representing higher QOL.The severity of insomnia symptoms (insomnia hereafter) was assessed by the seven-item Insomnia Severity Index (ISI)χ2 test was used to compare categorical variables, while two independent samples t test and Mann–Whitney U test were used to compare normally and non-normally distributed continuous variables, respectively. The association between depression and anxiety were examined with Spearman’s rank-order correlation analysis.Data were analyzed using the Statistic Package for Social Science (SPSS) version 24.0. The normality of continuous variables was tested, using the P–P plot. The demographic and clinical variables were compared between depression and no depression groups, between anxiety and no anxiety groups, and between combined anxiety and depression and no anxiety or depression groups, respectively. Specifically, P < 0.05 (two-tailed).Binary logistic regression analyses with the “enter” method were performed to examine the independent correlates of depression, anxiety, and comorbid anxiety and depression, respectively. All variables with significant group differences in univariate analyses were entered as independent variables, while depression, anxiety, and combined anxiety and depression were entered as the dependent variable separately. The independent associations of depression, anxiety, and comorbid anxiety and depression with QOL were examined using analysis of covariance (ANCOVA) after controlling for variables with significant group differences in univariate analyses. The significance level was set at n = 347) of the total sample were males.Altogether, 1068 patients were invited to participate in the survey during the predefined study period. Finally, 1063 met the eligibility criteria and were included, giving a response rate of 99.5%. The sociodemographic and clinical characteristics of the participants were presented in Table P < 0.01). The prevalence of combined depression and anxiety was 45.9% (95%CI = 42.9–48.9%). The prevalence of insomnia  was 56.9% (95%CI = 53.9–59.9%).The prevalence of the overall depression  was 62.3% (95%CI = 59.4–65.2%), while the prevalence of moderate to severe depression  was 30.8% (95%CI = 28.0–33.6%). The mean total score of PHQ-9 was 7.75 (SD = 6.73). The prevalence of the overall anxiety  was 52.4% (95%CI = 49.3–55.4%), while the prevalence of moderate to severe anxiety  was 25.6% (95%CI = 23.0–28.3%). The mean total score of GAD-7 was 5.95 (SD = 5.76). Spearman’s rank-order correlation analysis revealed that depression and anxiety had a significant correlation , suffer from severe physical diseases (P = 0.03), and have lower education level (P = 0.02), poor treatment adherence (P < 0.01), and difficulty attending psychiatric hospitals (P < 0.01) during the COVID-19 pandemic, and suffer from more severe insomnia (P < 0.01) and pain (P < 0.01). The prevalence of depression was significantly different across different psychiatric diagnoses (P < 0.01) , suffer from severe physical diseases (P < 0.01), have poor treatment adherence (P < 0.01), and difficulty attending psychiatric hospitals (P = 0.01) during the COVID-19 pandemic, and have more severe insomnia (P < 0.01) and pain (P < 0.01). The prevalence of anxiety was significantly different across different psychiatric diagnoses (P < 0.01) , suffer from severe physical diseases (P < 0.01), have poor treatment adherence (P < 0.01), and difficulty attending psychiatric hospitals (P < 0.01) during the COVID-19 pandemic, and have more severe insomnia (P < 0.01) and pain (P < 0.01). The prevalence of combined depressive and anxiety symptoms was significantly different across different psychiatric diagnoses (P < 0.01)  and pain , and was negatively associated with other psychiatric diagnoses . Anxiety was positively associated with severe physical diseases , poor adherence to treatment , and more severe insomnia  and pain . Combined depression and anxiety were positively associated with poor adherence to treatment , and more severe insomnia  and pain , and was negatively associated with schizophrenia  and other psychiatric diagnoses   = 36.11, P < 0.01), while patients with anxiety had significantly lower overall QOL compared to those without anxiety  = 40.35, P < 0.01), and patients with combined depression and anxiety had significantly lower overall QOL compared to those without depression and anxiety  = 51.85, P < 0.01).ANCOVA revealed that patients with depression had significantly lower overall QOL compared to those without depression 24 in China, using the same measurements during the COVID-19 pandemic. This high prevalence of depression and anxiety in older psychiatric patients could be partly due to the fear of high mortality rate and poor prognosis in older people infected with COVID-195, which leads to considerable psychological distress in older population. Furthermore, many older psychiatric patients suffer from comorbid impaired cognitive function47, which may cause difficulties to understand and process COVID-19-related information, resulting in depression and anxiety48. In addition, the quarantine and travel restrictions during the COVID-19 pandemic did not only create barriers to access health services, but also cause disruptions to regular daily life and activities, all of which could increase the risk of depression and anxiety49.This was the first study that examined depression and anxiety in clinically stable older patients with psychiatric disorders during a pandemic. The prevalence of depression (62.3%) and anxiety (52.4%) in this study were higher than the corresponding figures in adolescents 50. The association between depression and anxiety is bidirectional; anxiety can trigger depression51 and vice versa52. The co-occurrence of depression and anxiety may be related to alteration of activation and connectivity of ventral cingulate and amygdala, and the polymorphic variations in the serotonin receptor gene54.In this study, comorbid depression and anxiety were not only common  among participants, but also significantly correlated with each other, which is consistent with previous findings56. For instance, a meta-analysis found that insomnia is a major risk factor of depression  and anxiety 56. On the other hand, depression and anxiety can also contribute to the development of insomnia58. Comorbid insomnia and psychiatric disorders may share common pathophysiology, such as similar alterations of arousal states59 and levels of inflammatory markers60.Patients with depression and/or anxiety reported more severe insomnia. The association between insomnia and psychiatric disorders is complex. On the one hand, insomnia can increase the risk of psychiatric disorders, including depression and anxiety61, and has a negative impact on QOL, sleep quality, and social functioning62. Previous studies found that certain psychiatric disorders  and pain commonly coexisted63, with bidirectional associations67.Depression and anxiety were associated with more severe pain in this study. Chronic pain  is common in older population68, or their psychological interventions due to low motivation and poor therapeutic alliance69. The positive association between anxiety and comorbid severe physical diseases  could be due to relevant to various factors, including physical distress, medication-induced side effects, and treatment cost72. In this study, patients with schizophrenia and other psychiatric disorders, except for major depressive disorder and organic mental disorder, were less likely to have combined depressive and anxiety symptoms, while patients with other psychiatric disorders, except for major depressive disorder and organic mental disorder, were less likely to have depressive symptoms alone during the COVID-19 pandemic. However, it is noteworthy that there were only 73 schizophrenia patients and 63 patients with organic mental disorders; therefore, the associations between primary psychiatric diagnoses and psychiatric symptoms during the COVID-19 pandemic needs to be confirmed in future head-to-head comparative studies.We found that anxiety and combined depression and anxiety was positively associated with poor treatment adherence, which is consistent with previous findings that patients with anxiety were more likely to discontinue their medication treatment due to side effects73. Depression and anxiety were associated with cognitive dysfunction15, physical distress17, and impaired social functioning12, which could lower patients’ QOL.As expected, patients with depression and anxiety had lower QOL than those without. QOL is determined by the interaction between protective factors  and distressing factors 74, and type and dose of psychotropic medications17, were not assessed in this study due to logistical reasons. Fourth, COVID-19-related information was assessed with self-reported standardized questions. The results of relevant objective measures would be more reliable, but they were not developed at the study time.The strengths of this study included the large sample size, consecutive sampling, high participation rate, and multicenter study design. However, several limitations need to be addressed. First, this study only recruited clinically stable patients from outpatient departments, which could limit the generalization of the findings to those in acute illness phase. Second, due to the cross-sectional study design, the causal relationships between depression/anxiety and other variables could not be examined. Third, some factors associated with depression and anxiety, such as cognitive function76, should be recommended for this population.In conclusion, depression and anxiety were common in clinically stable older patients with psychiatric disorders. Considering the negative outcomes caused by depression and anxiety, regular screening, and effective treatment, such as appropriate pharmacotherapy and psychotherapy


