Considering that body fat mass and fat-free mass were genetically correlated with each other (r = 0.64), we further evaluated independent causal effects of body fat mass and fat-free mass using multivariable MR and revealed that only body fat mass was independently associated with severe COVID-19 . In summary, this study demonstrates the causal effects of body fat accumulation on COVID-19 severity and indicates that the biological pathways influencing the relationship between COVID-19 and obesity are likely mediated through body fat mass.Previous studies reported associations between obesity measured by body mass index (BMI) and coronavirus disease 2019 (COVID-19). However, BMI is calculated only with height and weight and cannot distinguish between body fat mass and fat-free mass. Thus, it is not clear if one or both of these measures are mediating the relationship between obesity and COVID-19. Here, we used Mendelian randomization (MR) to compare the independent causal relationships of body fat mass and fat-free mass with COVID-19 severity. We identified single nucleotide polymorphisms associated with body fat mass and fat-free mass in 454,137 and 454,850 individuals of European ancestry from the UK Biobank, respectively. We then performed two-sample MR to ascertain their effects on severe COVID-19  from the COVID-19 Host Genetics Initiative. We found that an increase in body fat mass by one standard deviation was associated with severe COVID-19 (odds ratio (OR) More than 500 million individuals have been infected by the coronavirus disease-19 (COVID-19) with 6 millions of deaths worldwide to date  and COVID-19 severity , which wRegarding a means of exploring the associations between risk factors and outcomes of the interest, observational studies can evaluate correlations but not causations; in fact, interpreting the results of observational studies as a causal relationship relies on untestable and usually implausible assumptions, including the absence of unmeasured confounders and reverse causation . Given tIn this study, we conducted a two-sample MR to assess independent causal associations of body fat mass and body fat-free mass with COVID-19 severity outcomes using data from the UK Biobank and the COVID-19 Host Genetics Initiative.P < 5 × 10-8) for exposure traits. Independence of SNPs was defined as not in linkage disequilibrium with other SNPs . The exposures used in this study were body fat mass, body fat-free mass, body fat percentage, and BMI. Body fat percentage and BMI were included as supplementary analyses. To select SNPs used as instrumental variables, we obtained the genome-wide association study (GWAS) results of body fat mass, body fat-free mass, body fat percentage, and BMI from individuals with European ancestry in the UK Biobank    on an outcome i on the exposure θ ) of the exposure on the outcome can be formulated as follows:We performed univariable MR using the inverse variance weighted method (hereinafter referred to as univariable MR) to evaluate the relationship of body fat mass, body fat-free mass, body fat percentage, and BMI with severe COVID-19 and COVID-19 hospitalization. Univariable MR is a weighted linear regression model in which the effect of genetic variants The instrumental variable assumptions are as follows: (I) Relevance–genetic variant is associated with the exposure. (II) independence–genetic variant does not share the unmeasured cause or confounder with the outcome. (III) exclusion restriction–genetic variant does not influence the outcome except through the exposure , 12. Thei (i = 1 … n) on the outcome i on two exposures of 1X(fat mass) and 2X(fat-free mass). In multivariable MR, genetic variants used as instrumental variables are associated with one or both of the exposures (Multivariable MR was performed using the inverse variance weighted method (hereinafter referred to as multivariable MR). This is an extension of univariable MR, in which the effects of genetic variant xposures .2).The causal associations were evaluated using odds ratios (ORs), which are expressed according to a standard deviation (SD) increase in genetically predicted body fat mass (kg), or body fat-free mass (kg), body fat percentage (%), and BMI . We note that such a correction is likely overly conservative, given that the exposures are non-independent. MR analyses were performed using TwoSampleMR (v0.5.6) in R (v4.02). This study was conducted in accordance with the STROBE-MR guideline , moderate (25% < I2index ≤ 50%), and high (2I index > 50%). Additionally, we performed the MR-PRESSO global test, which can detect horizontally pleiotropic outlier SNPs. A significant result indicates the presence of pleiotropic outlier SNPs and this method then generates ORs after removing and correcting for these outliers (outlier-corrected ORs). MR-PRESSO can also be used to evaluate the distortion of the causal estimates before and after the removal of pleiotropic outlier SNPs following the MR-PRESSO distortion test. MR-PRESSO requires at least 50% of the genetic variants to be valid instruments with no horizontal pleiotropy and also relies on the InSIDE assumption. We also performed leave-one-out analyses for all exposure-outcome associations, which repeated univariable weighted MR excluding each SNP to assess whether the overall estimate is driven by a single SNP. We also generated scatter plots and funnel plots to inspect for horizontal pleiotropy.We performed the MR-Egger intercept test, Cochran’s Q test, and the MR-PRESSO global test , 23 to dP < 0.05 were considered to indicate the presence of horizontal pleiotropy for the MR-Egger intercept test, Cochran’s Q test, MR-PRESSO global test, and MR-PRESSO distortion test. Sensitivity analyses were performed with TwoSampleMR (v.0.5.6) and MR-PRESSO (v1.0).Results with a The UK Biobank and COVID-19 Host Genetics Initiatives obtained ethics approval from the relevant institutional ethics committees. We used publicly available summary statistics of GWAS results of UK Biobank and COVID-19 Host Genetics Initiative and did not use individual-level data.2  are presented in body fat mass = 1.61, 95% CI 1.28–2.04, P = 5.51 × 10-5; and ORbody fat-free mass =1.31, 95% CI: 0.99–1.74, P = 5.77 × 10-2; ORbody fat percentage = 1.94, 95% confidence interval [CI]: 1.41–2.67; P = 5.07 × 10-5; ORBMI = 1.49, 95% CI: 1.19–1.87, P = 5.57 × 10-4) (r = 0.64 for the genetic correlation of the two traits)   , consistent with the findings for severe COVID-19 . The leave-one-out analyses showed that causal estimates were robust to exclusion of single SNPs . Nevertheless, results with MR-PRESSO after removal and correction for these pleiotropic outlier SNPs were directionally consistent with those from univariable MR, supporting the robustness of the findings with univariable MR. In addition, the MR-PRESSO distortion test detected no significant distortion in the causal estimates before and after the removal of outlier pleiotropic SNPs . To the best of our knowledge, the present study is the first to disentangle the independent causal effects of body fat mass and body fat–free mass on COVID–19 severity.During the COVID-19 pandemic, obesity has emerged as a major risk factor for COVID-19 outcomes. Multiple observational and MR studies suggested that obese individuals present an increased risk of severe diseases, hospitalization, and death due to COVID-19 –4, 24. HOur multivariable MR showed that one SD increase in body fat mass 9.6 kg) is causally associated with 2.91–fold and 2.38 fold–increase in the risk of severe COVID–19 and COVID–19 hospitalization, respectively, highlighting the burden of body fat accumulation on COVID–19 severity. On the contrary, body fat–free mass were not independently associated with increased risk of severe COVID–19 or hospitalization. We used multivariable MR since most instrumental variables of adiposity affect both fat mass and fat–free mass, although some variants more strongly and proportionally influence fat mass, whereas others influence fat–free mass more strongly. Therefore, multivariable MR can test the differential causal effects of fat mass and fat–free mass. Using this approach, recent MR studies showed differential associations between body fat mass and body fat–free mass with various disorders .6 kg is –34. The The underlying mechanism of these associations remains to be clarified. Obesity is a metabolic disease characterized by systemic changes in metabolism, including insulin resistance, glucose intolerance, dyslipidemia, changes in adipokines , chronic inflammation, and altered immune response, all of which could collectively increase the risk of COVID–19 severity –37. In aF–statistics > 10 for all exposure traits) and COVID–19 Host Genetics Initiative for the outcomes, both of which have large sample sizes, thus increasing the statistical power of the analysis. Furthermore, as proxy measures of body composition, we not only considered BMI, which is a common indirect measure, but also direct measures, including body fat mass, body fat–free mass, and body fat percentage and revealed associations of these traits with COVD–19 severity.This study has several strengths. We used an MR design, which minimized bias from reverse causation and confounders, thereby enabling us to test for causal effects, provided compliance with MR assumptions. In this MR study, we used the data from the UK Biobank for the exposure traits  instead of DXA–derived measures to maximize statistical power. Although the UK Biobank collected DXA–derived measures for body fat mass and body fat–free mass, the sample size was markedly smaller for these measurements . Moreover, although DXA–derived measures are generally more accurate than impedance–derived measures, high correlations between the two were reported for fat mass (r = 0.96) and fat–free mass (r = 0.86) in the UK Biobank dataset (2 (2). Fourth, we restricted our analysis to individuals of European ancestry given that majority of participants in the UK Biobank were of European ancestry. Future studies are warranted to evaluate the generalizability of our findings to other populations. Lastly, we did not evaluate other clinically established risk factors such as diabetes, respiratory, heart, kidney, liver, autoimmune disorders, older age, smoking, and lower socioeconomic status  can be an effective strategy to reduce the risk of COVID–19 severity.All GWAS summary statistics used in this study are publicly available. The original contributions presented in the study are included in the article/Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.SY conceptualized and analyzed the data. SY, HM, and JBR wrote the original draft of the manuscript. JBR and NY supervised the study. All authors discussed the results and contributed to the final manuscript.The Richards research group is supported by the Canadian Institutes of Health Research , the McGill Interdisciplinary Initiative in Infection and Immunity (MI4), the Lady Davis Institute of the Jewish General Hospital, the Jewish General Hospital Foundation, the Canadian Foundation for Innovation, the NIH Foundation, Cancer Research UK, Genome Québec, the Public Health Agency of Canada, McGill University, Cancer Research UK [grant umber C18281/A29019] and the Fonds de Recherche Québec Santé (FRQS). JBR is supported by an FRQS Mérite Clinical Research Scholarship. Support from Calcul Québec and Compute Canada is acknowledged. TwinsUK is funded by the Welcome Trust, Medical Research Council, European Union, the National Institute for Health Research (NIHR)–funded BioResource, Clinical Research Facility and Biomedical Research Centre based at Guy’s and St Thomas’ NHS Foundation Trust in partnership with King’s College London. These funding agencies had no role in the design, implementation or interpretation of this study. SY and HM are supported by the Japan Society for the Promotion of Science.www.5primesciences.com), which provides research services for biotech, pharma and venture capital companies for projects unrelated to this research. NI received research funds from Terumo Corp., Drawbridge, Inc., and Asken Inc. NI received speaker honoraria from Kowa Co., Ltd., MSD K.K, Astellas Pharma Inc., Novo Nordisk Pharma Ltd., Ono Pharmaceutical Co., Ltd., Nippon Boehringer Ingelheim Co., Ltd., Takeda Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Corp., Sumitomo Dainippon Pharma Co., Ltd., Sanofi K.K., Eli Lilly Japan K.K., received scholarship grant from Kissei Pharmaceutical Co., Ltd., Sanofi K.K., Daiichi–Sankyo Co., Ltd., Mitsubishi Tanabe Pharma Corp., Takeda