P = .002), total blood loss  and mean transfusion unit  were significantly lower in the without drainage group than in the with drainage group. But the morphine equivalent  was significantly larger in the without drainage group. No significant difference was found between the drainage group and without drainage group in Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index score at final follow-up. SBTHA without drainage can reduce postoperative blood loss and the requirement for transfusion without increasing other complication. But SBTHA without drainage is more painful method than SBTHA with drainage. Therefore, SBTHA without drainage will be a good option to reduce the burden on the patient by reducing postoperative bleeding if it can control pain well after surgery. III, Retrospective case-control study.Simultaneous bilateral total hip arthroplasty (SBTHA) is an effective procedure for patients with disease bilaterally. But there is concern about increased blood loss and complications of SBTHA than staged total hip arthroplasty (THA). This study aimed to evaluate the differences in the clinical outcomes and complication rate of SBTHA with drainage and without drainage for reducing the concerns. Between October 2015 and April 2019, a retrospective cohort study was conducted with modified minimally invasive 2-incision method and a consecutive series of 41 SBTHA performed with drainage (Group I) were compared to 37 SBTHA performed without drainage (Group II). It was assessed clinically and radiographically for a mean of 2.1 ± 0.8 years . Postoperative hematologic values , pain susceptibility, functional outcome  and complication were compared in the drained group and the non-drained group. Postoperative Hgb loss (I: 2163.2 ± 698.7 g, II: 1730.4 ± 572.5 g;  The number of patients undergoing total hip arthroplasty (THA) worldwide is increasing every year due to an increase in the prevalence of osteoarthritis (OA) of the hip joint and osteonecrosis of the femoral head (ONFH), among other causes. Bilateral hip joint disease is so frequent that it can occur in up to 42% of patients with OA, those undergoing unilateral THA with bilateral disease if they had Grade 3 and 4 radiographic changes and clinically displayed moderate or severe symptoms had a 97% chance of OA progression, eventually required contralateral THA.Rheumatoid arthritis, slipped capital femoral epiphysis, developmental dysplasia of the hip, and ONFH are also less common causes, but mainly affect both hip joints. These patients are required to undergo a total bilateral hip arthroplasty, sequentially or simultaneously.–5 Thus, cases of SBTHA have been recently increasing. However, SBTHA causes more blood loss than staged THA, and patients might require allogenic blood transfusion.,7 It is well known that allogenic blood transfusion in patients undergoing THA can cause complications, such as infection, delay of rehabilitation, prolonged hospital stay, and increase hospital cost.Simultaneous bilateral total hip arthroplasty (SBTHA) has many advantages like a shorter hospitalization period, faster rehabilitation, high patient satisfaction, and lower total hospital cost.–11 However, there is little report regarding SBTHA without drainage. Thus, in this study, we aimed to evaluate the differences in the outcomes of SBTHA with drainage and without drainage and identify any other associated complication.Multiple efforts have been made for reducing the requirement for allogenic blood transfusion after THA and not using drainage was considered as one of many efforts. There is still controversy over not using drainage after THA; however, not using drainage after THA has been reported to reduce blood loss. There are many reports demonstrating that unilateral THA without drainage can reduce blood loss, and there is no difference in the risk of complications between THA performed with and without drainage.We performed a retrospective study on patients who underwent SBTHA for OA of the hip joint or ONFH with a follow-up of at least 1-year at our institution. Between October 2015 and April 2019, 88 patients (176 hips) were treated with modified minimally invasive 2-incision method by 2 surgeons. All THAs were done by 2 experienced high volume (>300 hip surgeries per year) hip surgeons. grade < 4, body mass index < 30, completed ≥ 1-year of follow-up, and presence of disease such as OA and ONFH to be treated with simple THA. The exclusion criteria included history of previous hip surgery, follow-up loss during the study period, and severe unilateral or bilateral deformities such as septic hip sequelae, developmental dysplasia of the hip sequelae, posttraumatic OA or AVN. Patients with severe deformities of the hip joint and adhesion of the surgical site due to a previous surgery were excluded for easy comparison as this could increase the amount of bleeding during surgery. Finally, a total of 78 patients (156 hips) were eligible for inclusion in the study . 41 patients  underwent SBTHA with drainage (Group I) and 37 patients  underwent SBTHA without drainage (Group II) The patients/legal guardians signed written informed consent to participate in the study and agreed to use their images for publication of this article. In this study, all methods were performed in accordance with the relevant guidelines and regulations. All rights of the patients were protected against any kind of disadvantage and individual matters. This study was conducted with the approval of the institutional review board. All patients, except those with thromboembolic tendency, received intravenous tranexamic acid (TXA) (15 mg/kg) prior to skin incision of the first hip and received intra-articular TXA (15 mg/kg) within safety dose before wound closure of each hip. Femoral implanting using cementless tapered wedge stem was followed by Acetabular implanting using cementless acetabular cup in a press-fit manner.All operations were performed using modified minimally invasive 2-incision SBTHA in a lateral position, which method uses part of the Watson-Jones approach for anterior incision and part of the Moore posterior approach for posterior incision. In Group II, the drainage was not inserted, so the wound was covered with water-proof wound dressing material also used in group I after subcutaneous layer was closed.In group I, before the subcutaneous layer was closed, drainage was placed under the fascia. The patients were treated by using positive pressure for 24 hours postoperatively and after 24 hours, the negative pressure was maintained until the insertion was removed. The volume of drained blood was recorded daily and the drain tube was removed if the volume was <100 mL for a day. The volume of packed RBC was 320 mL per unit. Intermittent pneumatic compression device are used to help prevent deep venous thromboembolism. Intravenous patient-controlled analgesia was used as a postoperative routine for all patients. Nevertheless, if the patient complained of pain, visual analogue scale pain score 5 or higher, oral or parenteral opioids like tramadol IV, pethidine IV, or fentanyl transdermal patch were prescribed to control pain during hospitalization depending on the circumstances. The same rehabilitation protocol was used for both groups. On the first postoperative day, quadriceps strengthening exercises and ankle dorsiflexion exercise were initiated and ambulation with aid was recommended on the third postoperative day. If the patient’s general condition permitted, all patients were scheduled to be discharged within 7 days after surgery.After the surgery, hematologic values were checked preoperatively, immediately and on 1, 3, and 5 days after surgery. If the hemoglobin level was <8.0 g/dL, patients received red blood cell transfusion and the average transfusion unit (IU) was calculated.All hips were reviewed by an orthopedic surgeon who had not been involved with the original surgical procedure, and the data were entered into a computerized record. as follows:Estimated blood volume was calculated by the formula described by Nadler et al3 + k2 × weight(kg) + k3) × 1000Blood volume(ml) = (k1 × height(m). as follows:Based on the Hgb balance, the blood loss was calculated according to the formula described by Good et alpre − Hgbpost))×0.001 + HbtHgb loss(g) = ; the Hgb concentration before surgery, Hgbpost (g/L)l; the lowest Hgb concentration after surgery, Hbt (g); the total amount of allogeneic Hb transfused).(Hgb loss(g); the amount of Hb lost, Hgb Functional outcome scoring such as Harris Hip Score, The Western Ontario and McMaster Universities Osteoarthritis Index were collected from preoperative visit to final follow up. Lastly occurrence of wound complications , mechanical complications (intraoperative or postoperative periprosthetic fracture) and medical complications  during hospitalization period and deep infection during follow-up period were assessed.We evaluated postoperative pain susceptibility using morphine equivalent conversion formation for quantitative comparison.t tests. Differences in categorical variables between the groups were used to analyze using Chi-squared or Fisher’s exact tests. A significance level of ≤0.05 was used for all statistical tests.Statistical analyses were performed using SPSS statistical software system . Differences in normally distributed variables were analyzed using the independent 2), ASA status between the 2 groups. The patients were followed clinically and radiographically for a mean of 2.0 years  in group I and 2.3 years  in group II.The patients’ demographic information is summarized in Table P = .03 and P = .011) and third (P = .045 and P = .015) postoperative days with significant difference. Whereas there was significant difference between the drainage and non-drainage groups in only Hct levels (P = .048).In this study, Figure When these changes in the 2 groups were compared with the average of the preoperative and postoperative measures, there were significant differences between the preoperative and postoperative hematological values (Table P = .002), total blood loss  was significantly lower in Group II than in Group I; therefore, the transfusion requirements were significantly lower in Group II (0.1 ± 0.3 IU) than in Group I . As a result, 18 of 41 patients (44%) in group I received blood transfusions, whereas only 1 of 37 patients  received blood transfusions in group II.Postoperative Hgb loss   used was significantly larger in Group II (732.2 ± 591.5 mg) than in Group I . The mean Western Ontario and McMaster Universities Osteoarthritis Index was 52.4 (±16.8) in Group I and 54.4 (±18.9) in Group II. This improved to 8.2 (±6.3) in Group I and 6.0 (±6.7) in Group II (P = .151).The mean Harris Hip Score improved in Group I from 54.5 (±17.7) preoperatively to 90.5 (±10.6) postoperatively, and in Group II from 51.7 (±17.5) preoperatively to 93.2 (±8.3) postoperatively . The NRS is a subjective pain assessment method and it is a validated method for patients to evaluate the degree of pain. However, we postulate that differences would not have emerged in the study since NRS does not have an exact baseline for the introduction of pain control medication.Along with the positive aspects of without drainage, there were negative aspects as well. Higher morphine equivalent was derived in the patients without drainage, which means they felt more postoperative pain than the patients who underwent SBTHA with drainage. Rajesh and Prashant et al proved that the presence of drainage significantly reduces opioid consumption during the first 6 hours after total knee arthroplasty. Therefore TXA could play a exert an anti-inflammatory effect by inhibiting plasmin-mediated activation of complement, monocytes, and neutrophils recruitment to the implanted biomaterials, which may consequently minimize postoperative pain. Administration of TXA also helps to reduce postoperative pain by reducing intra-articular hemarthrosis. But JW Wurtz et al suggested an opposing opinion about role of TXA reducing postoperative pain. In this study, patients who received topical TXA reported higher mean 24-hour pain scores (P = .006) and requested opioid sooner (P = .033) compared to patients who did not receive TXA.In this study, since TXA was used by same method in both groups, the effect could be excluded, but TXA also contributes to reducing postoperative pain. TXA is a synthetic derivative of the amino acid lysine and binds the lysine binding sites on plasminogen, interfering with plasminogen binding to fibrin. By inactivating plasmin, TXA can prevent hyperfibrinolysis. Additionally, the coagulation-fibrinolysis process has been identified at interconnecting with inflammatory cascade.Several limitations existed in this study. Firstly, this was a retrospective cohort study based on the database of a single institute. Secondly, the mean follow-up period was not long enough to evaluate the long-term clinical outcomes. Thirdly, patients who undergo SBTHA usually have good physical conditions such as ASA grade 1 and 2; therefore, the result remain unknown in less healthier populations. Lastly, further studies are needed on the effect of TXA on postoperative pain.SBTHA without drainage can reduce postoperative blood loss and the requirement for transfusion without increasing other complication. But SBTHA without drainage is more painful method than SBTHA with drainage. Therefore, SBTHA without drainage will be a good option to reduce the burden on the patient by reducing postoperative bleeding if proper pain management is used.The authors thank all clinical researchers involved in the research we included in this article. This study was not supported by any company or grant.MG KIM: Collection and analysis of data and writing manuscript. CJ IM, WC JUNG: Collection and analysis of data. TR YOON: Make concepts and design of study. KS PARK: Make concepts and design of study. Review and correction of draft manuscript.Conceptualization: Min-Gwang Kim, Taek-Rim Yoon, Kyung-Soon Park.Data curation: Min-Gwang Kim, Chae-Jin Im, Woo-Chul Jung.Formal analysis: Min-Gwang Kim, Chae-Jin Im, Woo-Chul Jung.Investigation: Min-Gwang Kim.Methodology: Min-Gwang Kim.Project administration: Min-Gwang Kim.Supervision: Taek-Rim Yoon, Kyung-Soon Park.Validation: Kyung-Soon Park.Visualization: Kyung-Soon Park.Writing – original draft: Min-Gwang Kim.Writing – review & editing: Min-Gwang Kim.