The aim of this study was to evaluate chemosensory function and oral disorders in patients with primary Sjögren’s syndrome (pSS) and to compare these findings with those of age- and gender-matched healthy controls.This comparative cross-sectional study included 58 patients with primary Sjögren’s syndrome (pSS) and 55 age- and gender-matched healthy controls. Olfactory and gustatory function, burning sensations in the tongue (BST) and halitosis were assessed. Oral health-related quality of life (OHRQoL) was evaluated using the short-form Oral Health Impact Profile (OHIP-14).p = 0.016) and VAS taste score  than healthy controls. A greater proportion of patients with pSS had anosmia (3.8% vs. 0.0%) or hyposmia (36.5% vs. 13.2%) and ageusia for basic tastes: sweetness (34.0% vs. 7.5%), sourness (10.6% vs. 0.0), saltiness (10.0% vs. 5.7%) or bitterness (19.1% vs. 1.9%) as evaluated using Sniffin Sticks test and taste stripts, respectively. A higher proportion of pSS patients complained of dysgeusia  and BST , while similar number of patients with pSS and controls reported halitosis . The mean OHIP-14 score was significantly higher in patients with pSS  indicating patients’ poorer OHRQoL compared with controls.Patients with pSS had significantly lower self-reported visual analogue scale (VAS) smell score (8.6 ± 2.2 vs. 9.6 ± 0.7, The majority of patients with pSS had impaired chemosensory function and indicators of oral health in comparison with the age- and gender-matched healthy controls. Further studies of oral hygiene habits and dietary intake of these patients are needed to ensure better management of oral health problems in patients with pSS. Sjögren’s syndrome (SS) is a chronic, systemic, autoimmune disease with the prevalence between 0.05 and 1% in European population. Exocrine glands, especially salivary and lacrimal glands, are mainly affected leading to dryness of the mouth and/or eyes. Fatigue, joint and muscle pain are commonly present in patients with SS. Sjögren’s syndrome can be further subclassified into primary disease  and secondary disease , when it is associated with another connective tissue disease ,  and [Nemanja Damjanov] prepared study material, collected data and did all the analyses.The patients with pSS were aged 25–77 years and were randomly and continuously recruited into the study from the Outpatient clinic of the Institute of Rheumatology. The exclusion criteria for the patients were inflammatory rheumatic diseases or systemic connective tissue diseases, active infections, malignant diseases, metabolic diseases or any other condition that, in the investigator’s opinion, could make a patient ineligible to participate in the study. The exclusion criteria for the healthy controls were subjective mouth and eye dryness, presence of chronic rheumatic, metabolic or malignant diseases.Disease characteristics , patient’s medical history, chronic diseases, use of medications, and unhealty lifestyle habits (such as smoking) were recorded. Schirmer’s I test and Rose Bengal score were used for evaluation of objective xerophthalmia. Compromised function of the major salivary glands was assessed by salivary scintigraphy using radioactive technetium-99 m (Tc99m) pertechnetate, as easy, reproducible and well tolerated techique. Excretion rate was defined as the difference between maximum and minimum excretion after being stimulated by vitamin C, divided by the maximum counts. The excretion level ≥ 50% was classified as normal or dysfunctional if it was < 50% , 20.2) were scored from 0 to 4, according to the semiquantitative scoring method of Chisholm and Mason [Labial salivary gland (LSG) biopsies were performed in patients with pSS. The degrees of lymphocytic infiltration of the salivary gland tissue sections  were measured by indirect immunofluorescence on the HEp-2 cell line substrate . The serum levels of rheumatoid factor (IgM-RF) were determined by laser nephelometry. Anti-Ro/SS-A and anti-La/SS-B antibodies were detected by enzyme-linked immunosorbent assay  , 20.The participants were instructed not to eat, drink, or smoke for at least 1 h before their appointment at the Institute of Rheumatology. A detailed personal medical history was recorded. Also, the participants were examined by specialists in rheumatology and dentistry.The olfactory and gustatory assessments were carried out as described below. Before olfactory testing, the subjects were asked to score their own general subjective smell perception on a visual analogue scale (VAS) from 0 to 10, where self-reported smell was scored as 0 = no smell perception up to 10 = very good smell perception. In cognitive evaluation of olfactory function an identification test with 12 odor pens  was used. The pens were positioned under the subject’s nose, approximately 2 cm from either nostril, for a maximum of 4 s. The subjects were instructed to choose from the three possible answers  for each of 12 odors on a multiple-choice scoring card . The ans2; Burghart Messtechnik, Wedel, Germany) were gently rubbed onto the anterior tip of the extended tongue. Different taste qualities were presented in a random manner. A chart with names of the four taste qualities was placed in front of the subjects during testing in order to ask the subjects to identify the taste of the strip. The subjects were allowed to rinse their mouths with water during the gustatory testing. Semi-quantitative evaluation for each of four taste qualities was performed as follows: 0 = loss of ability to taste, 1 = reduced ability to taste and 2 = normal ability to taste. This protocol resulted in a total maximum score of 8, for each subject.Before gustatory testing, the subjects were asked to score their subjective taste perception on VAS of 0–10, where self-reported taste score 0 meant no taste perception and score 10 meant very good taste perception. A gustatory assessment was performed after the subjects had been given a detailed explanation of the testing procedure. Gustatory function was evaluated using taste strips with four basic taste qualities sweet, sour, salty and bitter . The tasThe subjects of this study completed a questionnaire for the assessment of dysgeusia, burning sensation in the tongue (BST), and halitosis , 10, 12.The total OHIP-14 sum score ranged from 0 to 56, giving an overall indication of the patient’s OHRQoL. A high OHIP-14 score indicated a poor OHRQoL.Disease activity and the presence of extraglandular manifestations were estimated by the EULAR index of disease activity  , 28. TheNecessary Sample Size = (Z-score)2 * StdDev*(1-StdDev) / (margin of error)2.Statistical analysis was conducted using the Statistical Package for the Social Sciences (SPSS) version 16.0. The sample sizing procedure was as follows: we defined our Population Size and set our Confidence Level to be 95%, which corresponds to a Z-score of 1.96. Based on the relevant literature, we used 0.5 for SD value, which was an adequate number for our sample size. After defining these values, we used the Sample size formula: t-test was used to compare normally distributed continuous variables in both patient and control groups. A chi-square test was used to compare dichotomous variables. Odds ratios (ORs) with 95% confidence intervals (CIs) for smell or taste alterations in patients with pSS and healthy controls were determined. P values < 0.05 were considered statistically significant.Normality of the data was assessed by Kolmogorov-Smirnov normality test. Independent samples p = 0.917). The majority of subjects in either group were females (p = 0.244). The two groups did not differ significantly in smoking habits (p = 0.560). In comparison with patients with pSS none of the healthy controls had subjective experience of ocular dryness (< 0.0001), oral dryness (< 0.0001), dysphagia (< 0.0001), nasal dryness (< 0.0001), dyspareunia (< 0.0001), salivary gland enlargement (< 0.0001) or Reynaud phenomenon (< 0.0001). The mean disease duration in patients with pSS was 7.65 ± 5.85 years, ranging from 1 to 22 years. The majority of patients with pSS (43%) had moderate disease activity as estimated by ESSDAI EULAR index of disease activity. More than half of patients (60%) reported that they were not satisfied with their current health status as assessed by EULAR SS Patient Reported Index ESSPRI. The vast majority of patients (more than 88%) had positive salivary gland scintigraphy, salivary gland biopsy and abnormal tear breaking-up time (BUT), Schirmer’s test and Rose Bengal score. The majority of patients (71%) were positive for antinuclear antibodies, SS-A autoantibodies (81%) and RF (69%). The mean value for erythrocyte sedimentation rate (ESR) was 25.7 mm/hour and it ranged from 2 to 88 mm/hour. Leucopenia was found in more than half of the patients (62%). Twenty–two patients with pSS (38%) were on corticosteroid therapy, whereas the majority among them (75%) took 10-50 mg of corticosteroids per day. The majority of patients (81%) used artificial tears, while only 4% of patients used artificial saliva, 46% received Chloroquine or Hydroxychloroquine, 3% Azathioprine and 2% Methotrexate. The majority of patients in this study received drugs that are not expected to have significant effect on chemosensory function.The characteristics of patients with pSS and healthy controls