Pharmaceutical Co., Ltd., Japan Tobacco Inc., Kyowa Kirin Co., Ltd., Sumitomo Dainippon Pharma Co., Ltd., Astellas Pharma Inc., MSD K.K., Ono Pharmaceutical Co., Ltd., Sanwa Kagaku Kenkyusho Co., Ltd., Nippon Boehringer Ingelheim Co., Ltd., Novo Nordisk Pharma Ltd., Novartis Pharma K.K., and Life Scan Japan K.K. NI is an advisory board member of Novo Nordisk. These agencies did not play any role in study design, the collection, analysis, or interpretation of data, the writing of the report, or the decision to submit this paper for publication.JBR institution has received investigator–initiated grant funding from Eli Lilly, GlaxoSmithKline and Biogen for projects unrelated to this research. He is the founder of 5 Prime Sciences (The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Patients with pulmonary large cell carcinoma (LCC) have a high incidence of synchronous brain metastases (SBM) and a poor prognosis. Our study was to evaluate the predictive and prognostic value of the clinical characteristics of pulmonary LCC patients with SBM at initial diagnosis by utilizing the Surveillance, Epidemiology, and End Results (SEER) database.LCC patients, diagnosed from 2010 to 2019, were identified from the latest SEER database which was released in April 2022. Logistic regression and Cox regression were used to identify the predictive and prognostic factors for LCC patients with SBM. Propensity score matching (PSM) and Kaplan–Meier analyses were applied to assess different therapy modalities.p < 0.001), age ≥ 80  and bone metastases  as significant independent predictors for developing SBM. Multivariable Cox regression revealed that age 60–79, T stage, bone metastases and chemotherapy were independent prognostic factor for OS. The surgery combined with chemotherapy and radiotherapy group, in which all patients were N0 stage and had no other site-specific metastases, exhibited the best median OS of 15 months.A total of 1375 LCC patients were enrolled in this study and 216 (15.7%) of them had SBM at the initial diagnosis. The median overall survival (OS) of LCC patients with SBM was 4 months. Multivariate Cox regression identified age 60–79 (OR 0.57; 95% CI 0.41–0.78; LCC patients with age < 60 or bone metastases were more likely to have SBM at initial diagnosis. Age, T stage, bone metastases and chemotherapy were independent prognostic factors for OS of LCC patients with SBM. Highly selected patients might achieve the best survival benefit from surgery combined with chemotherapy and radiotherapy.The online version contains supplementary material available at 10.1186/s12890-023-02312-y. Large cell carcinoma (LCC) is a rare subtype of non-small cell lung cancer (NSCLC), accounting for just 1.3% of all cases of lung cancer . LCC posUp to now, due to its rareness, there is still little information about the factors affecting incidence and prognosis of LCC patients with SBM. The Surveillance, Epidemiology, and End Results (SEER) database is a population-based clinical oncology repository maintained by National Cancer Institute. It recorded information about incidence, mortality, and morbidity of confirmed frequent malignancies, covering approximately 34% of the United States population. Therefore, by utilizing the SEER database, we aimed to analyze the risk factors for SBM incidence and prognostic factors of OS in LCC patients with SBM. We also estimated the impact of different therapeutic strategies on OS of LCC patients with SBM.The data analyzed in this study were obtained from Surveillance, Epidemiology, and End Results (SEER) 17 Registries (November 2021 submission). Because SEER did not record BM information until 2010, patients diagnosed before that year were excluded. Inclusion criteria were as follows: (1) age ≥ 18 years; (2) year of diagnosis from 2010 to 2019; (3) pathologically confirmed LCC based on histology, according to the International Classification of Diseases for Oncology, Third Edition (ICD-O-3), histology code 8012/3 ; (4) tumor site location in lung and bronchus; (5) only one primary tumor. Histology code 8013/3 (large cell neuroendocrine carcinoma) and 8014/3 (large cell with rhabdoid phenotype) were not included in this study because these two types have been grouped with other types of NSCLC since the 2015 World Health Organization (WHO) Lung Tumors Classification. In addition, we excluded pathological grade I (well differentiated) and grade II (moderately differentiated) that were not in accordance with the pathological requirements of large cell carcinoma. Patients with incomplete demographic or clinical information were also excluded from this study. The following covariates were collected from the database: year of diagnosis, age at diagnosis, sex, race, marital status, median household income, primary site, laterality, grade, derived AJCC T stage, N stage, synchronous tumor metastases, RX Summ-Surg Prim Site, chemotherapy recode, radiation therapy, survival months, vital status recode, and SEER cause-specific death classification. During the preprocessing phase, AJCC T stages were recalculated based on the guidelines of the AJCC Cancer Staging Manual eighth Edition.p < 0.05 was considered to indicate a statistically significant difference. Statistical analysis was performed using R version 4.1.1 software (http://www.r-project.org/).Pearson’s chi-square test and Fisher's exact test were used to compare the demographics, clinical features and treatment differences between LCC patients with and without SBM. To identify the risk factors of SBM incidence, univariate and multivariate logistic regression analyses were performed. Overall survival (OS) was defined as the time from the date of diagnosis to the date of death, or patients who were reported to be alive at the last follow-up date. Because only 5 patients with SBM (2.3%) died of causes other than cancer, lung cancer-specific survival (LCSS) was not estimated in this study. The OS curves were calculated using the Kaplan–Meier method and differences between groups were compared by log-rank test. Univariate and multivariate Cox regression analyses were conducted to determine the independently prognostic factors affecting OS. In the process of comparing the effects of different therapeutic strategies on patients with SBM, surgery alone and surgery combined with radiotherapy were removed from this part due to a quite small proportion (1 patient and 3 patients respectively). We used the propensity score matching (PSM) method to further compare the differences in survival between the chemotherapy and radiotherapy group and the chemotherapy alone group, as well as between the radiotherapy alone group and the no treatment group. All P values were two-sided and p = 0.327). The SBM group had significantly higher rate of N2 stage (46.8% vs 39.6%), bone metastases (33.3% vs 18.4%), liver metastases (18.5% vs 9.4%), lung metastasis (19.9% vs 13.3%).A total of 1375 LCC patients diagnosed from 2010 to 2019 were enrolled in this study and 216 (15.7%) of them had SBM at the initial diagnosis  and age ≥ 80  were identified as independent protective factor for having SBM at diagnosis, while bone metastases  was identified as independent risk factor. A trend for liver metastases towards statistical significance also emerged .As shown in Table p < 0.001, Fig. p < 0.001). Survival analysis of patients with SBM were further stratified by year of diagnosis , T stage , bone metastases and chemotherapy . A trend for T4 stage  towards significantly independent prognostic factor also emerged.94.0% of LCC patients with SBM died at the end of the time-point, and only 5 patients died of causes other than tumors. The median overall survival for the entire cohort was 6 months but the mOS of the SBM group was shorter than those of non-SBM group . 46.0% of all LCC patients received radiotherapy and 23.6% underwent surgery for primary site. Compared with the non-SBM group, the ratio of radiation in patients with SBM was significantly higher (75.5% vs 40.1%), while the rate of surgery was the opposite (4.6% vs 27.2). Baseline characteristics of patients with SBM receiving different treatments are summarized in Additional file 47.9% of all LCC patients received chemotherapy and the ratio between the SBM group and the non-SBM group had no significant difference p = 0.63. 46.0%Due to the low incidence and material changes in WHO Lung Tumors Classification of LCC, few clinical researches have focused on the prognosis of LCC, let alone LCC patients with SBM. To the best of our knowledge, this is the first study to explore the relationship between clinical characteristics and the occurrence as well as prognosis of SBM in LCC. This population-based study indicates that age ≤ 60 and bone metastases are independent risk factors for SBM incidence. Age, T stage, bone metastases and chemotherapy were proved to be independent prognostic factors for OS of LCC patients with SBM. In addition, our study also reveals the prognosis of LCC patients with SBM receiving different treatment schemes.In the recent past, the histologic subtypes of NSCLC mainly consisted of adenocarcinoma, squamous cell carcinoma and large cell carcinoma (LCC). As the third most common subtype of NSCLC, LCC historically accounted for about 10% of NSCLC, including several subtypes, namely clear cell carcinoma (CCC), lymphoepithelioma-like carcinoma (LELC), LCC with rhabdoid phenotype (LCC-R), basaloid carcinoma (BC), large cell neuroendocrine carcinoma (LCNEC) and the entirely undifferentiated LCC . As the p = 0.08). High T-stage and chemotherapy were also found to be independently poor prognostic factors for OS. The above findings were consistent with those described in previous studies on other types of lung cancer. Zhu et al. [The incidence of brain metastases is 10–20% in patients with NSCLC at diagnosis, and the lifetime incidence has increased up to 50% as a result of an increase in patients’ survival , 12. Ouru et al.  demonstru et al. .The reason why the SBM incidence rate of young patients is higher than that of old patients may be complicated. Aging in the central nervous system (CNS) is accompanied by alterations to the brain immune landscape and thus a changed immune contexture stood as a candidate mechanism to affect brain metastatic aggressiveness , 16.WoodUp to now, there is still no peculiar guidelines of treatment for LCC with brain metastases. Convincing evidence from clinical research seems difficult to obtain due to the low incidence of this disease. In this study, the mOS of LCC patients with SBM was 4 months, which is much shorter than that of adenocarcinoma (15 months) and nonadenocarcinoma (9 months) with brain metastases . NotablyThere are several limitations in our study. First, due to the retrospective nature of this study and the processing of the data, selection bias could therefore not be avoided as mentioned above. Second, the SEER database did not record some key factors, such as performance status, smoking status, the number of BM, RPA classification, driver mutations and the details of treatment regimens. Loss of these information might affect our research results to some extent. Finally, although PSM was used to reduce selection bias in the treatment subgroup analysis, limited number of patients made it difficult to avoid bias in all confounding factors. Despite these limitations, the present study included the greatest number of LCC patients with synchronous brain metastases and provided relatively reliable clinical values.Based on our findings, it is evident that LCC patients with age < 60 or bone metastases were more likely to have SBM at initial diagnosis. Age, T stage, bone metastases and chemotherapy were identified to be independent prognostic factors for OS of LCC patients with SBM. Notably, though the overall population prognosis was poor, highly selected patients might achieve the best survival benefit from surgery combined with chemotherapy and radiotherapy.Additional file 1. Table S1. Baseline characteristics of patients with SBM receiving different treatments. Table S2. Baseline characteristics of patients with SBM receiving chemotherapy only and chemotherapy plus radiotherapy before and after PSM. Table S3. Baseline characteristics of patients with SBM receiving radiotherapy only and no treatment before and after PSM. Figure S1. Kaplan–Meier curves of LCC patients with SBM receiving chemotherapy and radiotherapy vs radiotherapy before and after 1:2 PSM. Figure S2. Kaplan–Meier curves of LCC patients with SBM receiving radiotherapy vs no treatment before and after 1:1 PSM.