Staphylococcus aureus (MRSA) is a highly dangerous pathogen, and daptomycin has been increasingly used to treat its infections in clinics. Recently, several groups have shown that tolerance and resistance of microbes can evolve rapidly under cyclic antibiotic exposure. We have previously shown that the same tolerance and resistance development occurs in MRSA treated with daptomycin in an adaptive laboratory evolution (ALE) experiment. In the present study, we performed proteomic analysis to compare six daptomycin-tolerant and resistant MRSA strains that were evolved from the same ancestral strain. The strain with a higher tolerance level than the others had the most different proteome and response to antibiotic treatment, resembling those observed in persister cells, which are small subpopulations of bacteria that survive lethal antibiotics treatment. By comparing the proteome changes across strains with similar phenotypes, we identified the key proteins that play important roles in daptomycin tolerance and resistance in MRSA. We selected two candidates to be confirmed by gene overexpression analysis. Overexpression of EcsA1 and FabG, which were up-regulated in all of the tolerant evolved strains, led to increased daptomycin tolerance in wild-type MRSA. The proteomics data also suggested that cell wall modulations were implicated in both resistance and tolerance, but in different ways. While the resistant strains had peptidoglycan changes and a more positive surface charge to directly repel daptomycin, the tolerant strains possessed different cell wall changes that do not involve the peptidoglycan nor alterations of the surface charge. Overall, our study showed the differential proteome profiles among multiple tolerant and resistant strains, pinpointed the key proteins for the two phenotypes and revealed the differences in cell wall modulations between the daptomycin-tolerant/resistant strains.Methicillin-resistant  Staphylococcus aureus infections have become more dangerous and expensive to treat owing to the increased prevalence of antimicrobial resistance (S. aureus (MRSA) is one of the most dangerous pathogens to date, causing infections in both high-risk patients in hospitals  and in healthy, non-hospitalized individuals without risk factors (community-associated MRSA). Since 2001, the increase in MRSA exposures and infections in the United States was largely attributed to the community-associated strains because they cannot be controlled solely based on measures implemented within the health care settings , hence making daptomycin a more attractive treatment option  experiments on MRSA using daptomycin and generated strains with distinct tolerance and resistance phenotypes . All of  studied . Mainly,s CAMPs; . Ernst e. aureus . In contptomycin .S. aureus (MRSA) ATCC 43300 and daptomycin-tolerant  and resistant  MRSA strains. For our experiments, exponential phase cultures were prepared by incubating a 1:200 diluted overnight culture in cation-adjusted Mueller-Hinton (MH) broth until OD600 reached ~0.1 at 37°C with shaking. MH broth used in this study is supplemented with Ca2+ to a final concentration of 50 mg/l to mimic the physiological levels of calcium ions, which is important for the concentration-dependent bactericidal activity of daptomycin  experiment using daptomycin antibiotic . BrieflyTo measure the tolerance level of the different strains, we measured the time-kill curve under daptomycin treatment (10 mg/l). For susceptibility assay toward vancomycin, the concentration used for treatment is 30 mg/l. To assess cell viability after antibiotic treatment, the number of survivors were counted by serially diluting cultures in MH broth, plating 100 μl on MH agar and spread plates.The MICs of the population were recorded by the broth macrodilution method . The MIC600 ~ 0.6 and harvested by centrifugation. Cells were washed with water and resuspended in PBS supplemented with 5 mg/l lysostaphin (Sigma Aldrich). Cells were then incubated at 37°C and the decrease in OD600 was monitored over time.Lysostaphin lysis assay was performed following protocols described in literature with a slight modification . Cells wS. aureus strains was determined by quantifying the association of the positively charged cytochrome c (Sigma) to the staphylococcal surface . Samples were incubated for 10 min at room temperature, separated by centrifugation, and the supernatants were recovered. The amount of cytochrome c remaining in the supernatant after a 10-min binding interaction with S. aureus cells was quantified spectrophotometrically at an optical density at 530 nm (OD530). The more unbound cytochrome c is detected in the supernatant suggest that the surface charge is more positive.The relative positive surface charge of  surface . The cytterature . BrieflyFor proteomics analysis, exponential phase ancestral strain, tolerant  and resistant strains  were treated with sub-MIC doses of daptomycin (0.25 mg/l) for 1 h, which should enable the populations to elicit an antibiotic response . Exponeng for 10 min) to remove cell debris and insoluble materials. An aliquot of the sample was taken for BCA protein assay (Pierce™ BCA Protein Assay Kit). After protein quantification, the sample was reduced by dithiothreitol  at 37°C for 1 h. For shotgun proteomics, 150 μg of proteins were mixed with up to 250 μl of the exchange buffer , transferred to Amicon® filter device , and centrifuged . The proteins in the filter device were alkylated with iodoacetamide  in dark for 20 min, and then centrifuged . To reduce the urea concentration, 250 μl of 50 mM ammonium bicarbonate was added to the filter device and centrifuged . This step was repeated once. Proteins were digested by sequencing-grade modified trypsin  for 12 h at 37°C. Then, the sample was acidified with 10% formic acid to a final concentration of 0.1% (v/v) and centrifuged for 16,000 × g for 5 min. Finally, the samples were desalted by C18 reverse-phase ZipTip  and dried with SpeedVac  for 30 min.The cell pellet was suspended in 300 μl of lysis buffer , frozen in liquid nitrogen, and sonicated for 10 min. The sample was centrifuged . A volume of 1 μl (approximately 200 ng of the protein digest) was injected into the UHPLC system and separated on an IonOpticks 25 cm Aurora Series Emitter column with Captive Spray Insert  at a flow rate of 0.3 μl/min. The mobile phase composition is 0.1% formic acid in water for solvent A, and 0.1% formic acid in acetonitrile for solvent B. The gradient was applied from 2 to 5% of solvent B for 0.5 min, from 5 to 30% of solvent B for 26.5 min, and then from 30 to 95% of solvent B for 0.5 min. In the end, the mobile phase was kept at 95% of solvent B for 0.5 min, and then decreased to 2% of solvent B for 0.1 min. 2 min equilibration with 2% of solvent B was applied before the next injection.The samples were reconstituted in 25 μl water/acetonitrile/formic acid in a 97.9:2:0.1 ratio (v/v/v), and processed through Bruker nanoElute Ultra-High-Performance Liquid Chromatography  coupled to a hybrid trapped ion mobility-quadrupole time-of-flight mass spectrometer  Vs/cm2. The quadrupole isolation width was set to 2 Th for m/z < 700 and 3 Th for m/z > 700, and the collision energy was linearly increased from 27 eV to 45 eV as a function of increasing ion mobility. The overall acquisition cycle of 0.53 s comprised one full TIMS-MS scan and four Parallel Accumulation-Serial Fragmentation (PASEF) MS/ MS scans. Low-abundance precursor ions with an intensity above a threshold of 2,500 counts but below a target value of 20,000 counts were repeatedly scheduled and otherwise dynamically excluded for 0.4 min. The TIMS dimension was calibrated linearly using three selected ions from the Agilent ESI LC/MS tuning mix  in positive mode.A detailed description of the Bruker TimsTOF Pro mass spectrometer used in this work can be found in the literature , 2018. WS. aureus ATCC 43300 was converted into a protein database using the gene prediction tool GeneMark  estimation of the identified peptides. The search parameters criteria were set as follows: 40 ppm peptide mass tolerance, monoisotopic mass type, fully digested enzyme termini, 0.05 amu fragment bin tolerance, 0 amu fragment bin offset, carbamidomethylated cysteine, and oxidated methionine as the fixed and variable modifications, respectively. The search results from Comet were processed by PeptideProphet , and subsequently converted to mzML files by msconvert of the ProteoWizard  of the log NSAF values using the PCA function from the sklearn package with centering and scaling in python. We added 95% confidence intervals by calculating correlation matrices for the three replicates of each sample and then adding these intervals to our plot using the matplotlib package in python. To compare the protein expression profiles between different populations, we generated a heat map of fold changes of the differentially expressed proteins identified across the ancestral strain and evolved strains using the in-house scripts. To highlight potentially important proteins among the differentially expressed proteins, STRING version 11.0  was usedGene overexpression was accomplished using a tetracycline-inducible expression vector pRMC2. The bacterial strains, plasmids, and primers used in this study are listed in Briefly, competent cells were first prepared as previously described and stored at −80°C . Then, t−ΔΔCt method using gyrA as the internal-reference gene  was performed to confirm the overexpression of the selected genes. The primers for real-time PCR are listed in nce gene . The RT-mprF, but in different locations. The daptomycin-tolerant and resistant strains used in this study were generated from a recent adaptive laboratory evolution (ALE) experiment that mimics clinical conditions . The tolS. aureus strains. Using the protein expression data, we performed a principal component analysis (PCA) to determine possible features that distinguish the ancestral and the tolerant/resistant strains. We observed that all strains except TOL6 were positioned closely, with the 95% confidence interval (CI) ellipse overlapping each other , highlighting the proteins with different expression levels between the evolved strains and the ancestral strain. The list of DEPs is available in pgsA gene  had significant variations in the proteome profile compared to the ancestral strain  in normal growth conditions, without any treatment. Combining all replicates, 1,646, 1,499, 1,451, 1,544, 1,587, 1,489, and 1,302 distinct proteins were identified for ancestral, RES1, RES2, RES3, TOL2, TOL5, and TOL6 strain, respectively , coverinch other . TOL6 wal strain .mprF gene, suggesting that the daptomycin resistance phenotype is associated with MprF gain-of-function, consistent with previous reports  values from our proteomics data, we estimated the relative expression level of the proteins encoded by the mutated genes in the evolved strains  values f. First,  reports . In TOL2 reports .The PCA and volcano plots showed that the high-tolerance TOL6 strain had the most different proteome