are shown in Table p = 0.016; , as shown in Fig. The pSS group had a significantly lower mean self-reported smell score on VAS than healthy controls . Gustatory testing showed that the pSS patient group had significantly lower mean taste scores than the control group  (Table p = 0.054), salty (p = 0.018) and bitter (p = 0.001) than healthy controls.The patients with pSS had a significantly lower mean self-reported taste score on VAS than healthy controls . Thirty patients with pSS who complained of dysgeusia described the taste as metallic, sour, bitter, rotten or unpleasant. The majority of patients reported distorted bitter taste (36.7%), while all controls that reported dysgeusia (9.4%) complained of unpleasant taste. Similar proportions of the patients with pSS (77%) and healthy controls (67%) experienced distorted taste as a daily problem.Complaints of dysgeusia, BST, and halitosis in the patients with pSS and healthy controls are shown in Table 2 = 31.6, p < 0.0001). The majority of patients with pSS (38%) experienced burning sensation in the tongue during the meals and 39% of them reported sour taste sensation as a type of BST.While none of the controls complained of burning sensation of the tongue (BST), nearly half of patients with pSS reported BST (46%) . Half of the pSS patients experiencing halitosis complained of halitosis as a persisting daily problem, similarly to the majority of healthy controls (80%) who also reported halitosis as a daily problem (p = 0.328).About 32% of patients and 28% of controls complained of halitosis, but the difference between the two groups was not significant . The obtained results show that pSS is a risk factor for the development of dysgeusia, BST and anosmia.Odds ratios for the development of dysgeusia, BST and halitosis were determined in patients with SS and healthy controls and the results are given in Table p < 0.0001).The pSS group had a significantly higher mean OHIP-14 sum score than the control group   and poor OHRQoL in comparison with the healthy controls without sicca symptoms. We found similar frequencies of halitosis among patients with pSS and the healthy controls. Our findings are in agreement with other studies showing disturbed taste and smell functions in patients with SS , 30, 31.In our study, gustatory dysfunction was more frequently found in patients with pSS than olfactory dysfunction. This finding is consistent with some studies , 6, 31, There are indications that smell and taste impairments, as well as the burning sensation in the mouth may be caused by hyposalivation , 13, 32.We observed relatively high percentage of ageusic and hypogeusic patients within the group of patients with pSS. While ageusia is a rare condition that accounts for less than 1% of patients with chemosensory dysfunction –35, the As for olfactory function, anosmia is the most common complaint of patients with chemosensory disorders , 31, 33.About half of the patients with pSS complained of BST, while none of healthy controls experienced BST. BST in patients with pSS was mainly related to food intake. Burning sensation in the mouth is frequently found in patients with SS . More thPossible underlying cause of high occurrence of olfactory and gustatory dysfunctions in patients with pSS could be systemic inflammatory response such as overexpression of interferon–inducible genes . Toll-liOral malodor has been receiving increasing attention over the last decade. In the present study, a third of the patients with pSS complained of halitosis, whereas similar proportion of healthy controls reported oral malodor. The main oral causes of this disorder and effective treatment strategies are known . HoweverChemosensory and oral disorders, burning mouth syndrome in particular, usually reduce the patients’ quality of life, and ‘psychological dysfunction’ is common in patients with this diagnosis . ConsistA recently published meta-analysis by Al-Ezzi et al.  suppliesA most recent study demonstrated significantly high occurrence of dysgeusia, burning mouth sensation, halitosis and reduced taste sensation in non-SS sicca patients and patients with pSS. Although non-SS sicca patients do not fulfill Sjögren’s syndrome classification criteria, they had similar or even worse oral complaints than the patients with pSS . On the The results obtained in this study show that the patients with pSS had impaired olfactory and gustatory function. Impaired chemosensory function had negative impact on quality of life in patients with pSS. The occurrence of oral disorders, such as dysgeusia, BST, and halitosis was frequently found in patients with pSS and was associated with poorer OHRQoL compared with age- and gender-matched healthy subjects. Therefore, a regular assessment of chemosensory functions and oral disorders in patients with pSS should be performed. Symptomatic treatment of xerostomia and prevention of infections could improve the oral health-related quality of life in these patients. Future studies of habits related to oral hygiene and dietary intake are needed to ensure improved treatment of oral health problems in patients with pSS.


Little evidence has examined the therapeutic effects of methylphenidate (MPH) and Matrix Model treatment on addiction severity, craving, relapse and mental health in people who use methamphetamine (PWUM). This study was conducted to determine the effects of MPH, Matrix Model treatment, and Matrix-MPH on addiction severity, craving, relapse and mental health in PWUM.n = 25); 2) MPH 10 mg/day in the first month, 7.5 mg/day in the second month and 5 mg/day in the third month (n = 25); 3) Matrix Model treatment combined with MPH (n = 25); 4) control group (n = 25) for 12 weeks. Addiction severity, craving, relapse and mental status were evaluated at baseline and end-of-trial.This clinical trial was conducted among 100 patients with METH users. Participants were randomly divided into four groups who received: 1) 22 sessions of 45-min, twice a week for Matrix Model treatment (P < 0.001) and addiction severity (P < 0.001). In addition, Matrix Model treatment combined with MPH resulted in a significant increase of mental health (P = 0.001), compared with Matrix Model treatment, MPH, and control group. Also, negative METH urine test significantly increased in the Matrix Model treatment combined with MPH group compared with the other groups (P < 0.001).Matrix Model treatment combined with MPH significantly reduced MA craving  for clinical trials registration (http://www.irct.ir: IRCT20171105037245N1). Registration date: 9 December 2017.This study was retrospectively registered in the Iranian website ( Methamphetamine (METH) is a widely used illicit drug. In the world, between 162 and 324 million people used an illicit drug  at least once in the previous year. METH is a highly addictive psycho-stimulant and a current health concern in Iran . PWUM isMain strategy for managing stimulant disorders is psychosocial interventions  in Iran and in the world. Also, motivational interviewing, cognitive behavioral therapy, family therapy, and contingency management could be employed as treatments for PWUM –11. AccoPharmacotherapy has been emerged as a new platform in the treatment of drug use. This therapy can have some benefits. Regardless of various benefits, there are different challenges to utilize pharmacologic components in order to attain the best method of therapy in drug use. From the psychotic disturbance perspective, the impact of MPH on drug use therapy has been confirmed . MPH is To our best knowledge, studies demonstrating the effects of MPH, Matrix Model treatment and matrix-MPH on clinical symptoms improvement  in PWUM are scarce. Therefore, we hypothesized that joint Matrix model with Methylphenidate treatment is better than single Matrix model or Methylphenidate treatment on addiction severity, craving, relapse and mental health among PWUM.http://www.irct.ir: IRCT20171105037245N1). This clinical trial was performed on 100 patients with PWUM, 20 to 48 years old, who were referred to the Faraby Hospital Substance Dependency Clinic in Kermanshah, Iran. All participants fulfilled The Declaration of Helsinki requirements and signed an informed consent. This study was approved by the ethics committee of Kashan University of Medical Sciences (IR.Kaums.REC.1396.59).This study was registered in the Iranian website for clinical trials  of over-the-counter or prescription drug that would be expected to have major interaction with MPH, major cardiovascular disorder and epilepsy.This study was conducted from November 2017 to February 2018 among volunteers from PWUM in Faraby Hospital Substance Dependency Clinic in Kermanshah, Iran. All patients received MMT program. Methadone was consumed in the form of syrup by patients. The patients were divided into four groups: Matrix Model treatment, MPH, Matrix-MPH and control groups by a trained staff. The first group (25 people) was treated with Matrix Model treatment for 22 sessions of 45 min, twice a week for three months  designed by Franken et al. . DDQ is GHQ-12 includes 12 items rated on a 4-point Likert scale . A study on 421 adult outpatients in Germany has reported high internal consistency for GHQ-12 (α = 0.91) . In IranThe patients’ urine tests were examined for the presence of amphetamine, METH, and methadone at the beginning of the study and on every three weeks visit. These tests were performed to assess relapse for patients.Leeds Dependence Questionnaire (LDQ) was designed to measure the degree of dependency from mild to severe. It is used to assessment the dependency of