In 2011, a new mecC MRSA prevalence was available in Israel. In this study, to the best of our knowledge, we describe the first case of mecC MRSA in Israel, with focus on genomic analysis and global context.Until now, no reliable information regarding mecC MRSA isolate was analysed by WGS with focus on phylogeny, global contextualization, virulence and resistance genes. The strain was characterized by antibiotic susceptibility testing, spa typing and presence of mecA/C and pvl genes.The mecA and pvl genes. The MLST and spa type were ST130 and t1736, respectively. SA10610 presented resistance to oxacillin, penicillin and cefoxitin, and susceptibility to all non-β-lactam agents tested. Phylogenetic comparison with a global dataset of 586 mecC MRSA genomes revealed substantial genomic divergence. The nearest genomic relatives were human and animal isolates from Denmark. A screen of 12 761 S. aureus isolates collected during 2011–18 in Israel indicated this is the only mecC-positive strain.An MRSA strain (SA10610), isolated from a urine sample of an 83-year old patient, was found negative for the mecC MRSA isolated worldwide. The genomic and phylogenetic analysis suggest that mecC MRSA isolates have evolved independently rather than from a common ancestor.A high degree of genetic variability was found between the SA10610 strain and previously sequenced  In addition to infections in humans, MRSA can cause diseases in a wide range of hosts including livestock, wildlife and companion animals.Staphylococcus aureus is mediated by the mec genes, including mecA and mecC, which encodes an alternative PBP with a lower affinity for virtually all β-lactam antibiotics. The mec genes reside within a mobile genetic element named the staphylococcal cassette chromosome mec (SCCmec) and resistance to β-lactams is conferred by the acquisition of this cassette.1 Based on their genetic content and their structural organization, SCCmec elements have been classified into types and subtypes and to date 14 types (I–XIV) have been described.2–4Resistance to β-lactams in mec variant was described.5 This variant, named mecC (formerly mecALGA251) exhibits only 70% nucleotide sequence homology with the classical mecA gene6 and 63% identity at the amino acid level.5 The new mecC gene is located on a novel SCCmec element, designated type –XI SCCmec. As a consequence of the limited mecA–mecC sequence homology and their respective proteins, mecA PCR and immunological tests targeting PBP2a fail to detect mecC MRSA, posing a diagnostic challenge for clinical microbiology laboratories.5–7In 2011, during an epidemiological study of bovine mastitis, a new S. aureus can be found in the normal flora of healthy humans and animals. However, it can cause diseases in both hosts as an opportunistic pathogen. During the last few years a new type of MRSA has emerged, livestock-associated (LA) MRSA and infections with this type of MRSA have been increasingly reported worldwide especially in people with occupational livestock exposure.8–11 Clonal complex (CC) 130 is the most prevalent LA MRSA lineage in Europe although other lineages such as CC1 and CC7 also have been found to colonize and cause infections in livestock.mecC gene have been detected in different animal species and humans, mainly in European countries but also on other continents,12–18 with isolates mainly belonging to CC130, CC1943 and CC425.19 Zoonotic transmission of mecC MRSA has been previously reported, although data on the prevalence, animal reservoir and epidemiology of mecC MRSA are still limited.21In the last decade, MRSA clones with a mecC-positive MRSA isolation in Israel, with focus on genomic and phenotypic characterization. Phylogeny and global context were analysed by genomic comparison with mecC-positive MRSA genomes isolated from humans and animals.This study represents, to the best of our knowledge, the first report of S. aureus SA10610 was isolated from a urine sample of an 83-year old male patient in October 2017. The sample had been submitted to the national S. aureus reference centre for bacteriological characterization. All MRSA and MSSA isolates from bacteraemia as well as MRSA from wound infections are referred to the national centre for further analysis. Between 2011 and 2018, 12 761 S. aureus isolates were analysed by in-depth strain characterization and typing. All isolates were stored in a deep freeze in our strain bank. spa types known to be prevalent in mecC S. aureus strains: t843, t1773, t978, t1535, t7189, t6293, t7947, t7485, t7946, t7734, t11702, t6220, t9280, t373, 528, t1048, t1532, t3218, t3256, t3570, t5970, t6300, t6292, t6386, t742, t11706, t978, t7945, t2345, t3391, t8835, t529. NCTC 13552 strain, mecC MRSA, was used as a control in mecC PCR reaction. Strain SA104  was used as a positive control in mecA-PVL PCR and spa PCR. ATCC strain 43300 and 29213 were used as controls for Etest assay. All strains were cultured at 37°C for 16–24 h.22 and an isolate was transferred to Nutrient agar  for further analysis. Lysis of bacterial cells was performed by suspending 1–2 colonies in 100 μL of lysis buffer , incubation at 37°C for 30 min followed by boiling for 10 min. The lysate was centrifuged at 14000 rpm × 30 s and diluted 1:10, 1.5 μL of the diluted lysate was used as a template for PCR reaction.The strains were cultured on 4S agarmecA, pvl and 16S rRNA gene, which serves as an internal amplification control, was performed as described by McClure et al.23 PCR for the detection of mecC gene was performed as described by Stegger et al.24 Verification of SCCmec type XI presence was performed as described by Garcia-Alvarez et al.5 PCR for the detection of immune evasion complex (IEC) genes, chp and scn, was performed as previously described.25 PCR for amplification of φ3 int was performed as described by Lekkerkerk et al.26Multiplex PCR for the simultaneous detection of spa typing and MLST were performed as described previously.28spa typing and MLST analysis were performed using BioNumerics 7.6.3 software.Molecular typing of the isolate by De novo assembly by SPAdes and whole genome MLST (wgMLST) analysis were performed on the BioNumerics 7.6.3  using the default settings. Core genome MLST (cgMLST) comparison was performed by the BioNumerics software using 10 as scaling factor and categorical differences as similarity matrix.Genomic DNA was extracted by using the GeneAid kit. DNA library was prepared using Nextera XT kit . S. aureus database was screened for mecC-positive isolates by BLAST. wgMLST schemes of mecC-positive strains were downloaded from pubMLST site, imported to the BioNumerics software and used for phylogeny analysis. Phylogeny was deduced by calculating a minimal spanning tree based on wgMLST allelic profiles.The pubMLST S. aureus functional genotyping tool.Detection of resistance genes was carried out with the PATRIC tool using the Comprehensive Antimicrobial Resistance Database (CARD). Detection of virulence factors was carried out using the All MRSA strains were grown at 37 ± 1°C for 18–24 h before conducting susceptibility tests. For Etest, several colonies were suspended in saline to a turbidity of 0.5 McFarland. The suspension was seeded on a Mueller–Hinton agar plate  and then Etest strips (bioMérieux) were put on each agar plate for oxacillin and cefoxitin. Plates were incubated at 35 ± 1°C for 24 h (oxacillin) and 18–24 h (cefoxitin). MIC values were determined according to CLSI guidelines: resistance to oxacillin is defined at MIC values ≥4 mg/L; resistance to cefoxitin is defined at MIC values ≥8 mg/L.Broth microdilution was performed with Sensititre susceptibility plates (Gram-positive GPALL1F AST Plate) according to manufacturer’s instructions. Briefly, ∼5 colonies were suspended in DDW to a turbidity of 0.5 McFarland. Then, 10 μL of the suspension were transferred into 11 mL of CAMHB (cat. Number T3462). The plate was inoculated using the Sensititre AutoInoculator/AIM. Following incubation for 24 h, results were read using the VIZION platform (Sensititre). MICs were determined according to CLSI guidelines (M100 2020).Vitek AST was done with the Vitek 2 automated AST system using an AST-P649 card .mecALGA2515 (accession: FR821779); M10/00617 (accession: FR823292); Patient A20 (accession: ERR084771); Cow A20 (accession: ERR144792); Patient B20 (accession: ERR144788); Sheep B20 (accession: ERR144749); OFVD (accession: OFVD01000000); OFUF (accession: OFUF01000000); mecC MRSA isolated in Spain29 (accession: ERR403511); mecC MRSA isolated in Brazil15 (GCA_009763195.1); mecC MRSA isolated in New Zealand29 (ERR5417136); mecC MRSA isolated in England29 (ERR3595448); and mecC MRSA isolated in Australia18 (accession: LUFG00000000). WGS of strain SA10610 was deposited in the pubMLST database under the ID 34000.The following genomes were used for WGS analysis comparison: Strain SA10610 was isolated from a urine sample from an 83-year old prostate carcinoma patient referred to the HMO due to a urinary tract infection. Vitek analysis (GP CARD) at the regional HMO laboratory identified the isolate as MRSA (positive cefoxitin screen and oxacillin MIC ≥4 mg/L), and the patient was treated with ofloxacin (Oflodex). In order to broaden the antibiotic resistance profile of the SA10610 isolate, broth microdilution testing was performed. SA10610 was tested for phenotypic susceptibility to common antimicrobial compounds indicating resistance to oxacillin, penicillin and cefoxitin and susceptibility to all other non-β-lactam agents tested .S. aureus national reference centre revealed that this strain is seemingly MSSA genotypically, negative for the mecA gene by PCR. The strain was phenotypically resistant to oxacillin and cefoxitin as determined by Etest , and Vitek 2 . This observation was surprising and motivated us to check for the presence of the mecC gene. In PCR analysis for the mecC gene, SA10610 was found positive. The isolate was negative by PCR for the Panton–Valentine leukocidin (PVL) genes. MLST and spa typing assigned the isolate to ST130 and spa type t1736. PCR analysis for the detection of SCCmec type XI was positive.Further analysis at the mecC gene, and the phylogenetic lineage of the strain. WGS of strain SA10610 revealed 100% identity to the mecC gene sequence of S. aureus strain TRN6234, isolated from a patient in a German hospital with a wound infection,30 and 99.9% identity to the mecC gene sequence of strain M10/0061 isolated from an 85-year-old male inpatient in a regional hospital in south Ireland in 2010.7 The SCCmec sequence of strain SA10610 showed 99.9% identity to SCCmec type XI of strain M10/0061.7We applied WGS in order to investigate the genomic context of the mecALGA251, along with genomes of S. aureus isolates isolated from human and animal origin worldwide. The results presented in Table mecC MRSA strain isolated from Sheep B and mecC MRSA isolated in Brazil, which were positive for pT181, a tet(K)-carrying plasmid, and Tn552, a β-lactamase-carrying transposon, respectively.In addition, we compared the WGS-derived antimicrobial resistance profile of SA10610 isolate to that of the prototype mecC among a national strain bank maintained by the national reference centre. The fact that specific spa types were associated with mecC-positive S. aureus isolates motivated us to screen our strain bank database for common spa types, known to be prevalent in mecC S. aureus strains. None of the mecC-related spa types were found in our human-origin strains database. However, five S. aureus strains of animal origin  that belonged to spa type t529 were found in our database. Further analysis revealed that those strains are negative for mecA, mecC and pvl , an animal-origin marker, is also absent from the SA10610 genome.34The fact that mecC MRSA was as a result of epidemiological study of bovine mastitis in 2007,5 subsequently, more mecC-positive isolates were identified, both of human and animal origin, in other countries. As far as we know, this is the first report of mecC MRSA in Israel, which is assigned spa type t1736 and ST130 and belongs to clonal complex CC130, which is the major lineage responsible for the vast majority of mecC isolates to date.1The