and the highest number of DEPs among the tolerant/resistant strains. Therefore, we were interested in the affected processes due to the mutations it possessed. The protein–protein interaction network of the DEPs in TOL6 is visualized in de novo inosine monophosphate (IMP) metabolic process, protein repair, lipid metabolism, D-glutamine and D-glutamate metabolism, and glyoxylate and dicarboxylate metabolism. This shutdown of major metabolic processes and the increased expression of ribosomal proteins on TOL6 were not observed in the other tolerant/resistant strains. Instead, it was previously observed in the proteome of E. coli (S. aureus (S. aureus knockouts in glutamate dehydrogenase and other tricarboxylic acid (TCA) cycle enzymes  were previously shown to cause an increased proportion of persister cells and tolerance to different antibiotics  analysis and pathway enrichment study (KEGG) on the DEPs , we obse E. coli  and S. a. aureus  persisteibiotics . More ge. aureus . Since T. aureus , their sreatment . Stressereatment .Next, we treated the tolerant/resistant strains with a sub-inhibitory concentration of daptomycin to see the effect of antibiotic treatment on the proteomes of the mutant strains. The numbers of protein identified in the treatment groups were similar to the untreated ones , choline dehydrogenase (betA), glycine betaine aldehyde dehydrogenase (gbsA), opuD2, and proP genes , lactamase B domain-containing protein (SAOUHSC_01644), and immunoglobulin-binding protein Sbi. Interestingly, the last two proteins were also down-regulated in two other daptomycin-tolerant strains in our previous study (one with a high-tolerance level like TOL6 and one with a mild-tolerance level like TOL2 and TOL5) in the absence and presence of daptomycin , global transcriptional regulator Spx (a master regulator involved in stress response), redox-sensing transcriptional regulator Rex  was up-regulated in all of the tolerant strains upon treatment with daptomycin, suggesting that this protein might be important for the adaptation of the tolerant cells toward daptomycin. Indeed, overexpression of EcsA1 and FabG led to increased daptomycin tolerance in MRSA with ~150-and ~ 60-fold increase in survival after 3 h of treatment compared to the wild-type bearing empty pRMC2 plasmid , withoutptomycin . For insmembrane . Strainsmembrane . Indeed,membrane . BesidesecsA1 and fabG increased daptomycin tolerance by 150-and 60-fold, respectively, suggesting that ABC transporter system and fatty acid metabolism play key roles in modulating daptomycin tolerance. These experiments also demonstrated the utility of our strategy of cross comparing the proteomes of distinct resistant/tolerant mutants in identifying novel gene and protein candidates relevant to these phenotypes.Overall, we showed that overexpression of prkC gene, also had an increased survival toward lysostaphin. This was consistent with a previous study that shows an S. aureus ΔprkC mutant has cell wall modifications and increased resistance to Triton-X100 and fosfomycin , enhanced the net positive surface charge, and ultimately reduced daptomycin binding  under the accession number PRJNA724993.JS: conceptualization, methodology, and formal analysis. JS and LL: investigation. JS and HL: writing—original draft. JS, HL, LL, and P-YQ: writing—review and editing. HL: funding acquisition. HL and P-YQ: supervision. All authors contributed to the article and approved the submitted version.The authors acknowledge the support from Hong Kong Branch of Southern Marine Science and Engineering Guangdong Laboratory , Ministry of Science and Technology (MOST19SC06), and Research Grant Council , of the Hong Kong Special Administrative Region, China.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Hyperuricemia (HUA) is a common metabolic disease, and its prevalence has been increasing worldwide. Pharmaceutical drugs have been used for controlling HUA but they all have certain side effects, which thus calls for discovering alternative options including using treatment of probiotics to prevent the development of HUA.Lactiplantibacillus pentosus P2020 (LPP), a probiotics stain extracted from Chinese pickle. We also tried to discussed the underlying mechanisms.We established HUA mice model induced by potassium oxonate and adenine and performed in vivo experiments to verify the ability to lower serum uric acid of Oral administration with LPP significantly decreased serum uric acid and reduced renal inflammatory response by downregulating multiple inflammation pathways including NK-kB, MAPK, and TNFα. We also found that LPP administration significantly promoted uric acid excretion by regulating expression of transporters in the kidney and ileum. In addition, LPP intake improved intestinal barrier function and modulated the composition of gut microbiota.These results suggest that probiotics LPP may have a promising potential to protect against development of HUA and HUA-related renal damage, and its working mechanisms involve regulation of inflammation pathways and expression of transporters in the kidney and ileum. People with serum uric acid (SUA) levels higher than 420 μmol/l in men and 360 μmol/l in women can be diagnosed as HUA. Globally, the prevalence of HUA and gout both have increased over the last few decades. The prevalence of HUA in Chinese adults was 8.4%, accounting for approximately 92.9 million adults with HUA . The conSeveral methods are currently available to control HUA, such as diet, sport, drugs, and biotherapy, aiming to suppress HUA production or increase uric acid excretion . For manLactobacillus can reduce the levels of serum uric acid. For example, Limosilactobacillus fermentum JL-3 isolated from the Chinese traditional food “Jiangshui” was capable of degrading uric acid ex vivo and alleviating HUA in the mouse model (Lactobacillus gasseri PA-3 can directly utilize the purine compounds including adenosine monophosphate (AMP), inosine monophosphate (IMP), and guanosine monophosphate (GMP) for growth, and decrease the purine absorption in rats (Lactiplantibacillus pentosus P2020 (LPP) from the Chinese pickle and evaluated its anti-HUA function using a mouse model. Our results showed that administration of LPP significantly downgraded the inflammation in kidney. We also observed the altered expression of transporters related to urate transportation in both kidney and ileum. It has been reported that several probiotics can improve epithelial barrier function and rebuild the disrupted intestinal flora  in the intestine and the systematic inflammation reaction, both of which contribute to the development of HUA , 13, 14.se model . Lactoba in rats , 17. In al flora , 17, 18.2.2.1.This study was approved by the Ethics Review Committee of the National Institute for Communicable Disease Control and Prevention at the Chinese Center for Disease Control and Prevention .2.2.2 incubator  at 37°C for 24 h before use. The culture of LPP in the logarithmic phase was collected and washed twice with sterile phosphate-buffered saline (PBS) by centrifugation  and then resuspended with sterile PBS for oral inoculation to mice.LPP was isolated from a Chinese pickle. The strain was grown anaerobically in Man-Rogosa-Sharpe (MRS) medium in a CO2.3.The 16S rDNA sequence and genome sequence were used to identify LPP at the species level. The genomic DNA was extracted using FastPure DNA isolation mini kit . The 16S rDNA sequence was amplified using two universal primers, 27F and 1492R, and the draft genome was sequenced by the Illumina HiSeq TM2000 platform.Lactiplantibacillus pentosus DSM 20314 T  at 99.93%.The nearly complete 16S rDNA sequence  was obtained and blasted using the Ezbiocloud database  to search for similar sequences. LPP had the highest similarity to Lactiplantibacillus pentosus DSM 20314 T (CP032757) was obtained from the NCBI GenBank database. The digital DNA–DNA hybridization (dDDH) was assessed using the DDH web softwareLactiplantibacillus pentosus DSM 20314 T (CP032757) were 98.00 and 99.74%, respectively, which were much higher than the 70.0% and 95.0–96.0% threshold of dividing into species : negative control group (NC), hyperuricemic group (HUA), and LPP-treated group (LPP). The HUA mouse model was established according to literature with slight modification  respectively.Male Kunming mice  were purchased from the Chinese Beijing Vital River Laboratory Animal Technology Co., Ltd. All mice were housed in the Animal Center of China CDC Mice with temperature at 24–26°C, humidity at 40–60%, and a 12 h light–dark cycle. Mice had free access to the standard commercial mouse food and water. After one-week adaption, mice were randomly divided into three groups , and blood urea nitrogen (BUN) concentrations were determined with commercial kits from the Jiancheng Biotech , and Xanthine oxidase (XOD) and adenosine deaminase (ADA) activities in livers were determined with commercial kits form the Jiancheng Biotech , following the manufacturer’s instructions.2.6.Kidney tissues were collected and fixed in 4% paraformaldehyde solution for 24 h and the fixed tissues were embedded in paraffin, sliced into 4 μm sections, then stained with Hematoxylin and Eosin by Wuhan Servicebio Technology Co., Ltd. The HE sections were pictured and analyzed by CaseViewer software.2.7.p ≤ 0.01. KEGG pathway enrichment of differential genes was performed on the Dr. Tom analysis platform of Beijing Genomics Institute Co., Ltd. The heatmap of differential genes was exerted by online toolsTranscriptome analysis for kidney and liver samples was performed by the Beijing Genomics Institute Co., Ltd., . Briefly, the Total RNA of kidney and liver tissues was extracted using Trizol according to the manufacturer’s instruction. The qualified RNA sample, determined by Fragment Analyzer, was constructed data library. After enrichment and specific amplification of mRNA, the single-strand circular DNA library obtained was sequenced on the BGISEQ-500 platform by the Beijing Genomics Institute Co., Ltd. The clean data obtained from raw data by removing adapter-containing and low-quality reads were mapped to the reference genome using HISAT software for the second quality control of alignment. The matched clean data were normalized to FPKM by RSEM software with a threshold at |log2FC| ≥ 1, 2.8.RNA of kidney, colon and ileum tissue was extracted using Trizol and was reverse-transcribed using a Primescript RT master mix kit . The cDNA samples were amplified in duplicate. Quantitative real-time PCR (qPCR) was conducted on Bioer Fast 9,600  with TB Green Premix Ex Taq. qPCR was run under the following conditions: pre-denaturation at 95°C for 30 s, denaturation at 95°C for 5 s, and annealing at 60°C for 30 s followed by 40 cycles. The primer sequences of genes were designed using BLAST and listed as supporting information in 2.9.Colon and kidney tissues were homogenized in iced RIPA  and proteins were extracted following the manufacturer’s instructions. The concentration of proteins was quantified using BCA protein assay kit . Twenty-five micrograms of denatured