various substances. LDQ-10 items are a based on a four-point Likert scale. Cronbach’s alpha was demonstrated to be 0.94 and test-retest reliability was 0.95 . In IranIn this study, we were used a randomized clinical trial sample size calculation formula where type one (α) and type two errors (β) were 0.05, and 0.20 (power = 80%), respectively. According to our previously published trial , in the MPH group, 3 individuals [withdraw (n = 1) and health problems (n = 2)], and in the Matrix Model treatment combined with MPH group, 4 individuals [withdraw (n = 2) and the personal reasons (n = 2)] were excluded. The exclusions in the control group were 3 patients [the personal reasons (n = 3)]. Finally, 85 patients  completed the trial , LDQ score (P < 0.001), and GHQ score (P = 0.001)  Table .Table 4In four groups, all METH urine tests were positive in the beginning of the trial. Over the next few weeks, METH Positive Urine test (MPUT) were gradually reduced in four groups, but the reduction was greater in Matrix-MPH group compared with other groups. Twenty percent (4/20) in Matrix Model treatment group, 40.9% (9/22) in MPH group, 61.9% (13/21) in Matrix-MPH group, and 5% (1/22) in the control group had negative METH urine tests in the last week. In addition, our study revealed that there was a significant effect in METH positive urine tests among four groups (P < 0.001). GEE logistic regression model revealed Matrix Model treatment combined with MPH had an effective treatment on relapse rate with odds ratio 7.63  compared with other groups (Table The current study compared the efficacy of two therapies MPH and Matrix-MPH on reducing METH craving, addiction severity, relapse, and mental health in PWUM. Results showed that Matrix-MPH was effective in reducing METH craving, addiction severity, relapse, and improvement of mental health symptoms. In the current study, the effect size of LDQ and GHQ was nearly 0.2 means that the score of average person in the co-treatment group was nearly 0.2 standard deviations above the average person in other groups, and hence exceeds the scores of 58% of other groups. In addition, the effect size of DDQ was nearly 0.38 means that the score of the average person in the co-treatment group was 0.38 standard deviations above the average person in other groups, and hence exceeds the scores of 68% of other groups. It must be kept in mind that in the current study, METH use parameters at baseline demonstrated that individuals were using METH for a maximum of 2.3 years. Long-term PWUM may lead to abnormal findings in CNS, renal, skin, and gastrointestinal. Therefore, METH heavy users for a longer time may require longer treatment duration. Previous study showed that mental and clinical disturbances were present in PWUM under MMT. Based on these findings, Matrix Model treatment combined with MPH may be an appropriate adjunct therapy for PWUM. To our best knowledge, this clinical trial for the first time evaluated the effects of Matrix Model treatment and MPH on craving, addiction severity, relapse, and mental health in PWUM.Addiction is a mental disturbance that influences all aspects of life, family, individual health, and society . PWUM unCraving, withdrawal syndrome, physical, and psychological harms have been linked to amphetamine/methamphetamine use, especially with an enhancing frequency of use , 43, 44.The present study had some limitations. Duration of this study was short. Long-term duration may lead to better effects. Also, we did not evaluate the effects of Matrix Model treatment and MPH on metabolic profiles and cognitive function. In addition, we could not evaluate the pain in our methadone therapy program. Another limitation was that no female subjects were in the project, as cultural considerations tend to prevent women from referring to MMT clinics in Iran.In summary, the combination of the Matrix Model treatment with MPH in PWUM under a MMT program had a beneficial effect on addiction severity, craving, relapse, and mental health parameters. Further studies are needed to show the relative impact of Matrix Model treatment and MPH on PWUM under MMT program.


The indications for conversion were right ventricular failure (RVF) (65%), cardiogenic shock (26%), and other (9%). In the converted patients, there was a significant increase in Sequential Organ Failure Assessment (SOFA) scores between admission 12 (9–13) and conversion 15 . Compared to non-converted patients, converted patients also had a higher mortality rate  and a lower admission Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score (p < 0.001). Outcomes were especially unfavorable in those converted due to RVF. These results indicate that VA ECMO, as opposed to VV ECMO, should be considered as the first mode of choice in patients with respiratory failure and signs of circulatory impairment, especially in those with impaired RV function. For the remaining patients, Pre-admission RESP score, daily echocardiography, and SOFA score trajectories may help in the early identification of those where conversion from VV to VA ECMO is warranted. Multi-centric studies are warranted to validate these findings.No major study has been performed on the conversion from venovenous (VV) to venoarterial (VA) extracorporeal membrane oxygenation (ECMO) in adults. This single-center retrospective cohort study aimed to investigate the incidence, indication, and outcome in patients who converted from VV to VA ECMO. All adult patients (≥18 years) who commenced VV ECMO at our center between 2005 and 2018 were screened. Of 219 VV ECMO patients, 21% ( Extracorporeal membrane oxygenation (ECMO) has been successfully employed in pediatric and neonatal patients since the 1980s ,3,4,5. TDuring treatment with VV ECMO, cardiocirculatory failure, including right ventricular failure (RVF), may develop and necessitate a need for circulatory support . To achiConversion between ECMO modes was first described by Bartlett et al. in neonatal patients with progressive circulatory failure ,12. DespThe aim of this study was to review our institutional experience of patients who required conversion from VV to VA ECMO in order to provide population-based observational data on the indications for, the incidence of, and outcome following the procedure.All adult ≥18 years) patients admitted for VV ECMO support at ECMO Centre Karolinska, between January 2005 and December 2018, were eligible for inclusion. Patients who were partially treated at a different hospital or who underwent cardiopulmonary resuscitation during cannulation were excluded. Patients converted to VA ECMO within the first six hours of ECMO treatment were also excluded. This time frame was chosen since (1) patients who have not stabilized on VV ECMO within a few hours often require VA ECMO support  and (2) a few uncertain cases may have been precautiously cannulated for VA ECMO, as 80% of our patients were cannulated at a referring hospital with a 3–6 h transport time ahead of them  years pa.In accordance with the routine standard of care, all patients were treated with a positive end expiratory pressure (PEEP), low tidal volume , removal of fluid overload, pulmonary vasodilators, and optimized inotropic therapy. A tracheostomy was performed within the first 2–3 days, with the goal of keeping the patient awake and allowing pressure support ventilation. The typical patient may have higher tidal volumes in this phase of ECMO treatment than in many comparable European centers .http://www.respscore.com, accessed on 26 December 2020)—a score developed from ELSO Registry data and used to help compare ECMO cohorts.Data was retrospectively obtained from digital medical records and hospital charts. The following data were collected for all patients at ECMO initiation: sex, age, ECMO mode, Simplified Acute Physiology Score (SAPS-3) ,22 and Rin) and at the time of conversion to VA ECMO (SOFAconv). We used the SOFA score to quantify organ failure severity and trajectory over time. Survival After Venoarterial ECMO (SAVE) [http://www.save-score.com, accessed on 26 December 2020).The following additional data were collected for patients who were converted from VV to VA ECMO: body weight (on admission), ventilator settings, arterial blood gas data, blood pressure, number of vasoactive drugs, as well as vasoactive inotropic score  (VIS) (oO (SAVE)  score waPREO2 and/or increased plasma lactate. Right ventricular failure was defined as end-diastolic dilatation of the right ventricle, or a tricuspid annular plane systolic excursion of less than < 16 mm [Echocardiography, a well-accepted technique to assess central hemodynamics during ECMO ,28,29, a < 16 mm ,31,32,33t-test or ANOVA was used for comparison of normally distributed data, and a Mann-Whitney U test, Wilcoxon signed-rank test, or Kruskal-Wallis test was used for comparison of non-parametric data. For categorical variables, a Fisher’s exact test or chi-square test were used depending on sample size distribution. The statistical significance level was p < 0.05.Data were tested for normal distribution using a Shapiro-Wilk test. Normally distributed data are presented as mean (± 1 SD), non-parametric data as median (25–75% quartiles), and categorical data as numbers (proportion). A The study was approved by the Regional Ethical Review Board in Stockholm, Sweden (DNR: 2017/1671-32), who waived the need for informed consent.In total, 213 adult VV ECMO patients were screened , of whomn = 19); viral pneumonia (n = 6); sepsis/non-trauma acute respiratory distress syndrome (n = 8)), aspiration 9% (n = 4), trauma (n = 