To assess incidence rates (IRs) of VTE in patients with rheumatoid arthritis (RA) on different DMARDs and DMARD switchers.Adults with RA on a DMARD between 2007 and 2017 were studied in a US claims database. Conventional synthetic DMARD (csDMARD) users, first biologic/targeted synthetic DMARD (b/tsDMARD) users and b/tsDMARD switchers (from a b/tsDMARD to another b/tsDMARD) were followed for inpatient VTE (pulmonary embolism (PE)/deep vein thrombosis (DVT)). Crude and adjusted IR and 95% CIs of VTE were estimated. HRs for VTE were estimated via Cox regression. VTE risk was also evaluated by number of switches between b/tsDMARDs and in patients without a VTE history.adj (95% CI) being 1.36 (1.16 to 1.58), 1.36 (1.13 to 1.63) and 1.47 (1.18 to 1.83) for VTE, DVT and PE, respectively. Compared with first b/tsDMARD users, the HRadj (95% CI) for VTE was 1.35 (1.15 to 1.60) for first b/tsDMARD switchers and 1.48 (1.19 to 1.85) for second b/tsDMARD switchers.The age and sex standardised IR (95% CI) of VTE (per 100 person-years) was 0.86 (0.70 to 1.03), 0.60 (0.52 to 0.68) and 0.58 (0.51 to 0.65) for b/tsDMARD switchers, first b/tsDMARD users and csDMARD users, respectively. After adjustment, b/tsDMARD switchers had an increased risk of VTE, compared with csDMARD users, HRIn RA, b/tsDMARD switchers have a higher VTE risk compared with csDMARD users and first b/tsDMARD users. Switching b/tsDMARDs may be a proxy for higher disease severity or poorly controlled RA and an important confounder to consider in obtaining unbiased estimates of VTE risk in observational RA safety studies. The risk of venous thromboembolism (VTE) is increased in patients with rheumatoid arthritis (RA).After controlling for multiple risk factors, patients with RA who switch biologic/targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) have a higher VTE risk compared with conventional synthetic DMARD users and first b/tsDMARD users. This risk was even higher in the subgroup who switched b/tsDMARDs twice.Switching may be a proxy for higher disease severity or poorly controlled RA and an important confounder to consider in obtaining unbiased estimates of VTE risk in observational RA safety studies.Drug safety studies may want to consider treatment switching as a potential proxy for unmeasured clinical RA disease activity and severity which may confound associations with important clinical outcomes such as VTE.Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common cardiovascular disease after myocardial infarction (MI) and stroke.Patients with RA may be initially treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).In addition to RA, higher risk of VTE has also been associated with increasing age,et al reported the incidence rates (IRs) of hospitalised VTE in csDMARD initiators and bDMARD initiators.et al recently reported the IR of VTE in patients with RA treated with baricitinib, a tsDMARD.Limited data are available on risk of VTE in DMARD users. Kim A cohort study was conducted using the Optum Clinformatics Data Mart, a US claims database containing anonymised longitudinal data for patients insured with the United HealthCare plans since 2000.Adults were eligible for the study if they had at least two diagnoses of RA see  from med10.1136/rmdopen-2019-001013.supp1Supplementary dataThe VTE outcome was defined as the first hospitalised DVT or PE during follow-up, while when analysed separately, the earliest hospitalised DVT during follow-up and the earliest hospitalised PE during follow-up.Descriptive statistics were generated for baseline patient characteristics. A standardised difference with an absolute value of ≥0.1 was used to indicate meaningful difference between groups at baseline.For csDMARD users, the follow-up ended at the time of initiating a b/tsDMARD; for first b/tsDMARD users, the follow-up ended at the time of switching to a second b/tsDMARD. The follow-up of b/tsDMARD switchers continued when they switched to other b/tsDMARDS. In the main analysis, no further distinction was made among b/tsDMARD switchers . However, in a sensitivity analysis, b/tsDMARD switchers were further classified into ‘first’ b/tsDMARD switchers  and ‘second’ b/tsDMARD switchers after the index date, with the time of switch to a different b/tsDMARD treated as a censoring event for VTE for both cohorts. Eligibility criteria were re-assessed and covariates were updated for ‘second’ b/tsDMARD switchers based on the second switch date. Due to significant reduction in number of patients, risks beyond the ‘second’ b/tsDMARD switchers were not assessed.The crude IR of first hospitalised VTE, DVT and PE occurring after the start of follow-up and 95% CIsCox proportional-hazards models were used to estimate the effect (HRs) of treatment on the risk of VTE outcomes, with primary model adjusted for demographics. Additional variable selection was based on clinical knowledge and F statistic from Cox models. Data management and statistical analyses were performed using SAS V.9.4 . Institutional review board review is exempt for this study as data were de-identified.Patient disposition is presented in Crude IRs of VTE, DVT and