protein were separated by 12% SDS-PAGE gel and transferred to an Immobilon-P Transfer Membrane . The membranes were blocked with 5% non-fat milk and incubated with primary antibodies (1:1000) overnight at 4°C. Then the membranes were incubated with horseradish peroxidase- (HRP-) conjugated secondary antibodies . All primary antibodies were purchased from Abcam plc., , and HRP-secondary antibodies were purchased from Lablead Biotech Co., Ltd. . The bands were visualized using ECL with Amersham Imager 680R . The grey values of the bands were calculated and normalized to those of β-actin using Image J software.2.10.At the end of the experiment, fresh cecal content was collected and immediately stored at −80°C. 16S rRNA sequencing and data analysis were performed by the Beijing Genomics Institute Co., Ltd., . Briefly, V3 and V4 hypervariable regions of 16S rRNA were selected and amplified using the primer pairs: Forward primer (5′-CCTACGGGNGGCWGCAG-3′) and Reverse primer (5′-GACTACHVGGGTATCTAATCC-3′), and the amplicons and quality control of the raw data were conducted on the Illumina Hiseq 2,500 platform. The consensus sequence was generated by FLASH. The high-quality paired-end reads were combined into tags based on overlaps, then tags were clustered into Operational Taxonomic Unit (OTU) by scripts of software USEARCH with a 97% threshold. The α adversity and principal coordinates analysis (PCoA) was calculated and visualized by R software. Abundance prediction results of KEGG functions in bacterial communities were obtained by Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUST2) . The fun2.11.via a gastric gavage tube. Four hours later, blood was collected from inner canthus, and serum was collected by centrifugation (4°C 5000 × g 5 min). The FD-4 level was detected with multifunctional enzyme marker at 485 nm (excitation) and 528 nm (emission).The intestinal permeability was assessed using FITC-dextran  method. Briefly, after being deprived of water and food for 12 h, mice were subjected to FITC-dextran gavage at the dose of 400 mg/kg body weight 2.12.p < 0.05 was considered statistically significant.Statistical analysis was performed with GraphPad Prism (v9.1.0). The normal distribution data, which passed Levene test, were analyzed using one-way analysis of variance (ANOVA) followed by multiple comparisons (Tukey’s test) as post-hoc analysis to determine whether there was a statistical difference between every two sets of data. Results are presented as means ± standard deviation (SD). The nonparametric Kruska Wallis rank-sum test was used followed by Duncan’s test for multiple comparisons for alpha diversity analysis of the gut microbiota. 3.3.1.p < 0.0001), which confirmed the success of establishing a HUA mouse model. Orally administration of LPP significantly decreased the SUA level compared with the untreated HUA mice , which thus confirmed the SUA-lowering ability of LPP  and SLC22a12 (URAT1) contribute to UA reabsorption, while ABCG2 and SLC22a6/7/8 (OAT1/2/3) are related to UA excretion. The results of RNA sequencing showed that expression of  NC mice . Howeverd by LPP . Selectiquencing –D. Furthto blood .3.4.via influencing expression of UA transporters in the ileum  in HUA mice was significantly higher than that in NC mice, while the F/B ratio was reversed after LPP treatment  and decreased abundance of Clostridium XlVa (19.54% in LPP vs. 26.97% in HUA), suggesting that LPP may partially reverse HUA-induced alteration in gut microbiota  were also changed in HUA mice, which indicates that other TLRs other than TLR4 and TLR2 may also be involved in kidney injury caused by UA.To explore the mechanism of how oral administration of LPP protects the renal injury caused by HUA, transcriptome analysis for the kidneys from all groups was conducted. The volcano diagram showed that 2,535 differential expressed genes (DEGs) including1372-upregulated and 1,163-downregulated genes between HUA and LPP groups were identified . The bub tissues . Literat tissues . To unde results . BesidesRdh5, Rdh9, and Rdh16f2 were significantly increased in HUA mice and LPP intake could partially reverse the changes in these genes  between HUA and LPP groups . A bubblse genes . Retinolse genes . RBP4 be4.Lactobacillus showed diverse biological functions . NF-kB pathway is triggered by TLRs’ activation. It has been reported that secretions from some specific strains can suppress inflammatory reactions in a TLR4-dependent way  to inhibit XOD activity, (2) to affect the transport of UA in the kidney to enhance UA excretion, and (3) to alkalize urine to improve UA excretion , 44. Thedent way , 46. SimLacticaseibacillus paracasei MJM60396 intake increased expression of OAT1 and OAT3 and decreased expression of URAT1 and GLUT9 in the HUA mouse model  family and ATP-binding cassette (ABC) superfamily play a significant role in this process . Severalse model . To examse model . More stvia kidney, another important route of UA excretion is via the intestinal tract, which is responsible for about one-third of the total UA elimination. ABCG2 and SLC2a6 expressed in the intestinal epithelium translocate uric acid from the blood to the intestinal tract. When the renal excretion pathway of UA is disturbed, UA is compensated for by excretion from the intestine, resulting in elevated levels of uric acid in the patient’s stool  -mediated mucosal inflammation, which is in line with the marked capacity of Prevotella in driving Th17 immune responses in vitro  can be found at: The animal study was reviewed and approved by the Ethics Review Committee of the National Institute for Communicable Disease Control and Prevention at the Chinese Center for Disease Control and Prevention .ZW and ZR conceptualized the experiments. ZW, LS, XL, YH, YX, YZ, JL, and ML conducted the experiments. ZW and YH analyzed the data. ZH and ZR wrote the paper. ZW, XL, and ZR discussed and revised the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by grants from the National Natural Science Foundation of China (No. 81371761 to ZR), and the Ministry of Science and Technology of China (Grant No. 2018ZX10305409-003-001 to ZR).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Plasma mannose, an emerging novel biomarker of insulin resistance, is associated with both diabetes mellitus and coronary atherosclerosis, but the relationship between mannose concentrations and myocardial infarction (MI) across different glycaemic states remains to be elucidated. The aim of this study was to investigate the independent association between mannose and a first MI in a group of subjects characterized according to their glycaemic state.Fasting plasma mannose concentrations were analysed in 777 patients 6–10 weeks after a first myocardial infarction and in 770 matched controls by means of high-performance liquid chromatography coupled to tandem mass spectrometry. Participants without known diabetes mellitus were categorized by an oral glucose tolerance test (OGTT) as having normal glucose tolerance , impaired glucose tolerance  or newly detected type 2 diabetes . The association between mannose and MI was investigated across these glycaemic states by logistic regression.Mannose levels increased across the glycaemic states (p < 0.0001) and were significantly associated with a first MI in the whole study population . Considering the different subgroups separately, the association persisted only in subjects with NGT , but not in subgroups with glucose perturbations .Mannose concentrations increased across worsening levels of glucose perturbations but were independently associated with a first MI only in NGT individuals. Thus, mannose might be a novel, independent risk marker for MI, possibly targeted for the early management of previously unidentified patients at high cardiovascular risk.The online version contains supplementary material available at 10.1186/s12933-022-01630-5. With almost 18 million deaths per year, which corresponds to one third of the total global mortality estimated for 2021, cardiovascular disease (CVD) is currently the biggest killer worldwide , 4. The Elevated mannose, a C2 epimer of glucose, has been associated with incident type 2 diabetes (T2DM) and CVD , and hasThe relationship between mannose and CAD has, however, not been studied in relation to the glycaemic state. Based on the emerging notion that insulin resistance and hyperinsulinemia per se may predict CVD independent of hyperglycemia  and thatThe Periodontitis and Its Relation to Coronary Artery Disease (PAROKRANK) Study is a Swedish multicenter case–control investigation described in detail elsewhere . In shorAll study participants without known DM underwent an oral glucose tolerance test (OGTT) and were categorized as having normal glucose tolerance (NGT), IGT or T2DM according to World Health Organization (WHO) classification, thus based on post-load glucose but not on glycated haemoglobin A1c (HbA1c)-criteria , 17. FolBlood samples were collected during the outpatient visit after fasting and smoking abstinence for at least 12 h. Biochemical parameters, including complete blood count, plasma(P)-lipids , P-creatinine, P-fibrinogen, P-glucose, and HbA1c were analyzed at the local laboratories of each hospital. In the OGTT, P-glucose was assayed in the fasting state (fasting plasma glucose—FPG), and after 30 and 120 min (Two hours post-load glucose—2 h-PG) following ingestion of 75 g of glucose in 200 mL water and using a bedside point-of-care system . High-sensitivity C-reactive protein (hs-CRP) was assayed at a central laboratory  by an ELISA method . Plasma (6 mL) and whole blood (4 mL) were also collected and stored in a central biobank at Karolinska Institutet at − 70 °C. Mannose was assayed by high-performance liquid chromatography coupled to tandem mass spectrometry (HPLC–MS-MS) at the Mass Spectrometry laboratory in Pisa, Italy. In brief, plasma mannose was separated from its epimers, glucose and galactose, by HPLC and LC–MS-MS was then used to quantify its concentrations .2 test. The Mann–Whitney U test was used to carry out comparisons of mannose levels between patients and controls, both according to and regardless of their glycaemic status, and between individuals with different glycaemic states in the whole population. The difference in mannose concentrations across the four glucose tolerance groups (combining patients and controls) was determined by the Kruskal–Wallis test. Statistical significance was considered for a two-sided p < 0.05. The relationship between logarithmically transformed mannose concentrations and glycaemic parameters , body mass index (BMI), waist circumference, fibrinogen and hs-CRP were assessed by Spearman’s correlation coefficient. The association between log-transformed mannose concentrations and a first MI (patients vs controls) was investigated by a conditional logistic regression model, adjusting for covariates selected by using backward elimination method with an alpha level of 0.1 . The same association was assessed within each of the four glucose tolerance groups as well as in all patients