3), immune-related/cancer (n = 5), and one case of pulmonary edema. Patients who required conversion from VV to VA ECMO had significantly lower admission RESP scores compared to the non-converted cohort (−2.5 (−4–1) vs. 2 (0–4), p < 0.001). No such difference was observed for admission SAPS-3 scores  increased, pH normalized, and respiratory rate and tidal volume (Vt) were decreased while ventilator pressures and fraction inspired oxygen (FiO2) were adjusted to lower settings (p < 0.02) and VIS from 10 (3.8–38) to 4 (0–21) (p < 0.0001). Mean arterial blood pressure was maintained at 65 mmHg. At the time of conversion, positive end-expiratory pressure had been further reduced, Vt was reduced since the start of ECMO, and SO2 had dropped from 88 (79–93) to 80 (71–88) (p < 0.001) %. FiO2, SOFAc, the number of vasoactive drugs, and VIS were all significantly higher than during early ECMO support  of the cases  and RVF . The remaining four patients were converted to help decrease intracranial pressure (n = 1), pulmonary edema caused by a mitral valve prolapse (n = 1), and unknown (n = 2). Subsequently, to avoid selection bias, these four patients were not included in the detailed analyses of RVF and circulatory failure below. The mortality rate for the converted group was significantly higher compared to non-converted patients , with conversion inferring a relative risk (RR) for mortality of 3.76 . Detailed data for all 46 patients at the time of conversion and their outcomes are presented in The main indications for conversion were circulatory shock (p < 0.001)), indicating two different courses of development. Of note, both groups were converted within one day of recognition of the need for circulatory support (0 (0–0.5) days in circulatory failure vs. 0.9 (0–1) days in RVF (p = 0.12)). None of the patients who developed circulatory failure were diagnosed with a myocardial infarction (MI).For the twelve patients who were converted due to circulatory shock (without RVF), the time to conversion was 2.1 (1.3–4.1) days. The corresponding time for the RVF-group was 11 (5.4–15) days (significantly longer (p < 0.001). SOFAc and number of vasoactive drugs also increased, from 43 (3–4) to 4 (3–4) (p < 0.05), and 1 (1–1) to 21 (1–2) (p < 0.00021), respectively. VIS, which decreased during the first 12 h (p < 0.02), pivoted and increased significantly until the time of conversion (p = 0.012),  at admission to 15 (13–17) at conversion (nversion . The mos 0.012), .p = 0.46). However, converted patients with RVF showed a significantly longer time on ECMO compared to those in circulatory failure, 29.6 (17.3–42.1) vs. 10.4 (5.9–29.1) days (p = 0.048), respectively. Paradoxically, on admission, patients who later developed RVF presented with a significantly lower VIS, lactate, and SOFAin score than those who developed circulatory failure (p < 0.001)). Furthermore, their admission RESP score was higher than their pre-conversion SAVE score (−3 (−4–0.8) vs. −8 (−10–−6)). This indicates that they had deteriorated, as the corresponding EMR was 64% (95% CI 56–72%) for the RESP score and 74% (95% CI 67–82%) for the SAVE score. However, it should be noted that RESP and SAVE scores are not interchangeable when it comes to estimated risk to survival.Mortality for patients who were converted due to RVF without circulatory shock was 67% (10/15), which was the same as in patients with RVF and circulatory shock . Circulatory shock patients (in the absence of RVF) had a mortality rate of 50% (6/12). No increase in RR for death was seen in patients converted due to RVF as compared to those patients in circulatory shock without RVF, (RR 1.33 (95% CI 0.72–2.48),  failure . BesidesThe aim of this study was to present our institutional experience from a population-based cohort of adult patients who required conversion from VV to VA ECMO. Out of 213 patients, 21% required conversion to VA ECMO, a frequency higher than previously reported . This maCompared to non-converted patients, converted patients had increased in-hospital mortality. This was also implied by the lower admission RESP score . Somewhat worryingly, the mortality rate for the patients who were converted from VV to VA ECMO was also higher than the overall mortality rate for VA ECMO patients at our center (61% vs. 36%) . This sudid not overlap, indicating a probable absolute mortality risk difference of approximately 20%. This increased risk of death in patients with RVF has also been described in conventional intensive care patients not supported with ECMO [Patients converted due to circulatory shock were identified as candidates for conversion within 2 days of ECMO initiation, whereas those who developed RVF were recognized after 11 days. RVF was also the most common indication for conversion to VA ECMO. The RVF subgroup who did not develop circulatory shock were in this early phase of circulatory failure undistinguishable from the non-converted VV patients . This further stresses the importance of continued daily monitoring of organ and cardiac function to help identify the patients who will develop RVF during treatment. However, the RVF subgroup who developed circulatory failure significantly differed in admission RESP score compared to the whole VV cohort, suggesting that these patients were in a more severe state of illness already on admission. The confidence intervals of RESP “−3” and “1” ith ECMO .For all converted patients, SOFA scores increased from admission to the time of conversion by ~3 points. This corresponds to a >20% increased risk of mortality in that section of the SOFA score scale . A similLimitations of this study include the retrospective design and the use of high-volume center data for generalized recommendations to ECMO providers. No patients with circulatory failure suffered a MI. However, cytokines were not assessed, and we can therefore only speculate on cytokine/inflammatory influence on myocytes and vascular walls. While the study spanned over a 14-year period, the treatment and management protocols have been rather uniform during this time. We consider the exclusion of patients converted within the first 6 h after commencement of ECMO a reasonable way to avoid study bias since such an early conversion was presumably due to poor selection of the initial mode.The benefit of blood oxygenation achieved by VV ECMO is meaningless if the oxygen is not delivered to the tissue. Consequently, patients with respiratory illness and signs of shock or circulatory failure run the risk of deterioration even if VV ECMO is applied. If a patient on VV ECMO develops a need for circulatory support, the benefits of conversion to VA ECMO must be weighed against the risks involved in cannula re-configuration. As highlighted in this study, patients converted from VV to VA ECMO had a higher mortality rate than those not converted. Notably, this mortality was also higher than for patients who commenced and were treated with VA ECMO. These results, together with the results from a recent publication , suggestThe subsequent question is which patients should be started on VA instead of VV ECMO? Our results showed that patients who required conversion were identified using routine echocardiography but could also be predicted by their lower on-admission RESP scores and temporal deterioration in daily SOFA scores. Thus, it is imperative that VV ECMO patients who do not show significant recovery within the first 6–12 h, are considered at-risk for later VA ECMO requirements and undergo echocardiography exams and daily risk score assessments  to identify early signs of circulatory dysfunction. Naturally, in accordance with recommendations made by others ,15, we aLastly, while more studies are needed to elucidate the value of ECMO patients being converted from VV to VA ECMO, we believe that ECMO providers who only offer VV ECMO support should consider developing routines for or collaboration with a center that has experience with VA ECMO.At least 20% of patients subjected to respiratory support with ECMO may need combined cardio-respiratory support, i.e., VA ECMO from the start or during the course of treatment.Early realization of the need for VA ECMO probably improves patient prognosis, in the best case decision for VA is made already on admission. These patients may be identified on admission by a negative (-) RESP score. These patients need daily assessments.Patients converted to VA due to cardio-circulatory failure during VV ECMO are usually recognized within the first days.Patients who develop RVF are more difficult to recognize since typical features take up to two weeks to be present clinically. These patients cannot be distinguished from the general VV population at the time of admission for ECMO. Daily organ function assessments, including echocardiography and the trend of vasoactive support, are important tools to identify these subjects earlier.To summarize:We found that patients converted from VV to VA ECMO had a higher mortality rate compared to non-converted patients and compared to our historical VA ECMO cohort. We argue that VV ECMO should not be the default modality in “respiratory failure” in cases with signs of circulatory impairment. In these subjects, our findings suggest that evaluation, including a thorough assessment of the RV, is necessary, and in uncertainties of RV function VA ECMO should be considered. Admission RESP scores, daily echocardiography, and SOFA trajectories can be used for early recognition of VV patients who might need conversion to VA ECMO. Multi-centric studies are warranted to validate these findings.