first discovery of mecC MRSA isolates,32 is characterized by susceptibility to the majority of all non-β-lactam antibiotics.35 In addition, all the genomes tested in this analysis, except from the isolate isolated in Brazil, carry the same SCCmec and have very similar horizontally transmissible accessory genomes.The antibiotic susceptibility pattern of strain SA10610, as reported for most scn) and chemotaxis inhibitory protein (chp). Our comprehensive database, which incorporates data from 2011 onwards, was screened for the presence of mecC-harbouring MRSA isolates, based on spa types that are characteristics of mecC-positive S. aureus. Five MSSA isolates of animal origin were found. Those isolates were negative for chp, four were negative for scn and two were positive for φSa3. In addition, WGS sequences of mecC MRSA genomes isolated worldwide from humans and animals were screened for the presence of scn and chp genes and were found negative. In light of the above, it is hard to identify the cause or source of the infection.The patient from whom SA10610 was isolated lives in an urban environment and data regarding animal exposure was unavailable. Human-associated isolates carry phages encoding human innate immune modulators that are rare in livestock-associated isolates and therefore may be used as markers. These markers include the φSa3 phage, which contains an IEC of genes that include staphylococcal complement inhibitor  may imply the evolutionary origins of mecC MRSA. It seems that there is no one ancestral mecC MRSA origin from which descendant isolates evolved. Rather, mecC MRSA emerged in different places independently of each other.After the original discovery of mecC MRSA in Israel. The genomic and epidemiologic information presented in this research can support further mecC MRSA studies. The relative similarity between the SA10610 strain and previously sequenced mecC MRSA CC130 isolated from humans and animals in Denmark, in the cgMLST, resistance and virulence profiles may reflect a weakly clonal lineage.In conclusion, as far as we know, this study represents the first report of


Investigate the natural history of urinary incontinence (UI) in systemic sclerosis (SSc) and assess its impact on quality of life (QoL). A longitudinal, international observational study followed 189 patients with SSc for a median duration of 5 years (IQR: 4.8–5.3). Presence, subtype and severity of UI, hospital admission and QoL were assessed using serial self-administered questionnaires. Mortality data came from national death registries. Multilevel mixed-effect logistic regressions explored factors associated with UI. Cox models adjusted the effects of UI on hospitalization and death for age, sex and subtype of SSc. Mean annual rates of new-onset UI and remission were 16.3% (95%CI 8.3%–24.2%) and 20.8% (95%CI 12.6–29.1), respectively. Among UI patients, 57.9% (95%CI 51.8–64.0) changed from one UI subtype to another. Between annual questionnaires, the severity of UI was the same in 51.1% (95%CI 40.8–61.4), milder or resolved in 35.2% (95%CI 25.3–44.9), and worse in 13.8% (95%CI 6.7–20.9). Anti-centromere antibodies, digestive symptoms, sex, age, neurological or urological comorbidities, diuretics and puffy fingers were all associated with UI. The two strongest predictors of UI and UI subtypes were a recent UI episode and the subtype of previous leakage episodes. UI at inclusion was not associated with hospital admission , time to death  or change in QoL over time. Self-reported UI among SSc patients is highly dynamic: it waxes and wanes, changing from one subtype to another over time.The online version contains supplementary material available at 10.1007/s00296-022-05178-1. Urinary incontinence (UI) affects the quality of life (QoL)  and workUI is now recognised as a highly prevalent condition in cases of systemic sclerosis (SSc), affecting 52–63% of patients , 11. EpiTo date, there were no data available on the natural history of UI in SSc. Some reports have found a higher prevalence of UI in the limited form of SSc or among patients having anti-centromere antibodies (ACA) , whereasThis international, prospective, observational study enrolled patients suffering from SSc at four European tertiary hospital centres from January 2013 to December 2015. Patients underwent three annual evaluations of their lower urinary tract symptoms (LUTS) by questionnaires in two centers, two annual evaluations in one center and one evaluation in the last center. All patients were then followed until death or to 31 December 2019. The study complies with the Declaration of Helsinki. Locally appointed ethics committee has approved the research protocol. Written informed consent has been obtained from all patients included in the study. The following sections summarise our cohort population data, inclusion process and variable management, which have been published previously , 24.The main outcome was continence evolution at annual clinical evaluations. The secondary outcomes were first UI episode, QoL, first hospital admission, number of admission, length of stay, and death.Scenarios of urinary continence evolution between study visits were “new-onset UI”, “resolved UI symptoms”, “worsening of UI symptoms”, “decreasing UI symptoms”, and “changing UI subtype”. The first described patients continent of urine in the previous study visit, who complained of UI in the follow-up visit. The second described patients continent of urine, who used to complain of UI in the last study visit. The three last scenarios refer to patients with UI in two study visits, who changed the frequency of UI episodes (from daily to monthly for example), or changed the subtype of UI (changing from stress to urge UI for example).Eligible patients were aged 18 or older and satisfied the ACR/EULAR 2013 SSc criteria . They weAt inclusion and each annual study visit, participants completed a thirty-minute self-administered questionnaire on their LUTS, QoL, functional status, disease activity, medication, medical history and demographic characteristics. Patients were classified as having the limited or diffuse cutaneous form of SSc, according to Le Roy et al. .At each study visit, UI was characterised using the International Consultation on Incontinence Modular Questionnaires (ICIQ-FLUTS and ICIQ-MLUTS) . These eThe 36-item short-form health survey (SF-36) , 30 was First hospital admission, length of stay and number of admissions between study visits were collected using self-administered questionnaires and participating hospitals’ electronic databases. Data on the date of death were obtained from national death registries and each participating hospital’s electronic databases until the end of December 2019. Each participating centre stratified the cause of death into SSc-related and SSc-unrelated based on their expertise.The initial sample involved five institutions and was calculated to demonstrate differences in UI prevalence between SSc subtypes at the baseline evaluation . HoweverComparisons between the continent and incontinent participants were performed using the appropriate chi-squared test or Fischer’s exact test for categorical variables. The two-sided Mann–Whitney test was used for continuous variables. Variables for the same individual measured on two occasions  were compared using the paired Wilcoxon signed-rank test.To evaluate factors associated with the natural history of UI, we calculated multilevel mixed-effect logistic regressions accounting for repeated measures and patients being clustered in different study centres. Analyses were repeated for any evolutions in UI scenarios at annual clinical evaluations. A random intercept was given to any individual to account for repeated measures. Other models explored risks by UI subtype and severity (dependent variables). Potential associated factors were chosen based on our previous publications , 24. ConThe unadjusted effects of UI on time-dependent outcomes  were analysed using Kaplan–Meier survival analysis and unweighted, two-sided, log-rank tests to compare groups. Participants with unknown status on 31 December 2019 were considered lost to follow-up and were censored from their last medical visit. Multivariate Cox models were used to adjust for age, sex and type of SSc. The same analyses were performed according to the subtype and severity of UI and SSc-related death.The significance level was set at 5%, and all analyses were performed using STATA statistical software, version 12.0 .A total of 189 SSc patients were followed for a median duration of 5 years (IQR: 4.8–5.3)  of 118 patients between their inclusion and their second visit; it changed for 22 (26%) of 86 patients between their second and third study visits. The yearly rate of new-onset UI was 16.3% (95% CI 8.3%–24.2%). Each year, the symptoms of 20.8% (95% CI 12.6–29.1) of patients suffering from UI resolved, 57.9% (95% CI 51.8–64.0) changed from one subtype of UI to another , and 34.2% (95% CI 28.4–40.1) kept the same UI subtype . None of the factors was constantly associated with the risk of either “new-onset UI” or “worsening of UI symptoms”.The combined chance of being attributed an outcome of “decreasing severity of UI”, “resolving UI symptoms” or “maintaining continence” decreased with previous episodes of SUI  or UUI , the presence of ACA  or digestive symptoms , and it was higher in men . These factors’ effects on the risk of “decreasing severity of UI” or the risk of “resolving UI symptoms” were inconstant (Supplementary Table S1).The risk of UUI at subsequent visits increased with previous episodes of UUI  or SUI , ACA positivity , digestive symptoms , an age above than median  and higher frequencies of episodes of UI (Supplementary Table S2). The risk of SUI at the subsequent visit increased with previous episodes of SUI  or UUI  and with higher frequencies of episodes of UI. However, the risk was lower for men .Age, neurological palsy, urological comorbidities, UUI, SUI, diuretic treatments, ACA positivity, the limited cutaneous form of SSc and the previous severity of episodes of UI were inconstantly associated with monthly, weekly or daily episodes of UI (Supplementary Table S2).Except for the “physical functioning” domain of SF-36, patients’ QoL remained stable from the first to the third study visit, and there were no statistical differences between patients with and without UI. This was also true for changes in disability between these two evaluations and between the continent and incontinent patients (Supplementary Table S3).Between their inclusion and their third study visit, 43 (36%) patients were hospitalised at least once, with a median length of stay of 8 days (IQR: 5–18). UI at inclusion was not associated with time to first hospital admission in our univariate  or adjusted analyses . This was also true when considering different subtypes of UI and severity (Table Thirty deaths (19%) occurred during the median follow-up time of 5 years (IQR: 4.8–5.3), of which 22 (73%) were deemed to be SSc-related. UI at baseline was not associated with time to death in either our univariate  or adjusted analyses . There were also no associations between UI severity or UI subtype and death from any cause  among systemic sclerosis (SSc) patients is a highly dynamic phenomenon. Over a period of two years, almost 40% of participants changed their urinary status, and an episode of urine leakage (transient or persistent) affected the majority of patients. Nevertheless, compared to continent patients, UI was not associated with an unfavourable change in QoL or functional status over time or with an increased risk of hospital admission or death in SSc.In contrast to previous beliefs that UI is a binary and constant disease, there is growing evidence that UI changes over time, with active and inactive phases. In the general population, the annual incidence of new-onset UI is 2%–10% among men and 3%–20% among women, with remission rates of 27%–32% and 3%–12%, respectively –35. ThusAlthough UI is commonly divided into clinically independent subtypes, about a quarter of SSc patients in the present study changed from one UI subtype to another between annual visits. This has also been observed in longitudinal studies of women without SSc , 38. FurDue to its dynamic nature, UI must be reassessed often (at least once a year) among SSc patients. This reassessment is important to adapt UI management on its severity and subtype and to look for factors that might influence or predict its evolution. Although results were inconstant across the different natural history scenarios of UI over time, several factors—including ACA antibodies, digestive symptoms and, to a lesser extent, sex, age, neurological palsy, urological comorbidities, diuretic treatments, the limited cutaneous form of SSc and the presence of puffy fingers on clinical evaluation—appeared to be potentially associated with UI. Nevertheless, the two strongest predictors of UI and its subtypes were a recent UI episode and the subtype of the previous leaking episodes (SUI or UUI). Understanding the factors that influence the evolution of UI, and which phases of UI have the most significant health effects, will help to reassure some patients, provide tailored treatments for severe episodes of UI that are unlikely to resolve, and also give prevention based on risk factors.The present study had some limitations. First, as previously mentioned, because no controls were included, it was impossible to confirm whether SSc patients had higher new-onset or remission rates than the general population. Second, UI diagnoses were based on self-reported questionnaires without objective measures. The ICIQ questionnaires have nevertheless been correlated with objective measures of UI in other studies , 40. ThiIn conclusion, UI is a dynamic condition in SSc that waxes and wanes, eventually changing from one form to another subtype.Supplementary file1 (DOCX 44 KB)Below is the link to the electronic supplementary material.