with glucose perturbations , adjusting for sex, age, smoking status, family history of cardiovascular disease and education level. Different regression models were fitted to try to account for all sensible confounders while avoiding overadjustments. The OR and corresponding 95% CIs to estimate the association between mannose levels and a first MI in the total cohort was also calculated for a one-SD increase in mannose levels by use of logistic regression. The optimal cut-off of mannose concentrations was obtained by the maximum Youden’s J statistic on the adjusted receiver operator characteristics (ROC) curve testing the diagnostic performance in diagnosing a first MI, including a matching concordance index in the model [Continuous variables are presented as median and interquartile range; categorical data are given as number and percentages. Differences in baseline continuous data between patients and controls were compared using Mann–Whitney U test; proportions were compared using a χhe model . All anaAmong the original 1610 study participants (805 patients and 805 controls), samples for mannose assays were available in 1547 subjects (777 patients and 770 controls), who represent the current study population. Following the OGTT, patients and controls without known DM were classified according to their glycaemic state as described in the flowchart in Fig. Newly detected glucose perturbations  were significantly more common in patients than in controls (29.0% vs. 17.3%): 19.7% patients and 12.1% controls had new IGT (p < 0.0001), and 9.3% patients and 5.2% controls had new T2DM (p = 0.0018).Pertinent baseline clinical characteristics of the total population (patients vs controls) are presented in Table Overall, a family history of CVD and smoking were more common in MI patients than among controls, whereas the two groups did not differ by other characteristics, such as history of hypertension, known DM, stroke and depression. In comparison with controls, patients had higher levels of FPG, 2hPG, fibrinogen and white blood cell counts, but there was no significant difference in hs-CRP levels.Compared to subjects with NGT (patients and controls combined), those with glucose perturbations were older, with lower educational status and a lower proportion of current smokers. Moreover, they had higher BMI and waist circumference as well as significantly higher mannose levels  in subjects < 50, 50–60 and > 60 years of age, respectively; p = 0.001) and were higher in men than women .In the total population (patients and controls) mannose concentrations differed significantly across the four glycaemic groups  with a gradual and significant increase in the median levels  as shown by pairwise comparisons . Within-group differences between patients and controls, even though relatively small, remained significant in NGT  but not in subgroups with glucose perturbations  with glycaemic and anthropometric variables , although the correlation coefficients were low. These and related within-group correlations are shown in Table Mannose levels were significantly associated with a first MI , which remained after adjustment . The estimated OR for one SD increase of mannose levels in patients vs controls was 1.21. This suggests that each SD increase in mannose levels is associated with a 21% higher chance of being in the MI group. A similar association was found within the NGT group . There were no significant associations between mannose levels and MI in participants with IGT , newly detected T2DM  or known DM , or when grouping all patients with glucose perturbations together .The optimal cut-off value of mannose concentrations was 71.8 μmol/L, with a sensitivity of 75% and a specificity of 43% (AUC 0.59)  mannose levels gradually increase with worsening glucose perturbations; (2) mannose is independently associated with a first MI; and (3) this association persists in subjects with NGT, but not in those with glucose perturbations.Our results support previous works reporting higher mannose levels in individuals with glucose perturbations than in those without , 21, furThe potential role of mannose as a biomarker of CVD has recently gained interest, although it has been investigated only in a few studies so far. A large prospective cohort study reported an association between mannose levels and incident T2DM and CV outcomes including CHD and MI . A validInterestingly, the association between mannose levels and a first MI was no longer significant in the subgroup of subjects with altered glycaemic state, although its magnitude was similar to that found in patients with NGT (OR 1.8 vs 2.0). A reasonable pathophysiological interpretation of these findings may be that, in subjects with glucose perturbations, the association of mannose with CAD is, at least partially, trumped by the presence of severe insulin resistance, which is its main regulator . The absTo the best of our knowledge, this is the only investigation addressing the association between plasma mannose levels in a large group of subjects with different and well-characterized degrees of glucose tolerance. The major strength of the present investigation is its large, well phenotyped, and homogeneous population . The glySome limitations should be considered. First, the proportion of subjects with glucose perturbations is somewhat lower compared with previous works, reporting approximately two thirds of coronary patients being affected by either IGT or T2DM , 31. ThiFinally, because of the observational design of the PAROKRANK study , the curIn conclusion, the current data support the hypothesis that high mannose might represent a novel, independent and possibly more sensitive marker of risk for MI than glucose-related expressions for glucose perturbations. Therefore, the assessment of mannose concentrations could represent a valuable clinical tool for improving CV risk stratification and allow early personalized intervention in high-risk patients.Additional file 1:Table S1. Baseline characteristics of patients with and without dysglycaemia.Additional file 2:Figure S1. Adjusted receiver operator characteristics (ROC) curve testing the diagnostic performance of plasma mannose concentrations in diagnosing a first MI. AUC (Area under the curve): 0.59. Optimal cut-off value: 71.8 μmol/L, with a sensitivity of 75% and a specificity of 43%.


Shigella sonnei have become prevalent among men who have sex with men and have become a global public health concern. From June 2017 to April 2019, 32 men were infected with MDR S. sonnei acquired locally, in Montréal, which was suggestive of an outbreak. Antimicrobial susceptibility testing, whole-genome sequencing (WGS), phylogenetic analysis, antimicrobial resistance and virulence characterization, and association to international clusters were performed. The outbreak strain was ceftriaxone- and azithromycin-resistant due to the acquisition of blaCTX-M-27, and mphA and ermB genes, respectively, with reduced susceptibility to ciprofloxacin due to a single point mutation (gyrA S83L). One out of 27 patients treated with a fluoroquinolone experienced microbiological failure. Epidemiological evidence first supported by a rare unique MDR Shigella sonnei documented only in men in 2017 followed by similar pulsed-field gel electrophoresis profiles was confirmed by WGS. A core genome high-quality single-nucleotide variant (hqSNV)-based phylogeny found a median of 6 hqSNV differences among isolates. Virulence gene content was investigated, but no Shiga toxins were detected. An international cluster of highly related isolates was identified (PDS000019750.208) and belonged to the 3.7.29.1.4.1 S. sonnei genotype . Genomic analysis revealed that this Montréal cluster was connected to other documented outbreaks in Australia, the United States, and the United Kingdom. This study highlights the urgent need for public health measures to focus on the prevention and the early detection of S. sonnei, since global transmission patterns of MDR strains is concerning and few antimicrobial treatment options are available.Multidrug-resistant (MDR) IMPORTANCEShigella sonnei, an important foodborne pathogen, recently became a frequent sexually transmitted agent involved in large and persistent outbreaks globally among men who have sex with men. Most strains also harbor several multidrug-resistant (MDR) determinants of particular concern. This study characterizes an outbreak strain at the source of an important MDR cluster identified in Montréal in 2017. Associations were made to many high-profile international outbreaks, and the causative S. sonnei lineage of these clusters was identified, which was not evident in past reports. The worldwide occurrence of this strain is of concern since treatment with antimicrobials like ceftriaxone and azithromycin may not be effective, and rare microbiological failures have been documented in patients treated with ciprofloxacin. Our investigation highlights the threats of Shigella spp. infection and the necessity for antimicrobial susceptibility monitoring in order to mitigate S. sonnei’s impact on public health and to avoid transmission to other at-risk communities. Shigella spp. are one of the most important causative agents of diarrhea worldwide  have evolved separately but convergently from distinct Escherichia coli lineages to become facultative intracellular human-adapted pathogens that cause similar syndromes   –21.Shigella spp. infections are self-limited, ciprofloxacin, azithromycin, and ceftriaxone are the first-line, while ampicillin and trimethoprim-sulfamethoxazole (TMP/SMX) are the second-line, antimicrobial treatments recommended for adult patients with severe infections or weakened immune systems   , 24. ThiShigella sonnei with reduced susceptibility to ciprofloxacin  and the European Committee on Antimicrobial Susceptibility Testing [EUCAST] criteria). Between January 2017 and December 2019 at the Centre Hospitalier de l’Université de Montréal (CHUM), no other Shigella sonnei presented this resistance profile out of a total of 109 patients. The epidemic curve was highly suggestive of an outbreak event  years old, presented with an enterocolitis caused by a ceftriaxone- and azithromycin-resistant ak event . Of the 6/L. Of the 12 HIV-positive patients, 10 had an HIV viral load of <20 copies/mL, 1 patient had a viral load of 314 copies/mL, and 1 patient had a viral load of 171,130 copies/mL. Nineteen patients were HIV-negative, and the HIV status was unknown for one patient. In the previous 6 years, 23 of these patients were diagnosed with sexually transmitted infections: 16 Treponema pallidum, 47 Neisseria gonorrhoeae, 31 Chlamydia trachomatis (including 2 lymphoma venereum), 4 Shigella spp., 2 Giardia lamblia, 3 hepatitis C, and 2 hepatitis B infections.Of the 32 men, 12 were human immunodeficiency virus (HIV)-positive patients. The 12 HIV-positive men were all on antiretroviral treatment. All HIV-positive patients had CD4 cell counts that ranged from 270 to 710 (median 530) × 10n = 31), abdominal pain (n = 20), fever (n = 12), nausea (n = 9), pus/mucus in