Rhododendron delavayi, as a member of Ericaceae family, has been widely used as an important garden flower. The cp genome of R. delavayi exhibited a typical quadripartite cycle with 193,798 bp, comprising of a pair of inverted repeats (IRa and IRb) of 15,494 bp intersected by a large single copy (LSC) region of 160,234 bp and a quite small single copy region of 2576 bp. Totally, 123 unique genes were assembled in this cp genome, including 80 protein genes, 35 tRNAs and 8 rRNAs. Out of these assembled genes, 88 genes (71.54%) were single copy. Phylogenetic analysis based on 14 cp genome of related species showed that the R. delavayi was closely related to Vaccinium oldhamii. This study provides important information for future evolution, genetic and molecular biology studies of Rhododendron. Rhododendron delavayi Franch belongs to Ericaceae family, a large and widespread woody plant genera comprising of over 1000 species throughout tropical southeast Asia  genomes have been widely used for phylogenetic reconstruction attributing to advances in high-throughout sequencing technology   using CTAB method stored in Guizhou Normal University (accession number: LJR-003). After DNA quality assessment, two DNA libraries with insert size of 20 kb and 400 bp fragments were constructed and then sequenced by PacBio Sequel platform and Illumina HiSeq 4000, respectively. The cp genome of R. delavayi is 193,798 bp in length, comprising of a large single-copy (LSC) region of 160,234 bp and a small single-copy (SSC) region of 2576 bp, which is separated by a pair of inverted repeat (IRa and IRb) regions of 15,494 bp. Totally, 123 genes were assembled, including 80 protein coding genes (12 genes with two copies), 35 tRNA genes (six genes with two copies and one genes with three copies) and 8 rRNA genes. Among these genes, 80 and 21 genes were distributed in LSC and IR regions, respectively, and only one gene located in SSC region. Overall GC content of the whole genome is 35.99%. And 303 simple sequence repeats loci with a length of at least 10 bp were identified in the whole cp genome by the web service of Misa.The complete cp genome sequence of R. delavayi was closely related to Vaccinium oldhamii. The complete cp genome sequence of R. delavayi can be great benefit to further study on its population genetics and molecular breeding (Due to the lacing of cp genome information of Ericaceae family, 14 cp genome sequences from Ericales were downloaded from GenBank to construct phylogenetic trees by Neighbor-joining method of protein coding genes using MEGA7 (Kumar et al. breeding .


Kosakonia radicincitans is a species within the new genus Kosakonia. Many strains of this genus have been isolated from plants, but some strains are assumed to act as facultative human pathogens. In this study, an in-depth analysis of a Kosakonia isolate from human blood was performed. The strain was originally isolated from blood and identified as a member of the Enterobacter cloacae complex, exhibiting an atypical result in susceptibility testing. Therefore, the genetic background was examined, including phylogenetic classification and screening for virulence factors. Using whole-genome sequencing, the isolate was identified as a K. radicincitans strain, revealing a virulence gene cluster for yersiniabactin biosynthesis in contrast to all other strains of the species. Whole-genome sequencing was the perfect method for identifying putative virulence factors of a particular Kosakonia strain and will help distinguish beneficial strains from pathogenic strains in the future. To our knowledge, this is the first report of Kosakonia-related bacteraemia from Europe. Kosakonia radicincitans is a species within the new genus Kosakonia, until recently part of the genus Enterobacter. Many Kosakonia species have been isolated from plants and are known to improve plant performance2, but there are also rare reports that assume that some Kosakonia spp., such as Kosakonia cowanii, can act as facultative human pathogens3. There are also rare reports of Kosakonia radicincitans involved in human infections; however, all these reports are from outside Europe (mainly Asia and America). The first case of a human bloodstream infection with K. radicincitans was reported in a 61-year-old man with cholangiocarcinoma in Houston, Texas, USA, in December 20164. However, the actual number of infections could have been underestimated, as this genus is relatively new and is therefore probably not yet included in all automated databases of bacterial diagnostic tools. It seems that Kosakonia has no higher pathogenic or resistance properties than Enterobacter, making a more precise diagnosis unnecessary in many cases4.Kosakonia isolate from a patient with bacteraemia, including phylogenetic classification and screening for virulence factors.Therefore, this study used the rare opportunity to diagnose such an infection by careful evaluation. The aim of the study was to analyse the genetic background of a Enterobacter cloacae complex. Treatment with piperacillin/tazobactam (Pip/Taz) was initiated, and moxifloxacin was added later. Under treatment with this regime, the patient’s condition improved, and her inflammation parameters declined, and after six weeks of hospitalization, she was discharged.Description of the case: An 85-year-old woman presented at the Department of Internal Medicine, in Graz, Austria, with icterus, occasionally diffuse abdominal pain and loss of appetite. Upon admission, she was afebrile, showed atrial flutter (3:1), and a heart rate of 100/min; she was in slightly poor general condition and had pressure pain in the middle and lower abdomen. Her liver values were significantly increased. She was diagnosed with bile duct stenosis and received a stent by endoscopic retrograde cholangiopancreatography (ERCP) on the third day of hospitalization. Four weeks after admission, the inflammation values increased, and she developed a fever. Two pairs of blood cultures were taken during the increase in inflammation parameters. One aerobic blood culture was positive for a bacterium initially identified as a member of the Enterobacter cloacae complex. According to EUCAST  guidelines, however, this genus was not found to be susceptible .Of the two sets of blood cultures obtained during the increase in inflammation parameters, one aerobic blood culture showed positive growth 20 hours after inoculation. Using Gram staining, the bacteria were shown to be gram-negative bacilli. Agar diffusion test and subcultures were performed and revealed the growth of grey-coloured colonies on blood agar and pink colonies on MacConkey agar. The agar diffusion test showed pan-susceptibility, with the exception of amoxicillin Fig. . For ideKosakonia oryzae strain D4 (ID: LT799040.1), namely, atpD (640/642 base pair identity), gyrB (688/688), infB (611/612) and rpoB (635/637), and of Kosakonia radicincitans DSM16656 (ID: CP018016.1), namely, atpD (640/642), gyrB (688/688), infB (609/612) and rpoB (637/637). According to these sequence analyses, the isolate is one of these two species. However, the strains cluster together with K. oryzae strain D4  and the web tool PathogenFinder 1.1 , of which 10 proteins form the yersiniabactin iron uptake system, 3 are involved in flagellum biosynthesis and 1 is responsible for iron uptake regulation  provides assignments for the main functional categories: Metabolism (37.44%), Environmental Information Processing 23.44%), Genetic Information Processing 15.59%), Cellular Processes (10.1%), Human Diseases (3.26%), Organismal Systems (0.93%) and Others  are usually known as plant growth-promoting bacteria, improving the yield and quality of fruits such as maize, radish, sugarcane or cabbage11. There are rare reports of Kosakonia spp. involved in human infections, but there are known species that can act as human pathogens, such as Kosakonia cowanii3. To date, there are no epidemiological data on the occurrence of Kosakonia species in human samples. The first case of a human bloodstream infection with K. radicincitans was reported in a 61-year-old man with cholangiocarcinoma in Houston, TX, USA, in Dec. 20164. Unfortunately, the authors of this report considered some common features of enteric bacteria to be virulence factors, and confused