To investigate the effects of intensive gaze stability training (IGST) combined with conventional drug therapy and traditional Chinese medicine (TCM) therapy on hearing recovery and quality of life (QOL) in patients with bilateral vestibular dysfunction. n = 60) and group B (n = 60) based on the order of admission. Group B received conventional medication and TCM therapy, and group A received IGST plus conventional medication and TCM therapy. The serum biochemical indexes, blood rheology indexes, symptoms disappearance time, hearing recovery time, pure-tone hearing threshold, vestibular symptom index (VSI), and QOL of the two groups were compared.  A total of 120 patients with bilateral vestibular dysfunction admitted to our hospital from January 2019 to January 2020 were recruited and assigned to group A (P < 0.001). Patients in group A had a shorter time lapse before symptoms disappearance and hearing recovery than those in group B (P < 0.001). Group A had lower results of the pure-tone hearing threshold (P < 0.001) and of VSI (P < 0.05) than group B. Patients in group A had higher QOL scores than those in group B after treatment (P < 0.001).  The serum biochemical indexes and blood rheology indexes in group A were lower than those in group B after treatment ( IGST plus conventional drug therapy effectively improves the serum biochemical indexes and blood rheological indexes of patients with bilateral vestibular hypofunction, accelerates their hearing recovery process, and alleviates their clinical symptoms, thereby improving their QOL, which shows good potential in clinical application. When the bilateral vestibular function of the human body is impaired, patients may exhibit symptoms such as dizziness or hearing loss. In clinical practice, the activity of the inner and outer hair cells is reduced by weakening their excitability, which is conducive to restoring normal hair cell function and enhancing the patient's tinnitus sensation –3. The hn = 60) and group B (n = 60) according to the order of admission. The two groups showed comparable patient characteristics (P > 0.05), as shown in A total of 120 patients with bilateral vestibular hypofunction admitted to our hospital from January 2019 to January 2020 were recruited and divided equally into group A (Inclusion criteria of the patients in this study were as follows: (1) patients or their families had full knowledge of the study process and signed a consent form; (2) patients were diagnosed with bilateral vestibular hypofunction by combining medical history, examination results, and clinical manifestations –15; (3) Exclusion criteria for this study were as follows: (1) patients with psychiatric problems were incapable of communication; (2) patients with other organic diseases; (3) patients were diagnosed as inner auditory tract lesions or middle ear occupational lesions by imaging; and (4) patients with tinnitus symptoms before the onset of sudden deafness.Group B received conventional medication and TCM therapy, and group A received IGST plus conventional medication and TCM therapy.Conventional drug treatment: (1) patients received prednisone  for 3 days at a dose of 1 mg/kg. (2) The patients with positive curative effects with prednisone were given medicine for 2 more days at the same dose; those with poor effects were discontinued and switched to intravenous 10 BU bacitracin injection  dissolved in 100 ml of 0.9% sodium chloride injection, twice daily. The duration of treatment was 5 days.IGST: (1) gaze stability training: the patient was asked to keep both eyes open, shield one eye, and gaze horizontally forward with the other eye for 1 min. Two eyes were trained alternately for a total of 10 minutes. Eye movement was forbidden during the training. The training time was prolonged to 15 minutes after one day of training. (2) Visual tracking training: the patient needed to point out the positions on Schulte's square from the smallest one to the largest one and read out the number. The training lasted for 20 minutes. (3) Proprioceptive dependence training: the patient was asked to repeat the movements such as walking backward along the curve with eyes closed and skateboarding for 30 min.TCM dialectical therapy: the formula includes 10 g of Gastrodiae Rhizoma, 10 g of Uncariae Ramulus cum Uncis, 30 g of Haliotidis Concha (first decoction), 6 g of Chuanxiong Rhizoma, 10 g of Saposhnikoviae Radix, 10 g of Pinelliae Rhizoma, 15 g of poria, 15 g of Atractylodis Macrocephalae Rhizoma, 10 g of Viticis Fructus, 6 g of roasted liquorice root. Corydalis Rhizoma and Ligustici Rhizoma et Radix were added for severe headache, Caulis Polygoni Multiflori and Silktree Albizia Bark were added for insomnia, Polygoni Multiflori Radix and Rehmanniae Radix were added for liver and kidney deficiency, and Safflower and Peach kernel were added for blood stasis and obstruction. The above herbs were decocted twice in water to obtain 400 ml of filtrate, which was administered in the morning and evening before meals. The duration was treatment was 4 weeks.Serum biochemical indexes include endothelin (ET), nitric oxide (NO), and superoxide dismutase (SOD). The comparison was conducted 30 days both before and after treatment.Blood rheology indexes: whole blood viscosity (NS), whole blood viscosity at a high shear rate (NBH), and whole blood viscosity at a low shear rate (NBL) determined. The comparison was conducted 30 days both before and after treatment.Time lapse before symptoms disappearance: symptoms included were tinnitus and vertigo, and the symptoms disappearance time of both groups of patients was compared.Time lapse before hearing recovery: the time lapse before patients' hearing recovery was compared.Pure-tone hearing threshold: the lightest sound that patients could precisely hear in both ears for different frequencies of pure-tones was detected. The lower the value, the better the patients' hearing. The time points of comparison were 30 days before and after treatment.VSI: symptoms included balance, vertigo, dizziness, nausea, visual sensitivity, and headache, with a score between 0 and 10 points. The lower the score, the less severe the patient's symptoms. The time point of comparison was 30 days after treatment –19.Quality of life (QOL): the QOL-C30 scale was used as the basis for scoring, which includes emotional function, physical function, social function, cognitive function, and role function. Higher scores were considered better QOL. The time point for comparison was 30 days after treatment –23.t-test. P < 0.05 means that the difference is statistically significant.SPSS 20.0 software was used for data analyses, and GraphPad Prism 7  was used for graph plotting. Count data are analyzed using the chi-square test, and the measurement data were analyzed using the P < 0.001), as shown in The serum biochemical indexes in group A were lower than those in group B after treatment (P < 0.001), as shown in Group A had significantly lower blood rheological indexes after treatment than group B (P < 0.001) (Patients in group A had a shorter time lapse before symptom disappearance than those in group B (< 0.001) .P < 0.001), as shown in Patients in group A had a shorter time lapse before hearing recovery as compared to group B (P < 0.001), as shown in Group A had a better outcome of pure-tone hearing threshold values after treatment than group B (P < 0.05), as shown in After treatment, VSI scores in group A were lower than those in group B (P < 0.001) (Patients in group A had higher QOL than those in group B (< 0.001) .P < 0.001). Endothelin (ET) is an important indicator of the hypoxic state of a patient's inner ear cells. It facilitates vasoconstriction and when the elevation of its level is highly susceptible to cell necrosis. However, NO removes the newly emerged necrotic cells and an increase in NO leads to a rapid release of SOD that weakens oxygen-free radicals. IGST successfully stimulates the patients' brain cells, resulting in a sharp reduction in the frequency of excitotoxin secretion, the optimization of blood circulation after training [P < 0.001). In addition, IGST stimulates the inner ear nerve cells of patients to achieve a successful recovery with more satisfaction. As a result, group A with IGST intervention showed a lower pure-tone hearing threshold (P < 0.001) and a lower VSI (P < 0.05) after treatment as compared to group B. Consequently, patients in group A recovered faster with a superior treatment effect and had a higher QOL after treatment than group B (P < 0.001). The above results are consistent with the findings by Choi J S who proposed in his study that additional gaze stability training for patients in the experimental group based on medication treatment resulted in higher scores of physical function (73.21 ± 5.20), social function (59.16 ± 5.36), and role function (73.12 ± 6.21) than those in the control group (P < 0.001). This indicates that patients under the combination of treatment had a better QOL after treatment.Tinnitus is a common clinical symptom that is usually treated with medication to improve the patient's hearing by weakening the activity of the patient's hair cells and blocking the affected nerve pathways. However, the treatment compliance is considered poor due to its slow effect and higher recurrence –27. In ttraining , 29, andThe results of this study showed that there was a significant decrease in ET, NO, and SOD levels in both groups after treatment, and group A had significantly lower results, indicating the effectiveness of the treatment. Patients with vestibular hypofunction have an inadequate capillary blood supply to the inner ear , 11, andIn the present study, TCM therapy was used. According to TCM theory, vestibular dysfunction is attributed to the damage to the spleen and stomach qi, loss of spleen health, failure to transform water and grain essence and gathering of dampness and phlegm, and the blockage of phlegm and dampness, resulting in yin deficiency and internal wind, which disturbs the clear orifices and causes dizziness and headache . In the In conclusion, IGST plus conventional drug therapy effectively improves the serum biochemical indexes and blood rheological indexes of patients with bilateral vestibular hypofunction and accelerates the disappearance of their symptoms and hearing recovery, which further ensures a better QOL for patients.