stools (n = 6), blood in stool specimen (n = 7), and vomiting (n = 3). Five patients required hospitalization for their enteric infection. Twenty-five patients were treated with ciprofloxacin, out of which 14, 4, 5, and 2 patients were treated for 3, 5, 7, and 14 days, respectively. Two patients were treated with levofloxacin for 5 days, and one patient was treated with trimethoprim-sulfamethoxazole (TMP/SMX).Of the 32 patients, two were food handlers and one worked in a healthcare facility. These 3 patients were respectively the 3rd, 4th, and 25th patients, and none of them was the index case of the cluster. None of the 32 patients worked in daycare centers. Thirty-one of the 32 patients presented the following symptoms: diarrhea  revealed that the isolate (SS075624) was susceptible only to ciprofloxacin, and the patient was treated with oral ciprofloxacin 1,000 mg daily for 3 days. About a week after the end of ciprofloxacin treatment, the repeat stool culture was positive for the same S. sonnei strain (SS079888), collected 26 days after the first positive stool culture. Overall, he had persistent symptoms for 6 weeks. Two repeat stool cultures were negative.A patient consulted his primary care physician and reported up to 12 very loose nonbloody stools per day and abdominal cramps that lasted for a week. Microbiological analysis revealed that the patient’s stool was positive for n = 8 patients) or 2 (n = 6 patients) negative stool cultures after fluoroquinolone treatment. To our knowledge, none of the other 31 patients had a prolonged or recurrent enteric disease. As part of the interventions to control the outbreak, bathhouses were visited to raise awareness among owners and community stakeholders, and enhanced environmental health measures, especially for high touch areas, were recommended. Community-based organizations that work with MSM were contacted to disseminate information on preventive measures.The two food handlers and the healthcare worker were excluded from their work pending 2 negative stool cultures done on different days after the end of their fluoroquinolone treatment. Fourteen other patients had either 1 (S. sonnei isolates showed an extended spectrum beta-lactamase (ESBL)-positive phenotype, detected by ceftazidime, cefotaxime, and cefepime E-tests with and without clavulanic acid.The 33 isolates were resistant to ampicillin, TMP/SMX and nalidixic acid (6 mm for the 3 agents), azithromycin MICs > 256 mg/L), ceftriaxone (6 mm and 64–128 mg/L), cefixime (16–32 mg/L), and tetracycline (6 mm and 128–256 mg/L), but were susceptible to ertapenem (31–32 mm). These isolates had MICs of 0.12–0.25 mg/L to ciprofloxacin and were susceptible to this agent based on the CLSI 6 mg/L, c but wereS. sonnei isolates (from 30 different patients) confirmed that these isolates were genetically related. In fact, the isolates clustered all within the same clade and only differed from each other by 0–17 hqSNVs with a median and average pairwise distance of 6 hqSNVs  in a provincial context allowing the comparison with other circulating strains (Pulsed-field gel electrophoresis (PFGE) revealed that 28 out of the 33 isolates had similar PFGE patterns designated as pulsovar 179, and the remaining isolates belonged to 5 related pulsovars  (data not shown). Phylogenetic analysis performed on the 31 sequenced 6 hqSNVs  in concoIn silico AMR detection supported the AST results as all 31 sequenced S. sonnei isolates had acquired genes conferring resistance to TMP/SMX (dfrA1 and sul2), azithromycin (ermB and mphA), tetracycline (tetA), and ampicillin, ceftriaxone, and cefixime via an ESBL (blaCTX-M-27). Most isolates had acquired a total of 9 AMR-conferring genes, with the exception of SS138210, which acquired 10. A predicted resistance phenotype for streptomycin [aadA1 and aph(3″)-Ib] and kanamycin [aph(3′)-Ia and aph(6)-ld] was also detected, but not routinely tested by AST as aminoglycosides are not clinically relevant for the treatment of Shigella spp. All isolates also possessed mdfA, which encodes a multidrug exporter. The resistance to nalidixic acid and the reduced susceptibility to ciprofloxacin according to the CDC criteria can be attributed to a single amino acid change (S83L) found in the quinolone resistance-determining region (QRDR) of the gyrA gene, as no qnr genes were identified. One out of the 27 patients treated with a fluoroquinolone exhibited a clinical and microbiological failure (diarrhea for 6 weeks and stool culture positive after ciprofloxacin treatment). Using ResFinder, it was found that this failure was unrelated to any additional unique known or unknown mutations detected in the QRDRs of the isolates recovered before (SS075624) and after (SS079888) treatment.capU, celb, cia, gad, ipaD, iucC, iutA, lpfA, senB, sigA, sitA, terC, and traT) were found in our dataset of 31 sequenced isolates. The virulence genes celb (colicin E2 enterotoxin), gad (glutamate decarboxylase), iucC (aerobactin synthetase), iutA (ferric aerobactin receptor), lpfA (long polar fimbriae), senB (plasmid-encoded enterotoxin), sigA (Shigella IgA-like protease homologue), sitA (iron transport protein), terC (tellurium ion resistance protein), and traT (outer membrane protein complements resistance) were present in most isolates (83.9–100%). The genes capU (hexosyltransferase homolog) and ipaD (invasion protein) were always present together, but were only found in 2 out of the 31 isolates. The cia gene (colicin ia) was equally present only in 2 out of the 31 isolates. A total of 13 different virulence genes (n = 44), Belgium (n = 21), Canada (n = 28), New Zealand (n = 2), Spain (n = 1), Switzerland (n = 1), United Kingdom (n = 31), and United States (n = 306). The Swiss isolate was characterized in a study of CTX-M-producing S. sonnei in Switzerland  cluster PDS000019750.208) comprising 465 isolates. The distance between these isolates ranged from 0 to 49 SNPs, with an average distance of 16 SNPs. Excluding the isolates under study, the other 434 isolates were collected by various jurisdictions: Australia . The unique rare antimicrobial profile, the PFGE profiles’ similarity, and the genomic clustering confirmed that these 32 men were from an outbreak.In this 22-month long cluster of Shigella sonnei outbreaks are limited; however, a California study has characterized an S. sonnei outbreak of 42 cases differing by 0 to 11 SNPs from each other by using similar genomic methods (S. sonnei cluster of 35 ESBL isolates had a median pairwise distance of 3 SNPs (interquartile range 2 to 4 SNPs) using similar genomic approaches  than the other studies and that our analysis only included patients who had stool cultures at the CHUM. In addition, differences in the phylogenetic parameters and datasets used in regard to the reference-based core genome analysis could also have an impact on SNV distance comparisons.Genomic studies using SNVPhyl on well-characterized MSM-related  methods . In addiS. sonnei cluster were considered normal, since many hallmarks of S. sonnei were detected, such as celb, gad, lpfA, senB, and sigA (capU and ipaD) can be attributed to their location on the large virulence plasmid, which can be highly unstable in storage or in laboratory media and is therefore commonly lost upon subculturing (cia) is known to be produced by E. coli against competitors as a defense mechanism and was most likely acquired by a plasmid due to its sporadic presence in the phylogenetic tree. The absence of Shiga toxin virulence genes (stx), which had been detected in a Californian S. sonnei outbreak  generated by NCBI’s Pathogen Detection Isolate Browser. Thirty-five of the 44 Australian isolates included in this cluster were associated with a prolonged MDR S. sonnei outbreak harboring blaCTX-M-27 that occurred from June 2019 to March 2020 in Victoria, Australia  according to CLSI and EUCAST criteria and treated with ciprofloxacin, similar to our case. In previous studies, it was shown that nalidixic acid disk diameters or MIC breakpoints or both were reliable to document the reduced susceptibility to ciprofloxacin  and transposons (containing dfrA1 and aadA1)  . Concernfections , 34. An 2–1 mg/L , while Md EUCAST . In prev an ESBL , most haCTX-M-27 , 21. How. sonnei , and the. sonnei .Shigella spp. were resistant to ceftriaxone in 2018 (Shigella spp. were documented from 2009 to 2020 in 417 patients (unpublished data) other than the 32 patients infected with the Shigella sonnei described in this study. However, many countries have noted an increase in 3rd generation cephalosporin resistant S. sonnei isolates: 31.6% in 2012 to 64.3% in 2015 in China (mphA (S. sonnei isolates detected in their study emerged from the 3.6.1.1 genotype (CipR) and appeared as early as 2014. Concerningly, the 3.6.1.1.2 genotype (CipR.MSM5), which harbors triple QRDR mutations and mphA, was the dominant genotype found in S. sonnei surveillance data from Australia, England, and the United States in 2019  may be prolonged beyond 7 days  and treated with a fluoroquinolone, as suggested  and slide agglutination  and stool culture positive for the same MDR Shigella sonnei strain after completion of the antimicrobial treatment. The epidemic curve is illustrated in After review and approval of the Comité d'éthique de la recherche du CHUM concerning the patients and isolates data, the hospital’s charts, the Direction régionale de santé publique de Montréal’s investigation charts (standardized questionnaire), and the Shigella spp. PFGE was therefore initially used to investigate genetic relatedness according to PulseNet procedures (Shigella spp. isolates are sent to the Laboratoire de santé publique du Québec (LSPQ) on a voluntary basis for routine PulseNet surveillance. PFGE profiles and epidemiological data including time of collection, sex, and age of the patients were shared with the National Microbiology Laboratory (NML) for nationwide cluster detection.In June 2017, at the beginning of this outbreak, routine WGS was not yet implemented in Canada for the surveillance of ocedures . ShigellS. sonnei isolates were retrospectively subjected to WGS once it was implemented as a routine PulseNet procedure. Two S. sonnei strains were not sequenced due to a failure to locate the isolates. Short-read sequencing with Illumina  was performed either at the NML or at the LSPQ. Sequencing protocols were performed as described elsewhere . Resulting genome assemblies had a median of 361 contigs (range: 345–428).31 of the 33 lsewhere . The shohttps://github.com/phac-nml/snvphyl-tools/) (Shigella sonnei Ss046 chromosome (CP000038.1) was used for read mapping. PHASTER  detection was performed using the SNVPhyl pipeline v.1.1  integrat-tools/) . The pub PHASTER  and Isla PHASTER  were use PHASTER  was usedhttps://www.ncbi.nlm.nih.gov/pathogens/) enabled the identification of closely-related S. sonnei isolates submitted by other international public health agencies (accessed on 17 September 2021).Global phylogenetic reconstructions via the NCBI Pathogen Detection Isolates Browser  Short Read Archive (SRA) available at