type IV secretion systems with type IV pili that are involved in several phenomena, not only pathogenicity12.Here, we report the first case of bacteraemia with Comparison of the cases from Austria and the USA showed that both patients had problems in the bile duct system. The patient in the USA presented with cholangiocarcinoma and fever, and the patient in Austria presented with bile duct stenosis and fever. Nevertheless, with only two cases considered, this could also be pure coincidence.13, which has been solely found in strain DSM 107547 among Kosakonia spp. Such a finding simplifies the diagnosis of pathogenic bacteria significantly. The role of yersiniabactin (Ybt) in mediating the virulence of human pathogenic bacteria is unquestionable: (i) invasive enteric bacteria from the genera Yersinia, Escherichia, and Klebsiella secrete Ybt during human infection to combat host-mediated metal deficiencies13; (ii) comparative genomics revealed that the list of horizontally transferred gene sets in Salmonella enterica is dominated by virulence factors and the yersiniabactin gene cluster14, suggesting an important role of this siderophore in human pathogenicity; and (iii) in addition to uropathogenic enterobacteria expressing Ybt13, it was shown very recently that all isolates of Klebsiella pneumoniae from infant blood or stool samples taken during outbreaks in neonatal intensive care units produced Ybt15.Future genomic comparisons will show whether human pathogenic strains can be clearly distinguished from plant-associated strains of the same bacterial species based on true virulence factors, such as the syntenic yersiniabactin-like gene cluster encoding an iron, copper and nickel ion-chelating siderophoreKosakonia infections, it must be considered that some infections with this organism were not correctly diagnosed previously. The most important concern is that diagnoses may be imprecise and may provide no or even false positive results: Kosakonia sp. yields no ID in MALDI-TOF analysis, and Vitek2 susceptibility testing suggests the presence of Enterobacter spp. A growing database for MALDI-TOF MS might solve this problem, as would the use of different MALDI-TOF systems. A second look at unsuitable germs and the resistance would also be useful with regard to the increased use of automation in many laboratories, where a specific pathogen is inevitably assigned to a stored antibiogram. We would like to motivate colleagues to take a closer look at such germs and publish the sequences of more of these isolates to facilitate further genomic comparisons of human samples and perhaps to test therapeutic options or antibiotic efficacy, as well as to obtain actual epidemiological data.Regarding the current Kosakonia species in the future.However, sequencing approaches for the identification of these bacterial species are recommended. Especially in our case, whole-genome sequencing is the perfect means for species identification and might help reveal new Kosakonia spp. are rare events indeed or occur more frequently than previously shown.With improved diagnostic tools, researchers will be able to show whether infections with Kosakonia radicincitans strain used in this study was archived at the DSMZ (German Collection of Microorganisms and Cell Cultures) as Kosakonia radicincitans strain DSM 107547.The For identification, colonies from different agar media were subjected to MALDI-TOF (VITEK MS – bioMerieux), and N196 automated biochemical testing was performed using the VITEK 2 system (bioMerieux).16. Interpretation of zone diameters was performed according to EUCAST 2017.Susceptibility testing was performed as recommended by the European Committee on Antimicrobial Susceptibility testing (EUCAST)The following antibiotics were used: ampicillin (10 μg), amoxicillin/clavulanic acid (20 μg/10 μg), piperacillin/tazobactam (100 μg/10 μg), cefalexin (30 μg), cefuroxime (30 μg), cefoxitin (30 μg), cefotaxime (5 μg), ceftazidime (10 μg), cefepime (30 μg), imipenem (10 μg), meropenem (10 μg), amikacine (30 μg), gentamicin (10 μg), trimethoprim/sulfamethoxazole (1.25 μg/23.75 μg), ciprofloxacin (5 μg), and moxifloxacin (5 μg) . Sensi-DiscTM paper discs (BD) were used.et al.9, including the sequences of four housekeeping genes: atpD, gyrB, infB and rpoB. For better classification, a phylogenetic maximum likelihood (ML) tree was inferred based on the MUSCLE v3.8.3117 alignment of the concatenated sequences of these housekeeping genes against closely related species , supported with bootstrap values between 69% and 100%, the current affiliation to K. radicincitans is reasonable.Identification based on sequencing of single marker genes was performed according to Brady ies Fig. . The aliet al.21. Samples were sequenced on a NextSeq™ 500 instrument. Genome assembly was performed by applying the RS_HGAP_Assembly.3 protocol included in SMRT Portal version 2.3.0 using default parameters. The assembly revealed a circular bacterial chromosome and a plasmid, both with coverages of 110× . Both replicons were circularized, artificial redundancies at the ends of the contigs were removed and adjustment to dnaA (parA = soj) as the first gene was performed. Error correction was performed by mapping Illumina short reads onto the finished genome using Burrows-Wheeler Alignment (bwa 0.6.2) in paired-end (sample) mode using the default setting22 with subsequent variant and consensus calling using VarScan 2.3.6 23. A consensus concordance of QV60 could be confirmed.Whole-genome sequencing was performed using a combination of Pacific Biosciences long-read sequencing and Illumina short-read sequencing. For both sequencing runs, DNA was isolated using Qiagen Genomic-tip 100/G  according to the manufacturer’s instructions. The SMRTbell™ template library was prepared according to the instructions from Pacific Biosciences , following the manufacturer’s Procedure & Checklist – Greater Than 10 kb Template Preparation. Briefly, for preparation of 15 kb libraries, 8 µg of genomic DNA was sheared using g-tubes™ from Covaris  according to the manufacturer´s instructions. The DNA was end-repaired and ligated overnight to hairpin adapters by applying components from the DNA/Polymerase Binding Kit P6 from Pacific Biosciences . Reactions were carried out according to the manufacturer´s instructions. BluePippin™ size-selection to greater than 4 kb was performed according to the manufacturer´s instructions . Conditions for annealing of sequencing primers and binding of polymerase to the purified SMRTbell™ template were assessed with the Calculator in RS Remote . One SMRT cell was sequenced on the PacBio RSII instrument , taking one 240-minute movie. Libraries for sequencing on the Illumina platform were prepared by applying the Nextera XT DNA Library Preparation Kit  with modifications according to Kishony The genome sequence has been deposited at NCBI GenBank under accession nos. CP040392 and CP040393 for the circular chromosome  and plasmid, respectively  Diamond24 v.0.9.24 aligner and MEGAN v6.15.2 provided assignments for the main functional categories.Automated genome annotation, carried out with the NCBI Prokaryotic Genome Annotation Pipeline (PGAP), revealed a total of 5,487 genes, of which 5,253 are protein-coding genes, 116 RNAs and 118 pseudo-genes (Table Supplementary informationSupplementary information2Supplementary information3