Here, we present a case who is diagnosed with CD-POEMS and successfully treated with a combination of daratumumab, lenalidomide, and dexamethasone (DRd).Both classical POEMS syndrome with CD and CD variant of POEMS syndrome (CD-POEMS),A 54-year-old man had admitted to our department of neurology with weakness of both arms and legs. Three years ago, patient developed tingling on legs and ataxia. He needed assistance for walking. The neurological examination showed bilateral upper and lower limb muscle weakness especially dominant on distal parts of the extremities on admission. There was an evident atrophy on distal part of the extremities. Stocking-glove pattern for loss of vibration and pinprick sensation was found. Romberg sign was present. The rest of the neurological examination was normal. Electrodiagnostic study showed that sensory nerve action potential, compound muscle action potential is diminished on bilateral upper and lower extremities. To exclude a possible accompanying PCD, serum protein electrophoresis, serum immunofixation electrophoresis, serum free kappa, and lambda light chains were ordered and revealed an IgA/lambda monoclonal band. The amount of M protein was 0.23 g/dL and IgA was 559 mg/dL. A bone marrow biopsy was applied and showed a presence of 5% plasma cells with no clonality. The free light chain ratio was 1.5 at the time of diagnosis. Because of a previous computed tomography scan showing multiple mediastinal masses, a positron emission tomography (PET) scan was ordered to document any fluorodeoxyglucose (FDG) avid masses. Serum vascular endothelial growth factor (VEGF) level was 531 pg/mL (<96 pg/mL) and serum interleukin-6 (IL-6) level was measured as 24.75 pg/mL (<7 pg/mL) PET scan revealed axillary, paraaortic, and aortocaval masses with a biggest dimension of 5 × 4 cm and a maximum standardized uptake value of 3.5. Excisional biopsy of the most FDG avid mass was reported as hyaline vascular type CD. He also suffered from coronary artery disease and a chronic subdural hematoma, which are now regarded as the vascular complications of PCD. The patient was diagnosed as CD-POEMS and a combination of DRd was initiated with a protocol of daratumumab 16 mg/kg, weekly for cycles 1–2, biweekly for cycles 4–6, monthly for cycle 7 onwards; lenalidomide 25 mg, days 1–21 every 4 weeks; and dexamethasone 40 mg, weekly. The combination was well tolerated. After the first cycle of the treatment, a VEGF response was achieved and serum VEGF level was declined to 27.2 pg/mL. Also, the serum IL-6 level was decreased and measured as 6.31 pg/mL , ixazomib , and dexamethasone (20 mg weekly) was switched to DRd therapy and hematological-clinical complete response was achieved. In another case report, Gavriatopoulou et al4 preferred upfront DRd in 2 separate POEMS cases; also, clinical and hematological complete response was obtained. Tiew et al5 also mentioned the success of single-agent daratumumab usage in a relapsed/refractory POEMS case in their newly published article. The most important feature of our case was that it was the third one in “upfront usage” and the “first” among CD-POEMS cases.There are 3 separate articles with similar characteristics in literature. Khan et al1 In risk-adapted therapy, irradiation is the first-line treatment for a single plasmacytoma; systemic therapy is preferred in patients with diffuse sclerotic lesions or disseminated bone marrow involvement and progression 3–6 weeks after radiotherapy. Low-dose conventional therapy or high-dose stem cell transplantation forms the basis of treatment. Other treatment options are lenalidomide, thalidomide, and bortezomib with a manageable toxicity profile. For POEMS, cases not included in POLLUX6 and MAIA,7 the major studies that demonstrated the superiority of DRd compared with lenalidomide and dexamethasone in multiple myeloma, DRd is considered as a very promising therapy choice.Established risk factors for worse outcome in POEMS include low serum albumin, age, pleural effusion, pulmonary hypertension, and low glomerular filtration.We respectfully remember all the colleagues we lost in the fight against COVID-19.All authors contributed to the editing of the article. IS prepared the accompanying figure.Deva Holding A.S. was the sponsor for article processing charge. The authors have no conflicts of interest to disclose.Written informed consent was obtained from the patient for publication of this report and any accompanying images.


Echinococcus multilocularis, and dog ownership has been identified as a risk factor. We sought to specify the factors of dog ownership underlying this risk by conducting a case–control study among dog owners in Germany. The analysis revealed an increased odds ratio of ≈7-fold for dog owners whose dogs roam unattended in fields, 13-fold for dog owners who feed their dogs organic waste daily, 4-fold for dog owners who take their dog to a veterinarian only in case of illness, and 10-fold for dog owners who have never been informed by a veterinarian about the risk for infection. The results highlight the risk for infection associated with various factors of dog ownership and the value of veterinarians informing owners about prevention.Human alveolar echinococcosis is caused by the parasite  Echinococcus multilocularis , dogs, and cats , voles (Arvicolinae), bank voles (Myodes glareolus), and other species can become infected. In the intermediate hosts, larval E. multilocularis stages (metacestodes) usually grow in the liver, where they cause alveolar echinococcosis and travel with the blood or lymph to other organs, behaving similarly to malignant tumors. In this process, the parasite can irreversibly damage the organs of the intermediate host, which can lead to death , based on 673 patients with alveolar echinococcosis recorded during 1992–2018, show that 60%–75% of recorded patients own, have owned, or have had regular contact with >1 dogs. In Germany, according to a joint survey by the Central Association of Pet Owners  and the Pet Supplies Industry Association , an estimated 9.4 million dogs lived in 19% of households in 2018. This estimate represents an increase of 2 million dogs since 2011 , cases in the National Echinococcosis Registry Germany include extensive information on epidemiology, risk factors, diagnostics, treatments, and patient care. In accordance with the study design, we selected cases from Baden-Württemberg, an area in southern Germany where alveolar echinococcosisis is highly endemic. The National Echinococcosis Registry Germany is a national disease registry that is part of a Deutsche Forschungsgemeinschaft–funded project in cooperation with the Robert Koch Institute  includes all veterinary facilities in Germany registered on a voluntary basis. We identified 324 veterinary facilities for Baden-Württemberg. We sent 2 questionnaires to each veterinary facility in Baden-Württemberg (n = 648) and distributed them to dog owners without known alveolar echinococcosis. We received completed questionnaires back from 239 dog owners, resulting in a response rate of 36.9%. Of these questionnaires, we used 214 in the final analysis . We initially analyzed the data descriptively. We determined mean values ±SDs and median, minimum, and maximum values and presented them as absolute or relative frequencies. For variables that may influence the occurrence of alveolar echinococcosis, we used a multivariable logistic regression model to determine adjusted odds ratios (aORs), 95% CIs, and p values. Confounding variables determined a priori were included in the adjusted logistic regression model. We used Pearson χ2 and Fisher exact tests to identify possible relationships and differences in frequency distributions between dichotomous variables. The significance level was set at α = 0.05. Dot-density maps and choropleth maps of cases and controls and their distributions were created by using the QGIS geographic information system version 3.16.0 (https://www.qgis.org).For statistical analyses, we used SAS version 9.4  and conducted according to the Declaration of Helsinki. Written informed consent was obtained from all case-patients and controls.2 = 10.6757; p = 0.0011). A total of 41/43 (95.35%) case-patients and 182/214 (85.05%) controls reported that they had lived in Baden-Württemberg for >20 years (p = 0.0839 by Fisher exact test)  and 214 controls from Baden-Württemberg. The mean age of the case-patients was 50.09 ± 17.62 years and of controls was 44.23 ± 15.23 years (p = 0.0347). The proportion of women was significantly lower among case-patients (26/43 [60.47%]) than controls (177/214 [82.71%]) (χct test) . The mai2 = 1.2533; p = 0.2629).The duration of dog ownership and regular contact with dogs was >20 years for 27/43 (62.79%) of the case-patients and 116/214 (54.21%) of the controls. The duration of dog ownership and regular contact with dogs was 11–20 years for 10/43 (23.26%) of the case-patients and for 48/214 (22.43%) of the controls. Thus, duration of dog ownership and regular contact with dogs did not differ significantly between the groups (χ2 = 3.6938: p = 0.0546) but was remarkably discrepant between the groups  . For dogE. multilocularis infection and possible prevention, the analysis further revealed a 10-fold increase in odds for alveolar echinococcosis  . For dog owners who never received information from a veterinarian about their own risk for <0.0001) .In contrast, for dog owners who never had their dog’s feces tested for worm eggs, the odds for alveolar echinococcosis were not significantly increased  . Odds weOur case–control study of the potential contributions of factors of dog ownership to the risk for human alveolar echinococcosis in Baden-Württemberg was based on the findings of previous case–control studies and systematic reviews that described dog ownership as an evident risk factor for human alveolar echinococcosis  infrequently. These results seem plausible because studies have shown that dogs in rural areas where risk for infection is higher receive less veterinary care ; prevalence was higher in southern Germany  than in northern Germany   of dogs should be dewormed 12 times per year, according to European Scientific Counsel Companion Animal Parasites .Limitations of our study are the heterogeneous distribution of case-patients and controls, as well as possible recall bias. Because patients with alveolar echinococcosis and the risk factor of dog ownership in Baden-Württemberg are in a highly selected, heterogeneously distributed group, this potential confounding factor may be overcome only by conducting an international study, perhaps in a multicentered format. Because of the small number of cases and often heterogeneous group sizes, values may scatter substantially, and CIs can vary widely. E. multilocularis parasites.Our study shows that certain factors of dog ownership are associated with increased odds of human alveolar echinococcosis and provides an overview of other potential risk factors. Considering the rapidly increasing number of dog owners in Germany, the results emphasize the role of veterinary facilities and others in informing dog owners about preventing or reducing their risk for infection with