To develop a scoring system for hormone receptor-positive (HR+) breast cancer patients who are expected to achieve axillary pathological complete response (pCR) after neoadjuvant chemotherapy (NAC). To confirm the correlation between axillary status and survival rate in HR+ breast cancer after NAC. n = 175) and a validation set (n = 68) in a 7 : 3 ratio. A prediction risk score was then developed based on the odds ratios from the multivariate analysis of the test set (n = 175) before being validated in the validation set (n = 68). Finally, the Kaplan–Meier curves were used to explore the survival on this score system.  Women from the Shanghai Jiao Tong University Breast Cancer Database (SJTU-BCDB) who underwent NAC for cT1-4N1-3M0 primary HR+ breast cancer between 2009 and 2018 were included in the study. In this case, patient follow up was performed until 2022 for those with complete data before and after NAC. The main outcome measures were the axillary pCR rate, overall survival (OS), and disease-free survival (DFS). The patients were randomly assigned to a test set (P < 0.05). Using the above predictors of the model, the receiver operating characteristic (ROC) curve was used for calibration and inspection, with values for the test and validation sets being 0.847  and 0.813 , respectively. The total risk score ranged from 0 to 6 for the multivariate analysis, and from this range, a risk score of 0–2 was defined as a low-risk group, while scores of 3–6 were defined as the high-risk one. By constructing the survival curve, it was found that the 5-year OS rates for the low-risk and high-risk groups were 89.0% and 84.2% (P = 0.236). Similarly, the 5-year DFS rates for the low-risk and high-risk groups were 80% and 68.5% (P = 0.048), respectively. In addition, axillary pathological stages were significantly correlated with the overall survival (OS) and disease-free survival (DFS) .  From the database, 243 women were included, and the median follow-up period was 47.5 months . The axillary pCR rate was 18.9% (46 of 243), with the independent predictors of residual positive axillary lymph nodes (LNs) being lymphovascular invasion (LVI), breast conserving surgery (BCS), Ki67 < 14%, HER2 negativity, positive lymph nodes in ultrasound (US) before surgery, and stage III histological grade (All,  The prediction model showed good performance for HR + breast cancer. LVI, BCS, low Ki-67, HER2 negativity, suspected positive LNs before surgery, and stage III histological grade were all risk factors for residual positive axillary LNs. However, unlike pathological stages, achieving pCR in the axillary LNs does not affect the survival status. Breast cancer (BC) is the most common malignancy among women, with incidence rates even higher than for lung cancer , and it Achieving pCR is the most common target of NAC, and patients are still encouraged to perform BCS after effective NAC, including those for whom total mastectomy was initially considered as an option . HoweverTo efficiently select those HR+ patients who would benefit from NAC in the armpit, the clinical characteristics and treatment methods of cT1-4N1-3M0 patients who achieved axillary pCR after NAC were compared with those who did not. A model was subsequently developed to predict the response of axillary LNs to NAC in patients with clinical node-positive breast cancer. In this case, clinical lymph node positivity was defined as imaging positivity or punctures positivity and was evaluated by ultrasound (US), as required by the standards of the American College of Radiology (ACR) .Patients with HR+ breast cancer but no distant metastasis, biopsy-confirmed ones, or those with previously untreated diseases were eligible for enrollment, with their data selected from the breast cancer database of Ruijin Hospital, Shanghai. This retrospective study was approved by the institutional review board of the authors' institution, and the need for written informed consent was waived.n = 175) and the validation set (n = 68).For this study, 243 patients treated with NAC prior to surgery were identified for the period between September, 2009 and December, 2018. All the patients underwent axillary ultrasounds before and after NAC. In this case, as per definition, clinically node-positive breast cancer was either pathologically confirmed or included clinically suspected axillary LNs metastasis. Axillary pCR was then defined as the absence of metastasis in surgical pathology. These patients were randomized in a 7 : 3 ratio to the test set (n = 60), those for whom imaging data were absent, especially axillary US before or after NAC (n = 63), those with distant metastasis at initial status (n = 2), those with previous breast cancer history (n = 13) and those with unknown NAC data (n = 10)  . All thetory n =  and thosClinical and pathologic data, including age, body mass index (BMI), menopausal status, initial clinical and final T stage, initial clinical and final N stage, histologic type, breast surgery method, axillary surgery method, pathological T stage, and N stage were collected. In addition, information on Ki-67 expression, HER2 status, NAC regimen, and cycle and the lymphovascular conditions of all available patients was acquired. The primary variable was the axillary pCR rate for patients who had received NAC.P values <0.2 were included in multivariate analysis. To develop a generalized axillary correlation prediction model, each factor was defined as 1 which indicated the risk score. Hence, the total risk score for each patient in the test set was obtained from the sum of the eligible risk scores [P values <0.05 indicating the statistical significance of the results. Furthermore, survival curves were calculated using Kaplan–Meier analysis, while the level of significance was determined by the log rank (Mantel–Cox) test.Data were analyzed with the IBM SPSS statistics software version 25 , while GraphPad Prism version 9.0  was used for generating images. The patient group was randomly assigned to either the test set or the validation set in a 7 : 3 ratio by using the random sampling method. For the test set, logistic regression analysis was then used to examine the factors associated with residual positive axillary LNs. In this case, after univariate analysis, covariates with k scores . This prP > 0.05).Overall, 243 HR+ breast cancer patients were included in the study , with thAfter surgery, 34.6% (84 of 243) of the patients underwent chemotherapy again, 78.6% (191 of 243) received conventional adjuvant radiotherapy, and 87.2% (212 of 243) received endocrine therapy. Follow up was performed for all patients, with a median period of 47.5 months.n = 175), 20.6% (36 of 175) of the patients achieved axillary pCR, and 79.4% (139 of 175) had residual positive axillary LNs (n = 175). Univariate analysis first showed that the clinical N2 stage was more common in residual positive axillary LNs compared with axillary pCR (P < 0.2). Moreover, after completing neoadjuvant chemotherapy, patients with residual positive axillary LNs were more likely to present suspected nodules by US before surgery (P < 0.2). Finally, pathological examinations suggested that lower Ki-67, HER2 negative, histological III grade and lymphovascular invasion were significantly associated with residual positive axillary LNs (P < 0.2). Overall, no significant differences in age, clinical T stage, histologic type and grade, axillary surgery, as well as NAC regimens and cycles, were noted between the two groups .In the test set (lary LNs .  Table P < 0.05) were identified as independent predictors of residual positive axillary LNs . In addition, after performing internal validation, the AUC was found to be 0.813, , which was indicative of good calibration ability   and correction abilities  as well as a 5-year DFS rate of 72.8% versus 75.8% for pN0 versus pN+ (P = 0.804). Furthermore, there was no correlation between lymph nodes status and survival time after NAC (P < 0.05). Regarding the 5-year DFS rate, the values were pN0 (76.3%), pN1 (86.3%), pN2 (71.7%), and pN3 (59.2%), with the results being also significantly different between the groups (P < 0.05).Survival curves for DFS and OS, based on the axillary pathological nodal status after NAC, are shown in fter NAC . InteresBased on the data in P < 0.05). We expect that LVI will become a better marker for predicting recurrence and prognosis in the future. To sum up, tumor biology has been an important factor in predicting the pathological response in both breast and the armpit. In this study, for HER2-negative patients with histological grade III tumors and low expression of Ki-67, axillary pCR was not easily obtained, and this was consistent with previous research findings [In our study, among HR+ breast cancer patients who received NAC, the overall breast pCR rate was 6.6%, while the axillary one was 18.9%. Therefore, the results showed that the pCR rate in HR+ patients after NAC can be unsatisfactory, and this was consistent with previous studies , 16. Thefindings . SurprisP = 0.048). Although the pathological stage was significantly related to survival (P < 0.05), it was speculated that this could be related to an insufficient number of patients as well as variations in the treatment received after the operation.Based on multivariate analysis, we summarized the above factors as risk factors of axillary pCR with 1 point for each index, and patients with risk scores of 0 to 2 were defined as the low-risk group while 3–6 was considered to be the high-risk one. The low-risk group actually had 29.6% (42/142) of pCR rate while the high-risk one had a 4.0% (4/101) pCR rate; it shows the low and high defined scores of our model are ideal. On the survival analysis of the Kaplan–Meier curve, it was further found that the lymph node status after NAC was not associated with OS, but instead was related to DFS (P > 0.05). Unnecessary ALND increases the scope of axillary damage in patients, leading to complications after surgery, such as lymphedema and muscle strength decline. Hence, our model can guide management and treatment in the armpit so as to avoid unnecessary radiation therapy and complications.Current methods for the clinical evaluation of axillary LNs usually include physical examination and US. Some scholars believed that lymph node staging before NAC allowed local treatment decisions to be made without the risk of undertreatment . HoweverWe further reflected on the limitations and shortcomings of the model. First, ultrasound is an important measure for imaging evaluation, but we found that in suspected cases of positive axillary LNs by US, benign lymphadenopathy cannot be ruled out. The false negative rate (FNR) has been a difficult problem for many scholars, in previous studies; the FNR was about 5–15% , 26. AltIn conclusion, this study's predictive model based on imaging and pathology can help doctors and patients assess the responsiveness of HR+ breast cancer to NAC, especially in those with clinically positive LNs. As such, the model can guide the management of axillary LNs and avoid unnecessary dissection.