Sarcomas are a heterogeneous group of malignancies arising from mesenchymal cells. Epidemiological studies on sarcoma from Australia are lacking, as previous studies have focused on a sarcoma type (e.g. soft tissue) or anatomical sites.Linked cancer registry, hospital morbidity and death registration data were available for Western Australia (WA) from 1982 to 2016. All new sarcoma cases among WA residents were included to estimate incidence, prevalence, relative survival and cancer-related hospitalisation, using the Information Network on Rare Cancers (RARECARENet) definitions. To provide a reference point, comparisons were made with female breast, colorectal, prostate and lung cancers.For 2012–16, the combined sarcoma crude annual incidence was 7.3 per 100,000, with the majority of these soft tissue sarcoma . The age-standardised incidence and prevalence of STS increased over time, while bone sarcoma remained more stable. Five-year relative survival for the period 2012–16 for STS was 65% for STS , while five-year relative survival was 71% for bone sarcoma. Cancer-related hospitalisations cost an estimated $ 29.1 million over the study period.STS incidence has increased over time in WA, with an increasing proportion of people diagnosed aged ≥65 years. The analysis of health service use showed sarcoma had a lower mean episode of cancer-related hospitalisation compared to the reference cancers in 2016, but the mean cost per prevalent person was higher for sarcoma than for female breast, colorectal and prostate cancers. Sarcomas are a heterogeneous group of malignancies arising from mesenchymal cells. The incidence of soft tissue sarcoma (STS) is proportionately much higher than malignant osseous and chondromatous neoplasms (hereafter referred to as ‘bone sarcoma’) .In Australia there are some published studies on sarcoma epidemiology. Woods et al.  reportedIn WA there is a lack of contemporary information about the burden of sarcoma. Basic descriptive epidemiology – incidence, prevalence, survival – is essential to guide efforts to manage and plan resources for management of patients with sarcoma. Furthermore, description of the health service utilisation can provide insight into patterns of care for those diagnosed with sarcoma. These data can also be used to support a recent Australian Government program which aims to increase clinical trial activity in rare cancers and rare diseases .The aim of this study was therefore to determine the burden of sarcoma in terms of incidence, prevalence, relative survival, use and costs of hospital services in WA between 1982 and 2016, inclusive. As this information in isolation lacks a reference point, comparison was made to four common cancers: female breast, colorectal, prostate and lung cancers.The reporting of this population-based retrospective cohort study is based on the Reporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement . The stuThe data sources analysed were: (i) the WACR; (ii) the hospital morbidity data collection , and; (iii) death registrations. These datasets are routinely linked by the WA Data Linkage Branch ).WACR data from 1 January 1982 to 31 December 2016 were used. All new, invasive malignant cases among WA residents were included in the incidence and prevalence analyses, including cancers of unknown primary site. Multiple primary cancers were included, with the WACR following the International Association of Cancer Registry (IARC) rules for multiple primary cancers . MultiplSarcoma was selected using the latest definitions and three tier hierarchy reported by the Information Network on Rare Cancers (RARECARENet)  Additio. Tier 1 This topographical and histological inclusion is different to the allocation of sarcoma published on the Cancer Australia website , but allStudy outcomes were; (i) incidence; (ii) corrected prevalence; (iii) relative survival, and; (iv) annual total and rate of hospitalisation and associated costs.All analyses were conducted using Stata SE Version 15 .Descriptive statistics were generated stratified by the following diagnostic periods: 1982–87; 1988–93; 1994–99; 2000–05; 2006–11, and; 2012–16. Differences in categorical variables between periods were assessed statistically using the Pearson’s chi-squared test or Fisher’s Exact test , while continuous variables were assessed using the Kruskal-Wallis test.Age-standardised incidence per 100,000 was calculated using the WA mid-year populations published by the Australian Bureau of Statistics (ABS), stratified into 5-year age groups . Crude iPrevalence was calculated at 30 June for each diagnostic year by summing incident cases prior to this date among individuals who had not died. Because the prevalent period was 34.5 years (i.e. 1 January 1982 to 30 June 2016), it was assumed that the prevalence in 2016 was accurate. However, for previous years, there was less follow-up and thus a higher chance that people previously diagnosed with sarcoma and still alive were diagnosed before 1982 and therefore not counted among the prevalent population. The approach taken with an earlier analysis of WA data by Maxwell et al. [Where CP = corrected prevalence, P = prevalence, X = the year to be corrected, and Y = the number of years of look-back data available for year X. For example, if there were 1000 cases prevalent in mid-2016, but that number would have been 50 if the start of the study period had been 2016 instead of 1982, this would yield a ‘correction factor’ of 50/1000 (=0.05) for mid-1982, where there was only 6 months of diagnostic data available. If the measured prevalence in mid-1982 was 10, the corrected prevalence would then be 200 (10 divided by 0.05). As GIST was first recognised as a diagnostic entity during the study period, this was not reported separately in the prevalence analysis.Relative survival was estimated using the Ederer II method and a period approach for 2012–2016, using the – strs – user-written command , 18. TheLinked hospital admission records were considered cancer-related if they contained a cancer principal diagnosis, chemotherapy or radiotherapy procedure codes  Additio. The totn = 3951 included). Incident records comprised 54% males and 88% were diagnosed at ≥25 years (Table n = 3024), with 595 bone sarcomas (15%), 223 GISTs (6%) and 147 (4%) Kaposi sarcomas. The proportion of STS among the ≥65 age group increased over time (p = 0.03). Major notable differences between the broad sarcoma types were a tendency toward younger age at diagnosis for bone sarcoma  and a lower all-cause death (44.4%) and higher median follow-up for this group (5.4 years). Exceptions to the broad trends in age distribution and sex were a high proportion (79%) of those with STS of the uterus and STS of the peritoneum and retroperitoneum (60%) being aged 25–64 years, a higher proportion female than male among those with STS of the genitourinary tract (52%) and peritoneum and retroperitoneum (55%), and 50.5% of osseous Ewing’s sarcoma being diagnosed aged 0–14 years.In total 4512 records met the inclusion criteria. Of these, 523 (12%) were excluded on the basis of not being malignant (191 (4%) benign, 315 (7%) uncertain if malignant or benign and 8 (0.2%) primary malignant, but not new). A further 11 (0.2%) were for non-WA residents and 1 (0.02%) was a duplicate record. This left 3989 sarcoma records (3 records fulfilled more than one exclusion criteria) for the analysis of incidence and prevalence , followed by malignant fibrous histiocytoma (13%). STS of the head and neck were more often malignant fibrous histiocytoma (21%), while STS of the breast were mainly either Phyllodes tumours (50%) or epitheloid angiosarcomas (22%). STS of the skin had a higher proportion of dermatofibrosarcoma pertuberans (38%) relative to other sites. Bone sarcoma were 23% conventional osteosarcoma, 25% chondrosarcoma and 13% Ewing sarcoma (data not shown).At June 2016, there were 1445 prevalent STS cases, 329 bone sarcoma and 48 Kaposi sarcoma. Forty-four percent of prevalent STS cases were diagnosed > 10 years prior, with 19% 5–10 years prior, 26% 1–5 years prior and 11% in the previous year. The corresponding percentages for bone sarcoma were 54, 21, 22 and 4%. STS prevalence increased from 31 to 57 per 100,000 between 1982 and 2016, while bone sarcoma prevalence decreased from 21 per 100,000 to 13 per 100,000  and for a proportion of people the survival outcome is poor. The analysis of health service use showed sarcoma had a lower mean episode per prevalent person of cancer-related hospitalisation compared to the reference cancers in 2016, but the mean cost per prevalent person was higher for sarcoma than for female breast, colorectal and prostate cancer.Additional file 1. Sarcoma topographical and morphological codes and codes for cancer-related hospitalisations.Additional file 2. Corrected prevalence by year, 1982 to 2016.Additional file 3. One- and five-year relative survival for soft tissue sarcoma and bone sarcoma, stratified by age group.Additional file 4. Total episodes of cancer-related hospitalisation (a), rate per prevalent person (b), total associated cost (2019) Australian dollars, c, and cost per prevalent person based on corrected prevalence (d).