PE stratified by treatment groups and patient characteristics are presented in Using the US Census population estimates on 1 July 2010, the age-standardised and sex-standardised IR of VTE was 0.86 (95% CI 0.70 to 1.03) per 100 patient-years in RA b/tsDMARD switchers, higher than that in the first b/tsDMARD users  and that in the csDMARD users . When we stratified by history of MI or stroke, the age-standardised and sex-standardised IR of VTE among those without a history of MI or stroke was 0.79 (0.62 to 0.97) in RA b/tsDMARD switchers, 0.53 (0.45 to 0.60) in the first b/tsDMARD users and 0.51 (0.43 to 0.58) in the csDMARD users. The standardised IR of VTE in first b/tsDMARD users was not different from that in csDMARD users in overall and the stratified analysis. Similar patterns were observed for DVT and PE . The majadj) and 95% CI for VTE from multivariate Cox regression are presented in adj barely changed  of VTE was 0.96 (0.78 to 1.16) per 100 PY for ‘second’ b/tsDMARD switchers and 0.87 (0.74 to 1.02) per 100 PY for ‘first’ b/tsDMARD switchers . Compareadj 1.36, 95% CI 1.16 to 1.58) or first b/tsDMARD users . The increased risk was more pronounced in the second-time b/tsDMARD switchers than in the first-time b/tsDMARD switchers. This study also confirmed several independent risk factors of VTE in RA patient population.In this analysis, we found that VTE risk was increased with advancing line of RA therapy, which may reflect line of therapy being a proxy for increasing disease severity and inadequate control of RA disease activity. With the increasing availability of b/tsDMARD options for RA, our finding that b/tsDMARD switching was associated with significantly increased VTE risk is particularly important for future observational studies of drug safety using administrative healthcare databases when standardised RA disease activity measures are unavailable. Specifically, we found an increased IR of VTE among patients with RA who switched from b/tsDMARDs to alternative b/tsDMARDs, when compared with either csDMARD users ,et al studied a RA cohort from different data sources in an earlier calendar time period and excluded patients with claims for DVT or PE, or anticoagulants dispensing in the 12-month period before index date. Among similarly selected patients without anticoagulant use within 1 year before index date, the IR of VTE in our study  was consistent with theirs.Our findings are consistent with the current literature on RA.Unlike other reports, this study estimated the IR of VTE in the subgroup of patients with RA who switched from one b/tsDMARD to another. Switching from one b/tsDMARD to another b/tsDMARD may identify patients with insufficient response or intolerance to b/tsDMARD therapy in a real-world setting. Patients who are bDMARD users have been found to have more severe RA than patients treated with csDMARDs.We acknowledge that in a real-world setting, patients may switch RA treatments due to reasons such as insurance coverage or adverse events. However, the effect of such switching would be to underestimate, not overestimate, the differences in disease severity measures between the groups. Nevertheless, the increased risk in the second-time b/tsDMARD switchers, followed by the first-time b/tsDMARD switchers and the first b/tsDMARD users, demonstrated the utility of including switching b/tsDMARDs as a disease severity indicator.In addition, this study confirmed several independent risk factors for VTE in patients with RA. Although risk factors such as increasing age, male sex and African-American race have been reported in general population, to the best of our knowledge, this is among the few US studies to report VTE risk factors that are relatively common in RA populations: history of VTE, history of anticoagulant use, serious infections, hypertension, hospitalisation, COPD, CKD and MI/stroke.This study is subject to several limitations. First, the VTE outcome was identified based on ICD diagnosis on inpatient medical claims without further chart review. However, this method has been validated to have a positive predictive value ≥74%.In summary, this large US study provides incidence rates of VTE in patients with RA according to prior switching as a proxy for more severe disease in a real-world setting. Patients with RA with more extensive treatment experience, especially b/tsDAMRD switchers, have a higher risk of VTE compared with those treated with csDMARD and first b/tsDAMRD users. The heightened risk of VTE in b/tsDMARD switchers was somewhat attenuated when factors that reflect co-medications and comorbidities were controlled, yet remained significantly elevated, suggesting switching to an alternative b/tsDMARD may be a useful proxy for higher disease severity or poorly controlled RA in patients with other constellation of chronic conditions and risk factors. In addition to line of therapy, b/tsDMARD switching and the number of switches may be an important and independent risk factor to include moving forward in observational RA drug safety studies, particularly those using secondary data sources that lack standardised disease activity measures.