Proximal humerus fractures (PHFs) are one of the most frequent fractures in the elderly and are the third most fractures after those of the hip and wrist. PHFs are assessed clinically through conventionally standard imaging (X-ray and computed tomography (CT) scans). The present study aims to conduct the diagnostic evaluation and therapeutic efficacy of the 3D-printed models (3DPMs) for the PHFs, compared with the standard imaging.  In terms of fracture classification and surgical indication, PHFs have poor interobserver agreement between orthopedic surgeons using traditional imaging such as X-rays and CT scan. Our objective is to compare interobserver reliability in diagnostic evaluation of PHFs using 3DPMs compared to traditional imaging.  The inclusion criteria were elders aged >65 years, fracture classification AO/OTA 11 B and 11 C, and no pathological fractures or polytrauma. In addition, 9 PHFs were assessed by 6 evaluators through a questionnaire and double-blinded administered for each imaging (X-ray and CT scan) and 3DPMs for each fracture. The questionnaire for each method regarded Neer classification, Hertel classification, treatment indication (IT), and surgical technique (ST). Interobserver reliability was calculated through the intraclass correlation coefficient (ICC). p=0.116)) assessed better agreement compared with X-rays IT. The ST reliability using 3DPMs  was statistically superior to traditional imaging (ST-RX ICC = -0.004 (p=0.454); ST-CT ICC = 0.429 (p=0.116)).  Nine patients with PHF were included in the study . The Neer and Hertel classifications between imaging types had similar ICC values between raters with no statistical differences. IT reliability using CT scan and 3DPMs (ICC = 1; ( Classification systems like Neer and Hertel offer poor reliability between operators. The 3DPMs for evaluating diagnostics are comparable to CT images but superior to the surgical technique agreement. The application of 3DPMs is effective for preoperative fracture planning and the modeling of patient-specific hardware. Proximal humeral fractures (PHFs) are one of the most frequent fractures among the elderly and are the third most fractures after hip and wrist fractures , 2. PHFsY view [Radiographs should be used as the first-line study to evaluate PHF . Neer's Y view . HoweverY view , as it iY view . AlthougY view .Surgical treatment of PHFs has several options such as open reduction and internal fixation (ORIF) with plate in 2-3 fragments reducible fractures; intramedullary nailing is a great option for the fractures of humeral neck; external fixator or K-wires are useful for complicated cases, when open reduction have too many risks; shoulder arthroplasty is chosen for displaced 3-4 fragments fractures or PHF at risk of avascular necrosis in the elderly –17.Managing PHFs are not free from risks. In conservative treatment, some possible complications are represented by delayed union or nonunion and osteonecrosis of the humeral head.Surgical treatment complications described in literature are iatrogenic rotator cuff lesions, secondary displacement, partial or total osteonecrosis, screw penetration of the articular surface, nonunion, infection, cut out and aseptic loosening of implant devices, axillary nerve injury, iatrogenic fracture, heterotopic ossification, and dislocation , 19.It is also reported by Biz et al. a late onset axillary artery and deep vein thrombosis in PHFs dislocation .With the rapid development of technology, orthopedic has applied digital technology for clinical services . With thIn recent years, 3DPT has gradually been applied in the medical field owing to its ability to display fractures . In addiThe present study aims to evaluate the diagnostic and therapeutic efficacies of 3DPT compared to the standard imaging (X-rays and CT scan) in PHFs, by measuring the interobserver agreement differences among orthopedic surgeons in the most used classifications and the treatment indications.This was a triple-blind trial study that included 9 cases with PHF, in which patients were recruited from January 2015 to January 2021. The inclusion criteria were age >65 years, fracture classification AO/OTA 11 B, and 11 C. The exclusion criteria were age <65 years, pathological fracture, metabolic bone disease, and polytrauma.A diagnostic and therapeutic evaluation of PHFs was proposed using X-ray images , CT scanPHFs were assessed by raters through a questionnaire for each imaging and 3DPM for each fracture. The test was administered randomly by a second operator blinded to the questions. A third blinded operator processed collected data statistically.Patients had given voluntary informed consent to participate in this study research. Anteroposterior and “scapular Y” X-ray views  CT scans (Optima CT660)  were acqhttps://www.ultimaker.com)   to const Figures  for the  Figures .Each PHF was rated with the following medical information: Neer classification Hertel classification Treatment indication, and Surgical techniqueEach fracture was presented in the same way: gender, years, and fractured side. A blind operator presented data randomly to evaluators, which classified imaging and 3DPMs according toNeer classification: the Neer classification evaluates the fracture of the four proximal humeral fragments: greater tuberosity, lesser tuberosity, surgical neck, and anatomical neck. The classification helps to understand the numbers of the fragments, the diastasis, and the angle of bone fragments. Neer classification considered fracture to be unstable if angulation exceeded 45 degrees or if the fracture was displaced by more than 1 cm .Hertel classification: “Lego classification” assesses the risk of head ischemia based on model fracture, medial hinge integrity, and dorsomedial metaphysical extension length . A totalEach fracture was assessed by operative treatment or nonoperative treatment. The indications for nonoperative treatment for the patients included in the study were nondisplaced fractures, valgus impacted fractures, and mildly displaced fractures  .Evaluators could choose different surgical treatment for each PHFs: ORIF using plate and screws, intramedullary nailing, pinning, arthroplasty with reverse shoulder replacement, anatomic shoulder replacement, and external fixator. Patients included in the study were treated with ORIF with plate (77%), intramedullary nailing (11%), and arthroplasty (11%).t-test was used to compare ICC scores, with a significance level of p < 0.05 and 95% confidence interval (CI). All statistical analyses were performed using the SPSS software (IBM®).Data were collected with a questionnaire using Microsoft Excel (version 16.0.14527.20162). Continuous data are presented as means and standard deviations. The intraclass correlation coefficient (ICC) (two-way random effects model and single-measure reliability) was performed to evaluate the interobserver agreement. According to the Koo and Li [Nine patients with PHF were considered eligible and included in the study: 6 females (66%) and 3 males (33%). The mean age was 68 years (range: 54–74 years). Data were collected by questionnaire, and the following results were presented.F8,40 = 3.843; p=0.002). The same result was found for NC with CT scan, ICC = 0.792 , and NC with 3DPMs, ICC = 0.770   scores among operators had “good” reliability values according to ICC in each diagnostic method. NC with X-rays imaging between observers was significant, ICC = 0.740 (p=0.001) .F8,40 = 6.735; p=0.001). Similar result was obtained by HC with CT scan: ICC = 0.806  and HC with 3DPMs : ICC = 0.922  (Same results were obtained for the Hertel classification (HC) reliability, with higher ICC values compared to NC and “excellent” ICC value for 3DPMs. HC with X-ray had significant scores: ICC = 0.852 (p=0.001) .F8,40 = 1.875; p=0.091). Different results were obtained by CT scan IT: ICC = 1  and 3DPMs IT: ICC = 1  (The treatment indication (IT) with X-ray evaluation between operators had lower agreement, ICC = 0.467 (p=0.451) .F8,32 = 4.089; p=0.002). No significance and lower values were observed in the interobserver reliability in ST with X-rays: ICC = −0.004  and ST with CT scan: ICC = 0.429  (Surgery technique (ST) reliability resulted higher using 3DPMs with statistical significance resulting ICC = 0.755 (p=0.116) .This study is one of the first to use 3DPT to study PHFs, with an avant-garde method for diagnostic and surgical treatment. Treatment of PHFs can be conservative or surgical. However, surgery is the most recommended for fractures with marked displacement or young people with Neer 3-4 part fracture –30.The most used treatment in literature is the conservative, especially in elderly with poor baseline function. The surgery treatment must be preferred in young patients and complex fractures for an early functional recovery. Internal fixation and arthroplasty are the most employed strategies to manage complex fractures. There is a controversial treatment for 3 fragments of PHFs, neck fractures in elderly, and the surgery treatment with a plate for three fragments of PHFs , 31. ThiPresently, 3DPT has been demonstrated as a useful tool in the orthopedic field. The surgery team and other clinical professionals can use 3DPT, a real fracture printed model, to improve the performance of the treatment. 3DPMs can also be presented to the patients and their family members to facilitate their communication with surgeons. Traditional imaging tests fail to present the advantages of the configuration of the fracture, the deformities, and the sense of depth in 3DPMs , 30.Moreover, studies of Wu et al.  demonstrMajed et al.  suggesteIn the evaluation of 3DMPs of PHFs, we obtained a good interobserver correlation in the choice of the surgical treatment, which was statistically significant compared to other traditional methods. Results revealed that ORIF was the most widely used surgical treatment, in line with the literature , 30. CheLimitations of the present study include the unmentioned surgical experience of operators, a small sample of patients, no consideration of intraclass correlation coefficient index, the restricted evaluation of complex PHFs (AO/OTA 11 B and 11 C), and no 3D-CT digital imaging considered.The CT scan is considered the “gold standard” for PHFs classification systems and decision-making treatment. This study considers both CT imaging and 3DPMs valid and useful for classification systems and treatment choices, even if 3DPMs could help in the surgical managing of complex fracture better than CT scan. 3DPT limitations  would be overcome by the increased reproducibility and accuracy in diagnostics of complex fractures like PHFs.Studies like the study by Brown et al.  hypothesIn the present day, the recent development of 3DPT have a great potential in orthopedics . The app