To investigate the predictive value of preoperative nutritional risk assessment on the occurrence of complications after radical cystectomy plus urinary diversion for bladder cancer.  Retrospective analysis of 178 patients with bladder cancer between July 2010 and March 2022 who underwent elective radical cystectomy plus urinary diversion was conducted. The occurrence of complications within 90 days after surgery was counted for all patients, and the postoperative complication rates of patients with and without nutritional risk were compared and analyzed. Also, logistic regression analysis was used to assess the relative risk coefficients of NRS-2002 and the occurrence of postoperative complications. P < 0.05).  Comparison of clinicopathological characteristics and surgical conditions between the two groups showed that the proportion of combined diabetes mellitus, operative time, and postoperative hospital stay were higher in the nutritional risk group (NRS ≥3 score) than in the no nutritional risk group (NRS <3 score), while the preoperative blood albumin (ALB) level was lower than that in the no nutritional risk group (NRS <3 score). The results of multifactorial risk regression analysis showed that low preoperative ALB level and high NRS score were independent risk factors for postoperative complications in bladder cancer ( The NRS-2002 nutritional risk score has good predictive value for the incidence of postoperative complications in patients with bladder cancer and provides a scientific basis for perioperative nutritional support. Bladder cancer is the most common malignant tumor in urology, which is divided into two types, non-muscle layer invasive bladder cancer (NMIBC) and muscle layer invasive bladder cancer (MIBC) , 2. UndeThe NRS-2002 nutritional risk scoring system is a simple and easy tool for nutritional risk screening, which was already recommended by ESPEN in 2002 as the tool of choice for nutritional risk screening in hospitalized patients, and has since been gradually promoted worldwide . In 2006The method of this study was retrospective case analysis, and we retrospectively searched electronic medical record database system, and the time interval of the search was set from July 2010 to March 2022. A total of 207 adult patients who underwent inpatient treatment in our urology department during this period were retrieved, and all of them were clinically diagnosed with bladder cancer and had detailed clinical and follow-up records. All patients were then screened according to predefined inclusion and exclusion criteria, and a total of 178 patients were eventually enrolled in this study.Adult patients with clinical and first confirmed diagnosis of bladder cancer.Received surgical treatment for the first time.Surgical treatment option chosen as radical total bladder dissection combined with urinary flow diversion.Patients with preoperative perfection of relevant laboratory, imaging, pathology, and other tests.At least 18 years old.Pediatric patients.Those with relapsed bladder cancer.Patients who had received adjuvant radiotherapy or bladder irrigation prior to surgery.The first surgical treatment plan was partial cystectomy or radical cystectomy for bladder cancer.Intraoperative conversion to open surgery for radical cystectomy plus urinary diversion.Patient data were collected through the hospital information management system, which included (1) preoperative general information: patient gender, age, BMI, NRS-2002 score, presence of hypertension, diabetes mellitus (DM), coronary heart disease (CHD), preoperative serum albumin (ALB), and hemoglobin (HB); (2) surgery-related information: operation time, intraoperative bleeding, intraoperative blood transfusion, surgical procedure , urethral diversion method  and ileal cystectomy (IC)), tumor site, postoperative pathological staging; and (3) prognostic information: postoperative complications, hospitalization time, etc.NRS-2002 was used for preoperative nutritional assessment, which included three aspects: disease severity score (0∼3), impaired nutritional status score (0∼3), and age score (0∼1). The final nutritional risk score was the sum of age score, impaired nutritional status score, and disease severity score. Those with a final score greater than or equal to 3 were considered to be at nutritional risk. Those with a final score less than 3 were considered to be patients without nutritional risk , independent sample t-test is used for comparison between groups, count data are expressed as [n (%)], and chi-square (χ2) test is performed. Logistic regression analysis was used for multifactorial analysis of the risk of postoperative complications. The difference is statistically significant when P < 0.05.SPSS 17.0 statistical software was used for data processing. Measurement data are expressed as mean ± standard deviation (P > 0.05). The proportion of patients with combined diabetes mellitus and preoperative blood albumin levels were higher in patients with NRS ≥3 than in patients with NRS <3 (P < 0.05) , and those with NRS <3 were included in the no nutritional risk group . There were no statistically significant differences in gender, age, BMI, presence of hypertension, coronary artery disease, ASA classification, preoperative hemoglobin, pathological grade, tumor size, and tumor location between the two groups ( < 0.05) .P < 0.05). The differences in intraoperative bleeding, intraoperative blood transfusion, surgical procedure, urethral diversion method, and other surgical treatments between the two groups were not statistically significant (P > 0.05)  and the patients in the no nutritional risk group (NRS <3 points) were (322.19 ± 46.04) min and (301.27 ± 40.12) min, respectively, and the postoperative hospital stays were (17.80 ± 4.90) d and (15.25 ± 4.02) d, respectively, and the differences between the two groups were statistically significant ( > 0.05) .P < 0.05) when comparing the two groups (The complication rates in the NRS-2002 score ≥3 subgroup and the NRS-2002 score <3 subgroup were 54.84% (34/62) and 23.28% (27/116), respectively, and the differences were statistically significant  and NRS scores . Low preoperative ALB level and high NRS score were high risk factors for the development of postoperative complications in bladder cancer . Serum albumin is one of the indicators of the nutritional status of the body, and its decrease can cause low immune function of the body, which can lead to symptoms such as delayed wound healing and infection [More studies have pointed out age, BMI, duration of surgery, and urinary diversion method as risk factors associated with the occurrence of postoperative complications, and more factors are not modifiable and not very accurate , 15. A snfection . This suP < 0.05). This indicates that the nutritional status of the body is closely related to the incidence of postoperative complications in patients with malignant tumors [P < 0.05), with no significant differences in other groups.Notably, the results of this study also showed that high NRS score was also a high risk factor for postoperative complications of bladder cancer (t tumors , 19. FurNRS-2002 is the first nutritional risk screening tool developed on the basis of evidence-based medicine . KaratekIn conclusion, the NRS-2002 nutritional risk score has good predictive value for the incidence of postoperative complications in bladder cancer patients and provides a scientific basis for perioperative nutritional support, which is recommended to be promoted. However, considering the relatively small sample included in this study, more randomized controlled studies with multiple samples are still needed to support the study, which is the direction of further research in this topic.


Bradysia impatiens  is an important pest of various mushrooms and plant seedlings, while it also damages plants as vectors transmitting pathogens. The complete B. impatiens mitogenome is 16,479 bp in length, with an A + T content of 80.6%. The mitogenome had three overlapped regions; the longest overlap is 7 bp. Phylogenetic analysis reveals that B. impatiens is closely related to Bradysia amoena. The study provided a basis for future studies of species divergence in Bradysia. Bradysia species are discovered as agricultural pests, as their larvae feed on mycelia, plant roots, and decayed plant tissues. Several species in the B. tilicola group, including B. impatiens , B. ocellaris , and B. odoriphaga , are worldwide pests that damage economically important plant seedlings and edible fungi . Genomic DNA was exacted from the thorax of an adult male using a Qiagen® DNeasy Blood & Tissue kit . The genomic DNA libraries (350 bp) was generated using Illumina HiSeq 4000 platform. Adapter sequences and low-quality reads (base pairs ≤40 or ‘N’ ≥10) were trimmed using Trimmomatic 0.36  in May 2020. The specimen was deposited at Zhejiang A&F University, China under the voucher number WQY013 . There are three overlapping regions ; the longest overlap is 7 bp. The total length of the 13 PCGs is 11,232 bp. All genes are in the same locations and strands with the species from the same subfamily Megalosphyinae   is 16,479 bp, with an A + T content of 80.6%. The circular mitogenome contains 37 genes, 22 transfer RNAs (tRNAs), 2 ribosomal RNAs (rRNAs) and 13 protein-coding genes (PCGs) . The J-scox2, atp8, cox3, nad6 and cob), while the other start codons are ATG , AAT , ATT (nad3), CAT (nad4), and ATT (nad1). The stop codons of the PCGs include eight TAA , two CTA (nad5 and nad1), two TTA (nad4 and nad4l), and one TAG (nad3). Codon usage of the B. impatiens mitogenome is presented in Table S2. The mostly frequently codons  are composed of T or A + T, whereas the least used codons  have a high content of G + C. The relative synonymous codon usage exhibits extensive similarity with other mitogenomes from the same superfamily Sciaroidea , which are interspersed along the genome, range in size from 47 to 72 nucleotides (Peng et al. The 12S and 16S ribosomal RNA genes contain 824 and 1,361 bp, respectively. These genes are located between the genes for tRNA Phe and control region, and are separated by the gene for tRNA Val. The B. impatiens belonged to the subfamily Megalosphyinae and is closely related to B. amoena. The topology of Bradysia species on the tree suggested the polyphyly of this genus, which was consistent with previous studies based on morphological characters and molecular markers (Menzel and Mohrig 2000; Shin et al. B. tilicola group are difficult to be differentiated morphologically, as they are usually distinguished only by the number of the apical megasetae on gonostylus (Sueyoshi and Yoshimatsu Bradysia.The phylogenetic tree was constructed based on all PCGs of seven published sciarid mitogenomes . It confYang Wang: data curation; formal analysis; software; writing original draft; writing editing. Caixia Liu: writing - review & editing. Qinyun Wang: methodology; software; writing review & editing. Hong Wu: supervision. Junhao Huang: conceptualization, writing - review & editing, funding acquisition.Click here for additional data file.