Clostridium difficile infection (CDI) is known as one of the most important causes of nosocomial infections. The main objective of this study was to evaluate the presence of Clostridium difficile in the stool of hospitalized patients with diarrhea as well as in their environments.C. difficile isolates were characterized according to the presence of toxin genes and antibiotic resistance. Multilocus Sequence Typing Analysis (MLST) was applied for finding the genetic polymorphism and relationship among strain lineages.C. difficile isolates was 28.6% (164/574) in patients and 19% (47/247) in swabs taken from medical devices, hands of healthcare workers and skin patient sites. Finally, 11.5% (66/574) toxigenic C. difficile strains isolated from stool samples of inpatients and 4.4% (11/247) from hands of healthcare workers and skin patient sites. All the toxigenic isolates were inhibited by a low concentration of vancomycin (MIC < 0.5 μg/ml). About 43% (33/77) and 39% of isolates were resistant to Clindamycin and moxifloxacin respectively. All isolates were susceptible to metronidazole. Toxigenic C. difficile strains were analyzed by MLST and were divided into 4 different STs. The detected types were ST-54 (57.9%), followed by ST-2 (31.6. %), ST-15 (5.3%) and ST-37 (5.3%), while none of the isolates were identified as ST-1 or ST-11. Significant risk factors for CDI appear to be advanced age, undergoing chemotherapy, previous surgery, and residence in the nursing home.A total of 821 samples (574 stools and 247 swabs) were collected between April 2015 and May 2017. The prevalence of CDI is common in Iran and further studies are recommended to monitor its epidemiological variations. Moreover, greater attempts must be made to encourage antibiotic stewardship by healthcare workers and the public. Clostridium difficile is an obligate anaerobic bacillus opportunistic intestinal pathogen with the capability of large glucosylate toxins production ) [C. difficile infections (CDI) ranges from mild diarrhea to pseudomembranous colitis [C.difficile spores may account for 40% of CDI [C. difficile isolation from medical devices, hands of healthcare workers and its transmission to patients in the hospital settings [C. difficile strains globally [https://pubmlst.org/cdifficile) [C. difficile isolates from patients and their environment have been conducted in Iran using the MLST method.d cdtB)) , 2. The  colitis . About 3% of CDI . Both as% of CDI , 4, 5 Th% of CDI . There asettings . The episettings . Epidemisettings . These eglobally . In receglobally . In Iranglobally , 12. Thefficile) –15. The fficile) , 16. MorC. difficile in hospitalized patients and hospital environments. Additionally, we intended to study the genetic polymorphism and relationship among strain lineages using MLST as an unambiguous molecular procedure.The main objective of the current study was to determine the incidence of C. difficile culture and toxin tests [A cross-sectional study was conducted in medical wards of the university hospitals in Isfahan, the central of Iran from April 2015 and May 2017. Our study included the patients aged at least 18 years who were admitted to medical wards for different problems and acquired diarrhea in hospital. Diarrhea was determined as the passage of more than two loose or watery stools per day for at least two days [To avoid overrepresentation, only the first stool specimen from each patient was included. A total of 247 samples were collected from the dominant hand of healthcare workers, the different skin sites of patients  and medical devices using sterile swab moistened with normal saline rotated all 5× 20 cm of the surfaces. All surfaces frequently touched by health care workers were documented. Fecal and environmental samples from patients were collected in sterile containers and were then immediately transferred into the laboratory of Infectious Diseases and Tropical Medicine Research Center, Isfahan, Iran and preserved at − 70 °C. Variables were included the demographic characteristics, type of comorbidities and antibiotic treatment in 8 weeks prior to CDI diagnosis.The study was approved by the human research ethics committee of Isfahan University of Medical Sciences (the grant No. 293347), and the study was carried out in full accordance with the approved guidelines.C. difficile moxalactam norfloxacin (CDMN) broth culture. Then the cultures were incubated anaerobically for 48 h at 37 C° using an Anoxomat system . Alcohol shock treatment was performed to inhibit non-sporulating organisms and enhance the isolation of C. difficile (a 1:1 suspension cultured sample with 95% ethanol was slowly vortexed and held at room temperature for 30 min). The pellets were inoculated by a swab into the C. difficile moxalactam norfloxacin agar (CDMN) supplemented with 7% sheep blood and incubated anaerobically for 48 h at 37C°. Negative cultures remained in the incubator for up to 7 days. Irregular yellowish colonies with