To investigate the distribution and influencing factors of preoperative conjunctival flora from patients undergoing penetrating ocular surgeries in northeast China.An observational and cross-sectional study design was used. In 305 eyes of 305 patients without infective eye diseases who underwent ocular surgeries at the First Affiliated Hospital of Harbin Medical University between May 2018 and May 2019, conjunctival sac scrapings were collected on the day before surgery.Staphylococcus epidermidis (64.92%), surpassing Staphylococcus aureus (5.76%). The culture positive rate of the young (18–40 years) group was different between the females (26.67%) and males (69.23%) (P = 0.024), but in the middle-aged group and the elderly group, the rates between the sexes were similar, with an increasing trend. Patients who visited in summer or autumn presented a higher positive rate than other seasons. Hypertensive women had a higher rate than hypertensive men .The mean age of the participants was 60.73 ± 14.23 years, with the majority being female, married and unemployed with at least primary school education. The positive culture rate was 48.20% (147/305 eyes), and 191 bacterial strains were isolated; two or more strains were isolated from 22.45% (33/147) of positive samples. The most commonly isolated bacteria was Staphylococcus were the most common preoperative conjunctival bacteria. Hypertensive female patients, elderly patients, or those operated on in the summer and autumn should pay more attention to perioperative treatment.In northeastern China, coagulase-negative ChiCTR2100044659.The online version contains supplementary material available at 10.1186/s12886-022-02441-8. The conjunctiva is the mucous membrane that lines the internal aspect of the eyelids and extends to the orbital globe, and the conjunctival sac is the space bound between the palpebral and bulbar conjunctiva . Given iCoagulase-negative staphylococci (CoNS) and Corynebacterium sp. are the two most commonly found bacterial flora of the normal conjunctiva [junctiva , 6. Due junctiva . Numeroujunctiva  and infejunctiva  and hypejunctiva ), alcohojunctiva  and patijunctiva . InvestiThe objective of this study was to investigate the bacterial flora of the conjunctival sac in patients scheduled for ocular surgeries and to explore the influencing factors of culture-positive or varied numbers of bacteria in patients before surgery in a city located in northeast China.This was an observational and cross-sectional study that enrolled 305 eyes from 305 patients undergoing eye surgery at the First Affiliated Hospital of Harbin Medical University between May 2018 and May 2019. The inclusion criteria included consenting patients suffering from cataract, diabetic retinopathy, pterygium, strabismus, macular hole or epimacular membrane, retinal detachment and silicone oil-filled eye. Patients were excluded if they had active ocular inflammation , nasolacrimal duct obstruction, ocular trauma, history of contact lens wear, topical or systemic administration of antimicrobial or immunosuppressive agents in the past 3 months or use of eyedrops in either eye within 3 days. All methods were carried out in accordance with research guidelines and regulations. All experimental protocols were approved by the First Affiliated Hospital of Harbin Medical University Ethical Committee (No. 201848) and strictly followed the Helsinki Declaration. All patients provided written informed consent before participating in the study. This study was registered in the Chinese Clinical Trial Registry (registration number is ChiCTR2100044659).The culture samples were obtained using a previously described method . The spe2 at 35 °C for 48 h. The bacteria, if any, were immediately streaked onto 5% sheep blood  and chocolate agar plates  and incubated at 35 °C for another 24 h. The identification of bacterial species was carried out by analytical profile index (API) panels .Thioglycolate medium was used as the enrichment culture, and specimens were incubated in 5% COP < 0.05 was considered a significant difference.Sociodemographic and clinical characteristics for the study population were summarized with frequencies and percentages for categorical variables and mean values and standard deviations for continuous variables. Variance analysis and the chi-square test were used to compare differences in positivity rate. Spearman rank correlation coefficients were calculated between the total bacterial count and patient characteristics. Univariate logistic analysis was conducted to analyse the relationship between the positive rate and patient characteristics. All statistical analyses were performed using SPSS software . Overall, 305 conjunctival samples were collected from the operative eyes of 305 patients enrolled in the study. The average participant age was 60.73 years ±14.23 SD years (range 18 to 89). The positive culture rate from patients was 48.20% (147/305 eyes). Other sociodemographic and clinical characteristics of the patients are summarized in Table Staphylococcus epidermidis (64.92%), followed by Staphylococcus aureus (5.76%) and Staphylococcus xylosus (5.24%). The isolation rate of gram-negative bacteria was 8.38%, and the three most common isolates were Citrobacter freundii (1.57%), Burkholderia cepacia (1.57%) and Pseudomonas aeruginosa (1.05%). The microorganism profiles isolated from the conjunctival sac are shown in Table The positive culture rate from patients was 48.20% (147/305 eyes). Of the 147 samples with positive culture results, 33 (22.45%) had mixed cultures with two to three isolated strains. Altogether, 31 types of bacteria were identified. The most common microorganism was 2 = 0.0791, P = 0.7785). According to age, the patients were divided into three groups: 18–40 years old (young), 41–65 years old (middle aged), and > 65 years old (elderly). The positive culture rates were 46.43% (13/28), 44.23% (69/156) and 53.72% (65/121) in each group, respectively. Although not statistically significant , the frequency of culture positivity in the conjunctiva of elderly patients was higher than that in young patients.First, the separate impacts of age and sex on the culture-positivity rate were analysed. As shown in Table 2 = 5.072, P = 0.024). Between the young group and the middle-aged group, the frequency of culture positivity in the conjunctiva of male patients showed a trend towards an initial reduction, and the incidence then increased with advancing age in the elderly group . Therefore, age and sex have a synergistic effect on the bacterial isolation of patients.Furthermore, we analysed the interactive impact of age and sex on culture-positivity rates. As shown in Table P = 0.0605, OR (95% CI) = 1.88 ), the difference in the culture positive rate between autumn and spring was still the largest.Harbin is located in northeastern China, which has a predominantly dry climate and a lower temperature than other parts of China. According to the internationally recognized astronomical seasons, spring is defined as March 21 to June 21, summer as June 21 to September 22, fall as September 22 to December 21, and winter as December 22 to March 20 of the following year . The cul2 = 0.8866, P = 0.6419). A history of alcohol consumption did not affect the culture-positive rate   was higher than that of those who never smoked (46.65%) . Furthermore, we analysed the interactive impact of hypertension and sex on culture-positivity rates. The culture-positive rate was higher among hypertensive women  than among hypertensive men  . However, for diabetes mellitus patients, the culture-positive rate was 45.54%, which was lower than that for patients without diabetes mellitus (49.51%)   was higher than that of patients without hypertension (45.98%) . Male patients (1.367 ± 0.581) had more bacterial species than female patients (1.195 ± 0.478) (Table P > 0.05).There was a positive correlation between the numbers of detected species and sex , followed by Staphylococcus aureus (5.76%) and Staphylococcus xylosus (5.24%). This finding was consistent with previously published findings showing that CoNS was the most frequently isolated ocular bacteria of patients undergoing eye surgery [Citrobacter freundii and Burkholderia cepacia being the most frequent (1.57%), and P. aeruginosa (1.05%) was also isolated.In this study, the overall positive culture rate was 48.20%, which fell in the lower middle range of the previous results of 36.0–81.7% , 18. Dif surgery , 20 and  surgery . Gram-neAge can affect the rate of conjunctival sac flora culture in patients of different genders. In our study, the frequency of culture positivity in the conjunctiva of male patients showed an initial trend towards a reduction, and the incidence then increased with advancing age in the elderly group. The middle-aged group of 41–65 years showed the lowest positivity of bacterial isolation (40.30%). Our results were in agreement with the same type of study in Zhengzhou, which is located in the central area of China . Their r2 = 0.4297, P = 0.8067).A previous study reported that diabetes mellitus was significantly more prevalent in patients with a positive bacterial culture of the conjunctival sac than in control patients . DespiteAs is well known, climatic factors affect the morbidity of conjunctivitis around the world , and it Potential limitations of the present study should be mentioned. First, in this study, the traditional culture method was used, which may have skewed or compromised the growth of the cultivable microbiome from the ocular surface and missed some nonculturable microbes. Modified methods, such as genetic analysis and 16S rRNA sequencing, may lead to a much more rapid, precise and complete analysis. However, these techniques cannot distinguish viable and nonviable bacteria, and the bacteria obtained by traditional culture methods are living and the dominant bacteria. Second, because the local anaesthetic eye drops had strong antimicrobial effects, we did not use the local anaesthetic, which brought local pain to the subjects.Staphylococcus was the most common preoperative conjunctival bacteria isolated. Hypertensive female patients, elderly patients, or patients operated on in the summer and autumn should pay more attention to perioperative treatment.In conclusion, in northeastern China, coagulase-negative Additional file 1.Additional file 2.Additional file 3.Additional file 4.