horse-manure odour, ultraviolet fluorescence (365 nm), Gram stain morphology, malachite green for spore and biochemical reactions such as L-proline aminopeptidase test  were identified as C. difficile strains and stored at 4 °C. These colonies were subjected to further molecular identification [For culture analysis, Lemee L method was used . About 2fication , 19.tcd A and tcd B), binary toxin  and triose phosphate isomerase (tpi) as described by Stubbs et al. and Lemee et al. [C. difficile strains grown in BHI broth were centrifuged and cells were treated with lysozyme and resuspended in TE . Then guanidine isothiocyanate and ammonium acetate were added to the mixture and Chloroform/isoamyl alcohol (24:1). The DNA was precipitated and washed with ethanol [All isolates were screened for the presence of the genes encoding toxin A and B , 5 pM of primers (tpi), 1 U Taq polymerase  and 100 ng of DNA. Amplification was carried out in a touchdown protocol [Clostridium difficile ribotype 027 was used as a positive control for molecular and microbiological analysis and C. perfringens 450 MTCC  was used as the negative control [Multiplex PCR amplification performed in a thermocycler . An amount of 25 μl of reaction mixture contained 1× PCR buffer, 250 μM of each dNTPs, 10 pM of primers  was performed on detected isolates as described previously by Griffiths et al. [MLST was carried out and analyzed for s et al. . Sequencs et al. .C.difficile isolates was determined using the Etest strips  for vancomycin, metronidazole, moxifloxacin, fusidic acid, rifampin, and clindamycin. Briefly, the Etest was performed by inoculating the surface of pre-reduced Brucella Agar plates containing vitamin K1 (0.5 mg/mL), haemin (5 mg/mL) and 5% defibrinated sheep red blood cells with 1 McFarland standard matched C. difficile inoculum. The plates were incubated at 37 °C for 48 h under anaerobic conditions. The breakpoints and interpreting of the minimum inhibitory concentrations (MICs) were carried out according to the Clinical Laboratory Standards Institute (CLSI 2012) and the European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines . Clostridium perfringens MTCC 13124 and Streptococcus sp. MTCC 689 strains were included in each run as controls. The breakpoints used were 8 μg/ ml for Clindamycin, 4 μg/ ml for moxifloxacin; 2 μg/ ml, for vancomycin and 32 μg/ ml for metronidazole; rifampin; fusidic acid as described previously [Antimicrobial susceptibility of toxigenic eviously , 24. TheP-value of < 0.05 was defined as statistically significant. The logistic regression model was used to determine clinical factors associated with C.difficle infection. First, a univariate logistic regression model was fitted on each clinical factors, and then a multivariate regression model with adjustment for the effects of other covariates was used. Variables that were significant in univariate models (P < 0.05) were entered into the multivariate model. Selection of variables in the multivariate model was based on a stepwise procedure. Statistical analysis was performed using the statistical software .Data were expressed as count and percentage. All probabilities were two-tailed and a C. difficile culture positive and the tpi gene was recovered from these stool specimens. Based on PCR amplification of tcdA and tcdB, 66 isolates (40.2%) carried one or both of these genes and were considered toxigenic, while the remaining 98 isolates (59.8%) were nontoxigenic.  were P < 0.001). The use of antibiotic was identified in all patients in the 8 weeks prior to CDI diagnosis. Patients were treated with one to four antibiotics, about 96% and 63/5% of them had been used more than one and two antibiotics, respectively (Table Mean age of CDI cases was 55.4 years (standard deviation 19.4 years) and mean age of Non-CDI cases was 44 years(standard deviation 15.5 years). Risk of CDI increased by nearly 4% per year  toxigenic strains. Toxigenic C.difficile strains were detected from different skin sites (hands and abdomens) of 7 CDI patients and 4 of healthcare workers hands . They represented two different PCR ribotypes  selected to validate the MLST scheme analyses. Toxigenic C. difficile strains from different hospitals were analyzed by MLST and divided into 4 different STs .The detected types were ST-54 (57.9%), followed by ST-2 (31.6%), ST-15 (5.3%), and ST-37 (5.3%), but none of the isolates was identified as ST-1 (BI/NAP1/027) or ST-11(ribotype 078). We found a correlation between the toxin genotypes and STs. All of the ST-54 strains were toxin type AP > 0.05).We used E test strips to determine the minimum inhibitory concentration (MIC) of each antibiotic in the toxigenic isolates for six antibiotics. All the isolates were inhibited by a low concentration of vancomycin (MIC < 0.5 μg/ml). Two isolates, from 2 ICU patients aged 70 and 72 years, were resistant to fusidic acid, while the remaining isolates 97.4%) proved susceptible to it. About 42.8% (33/77) of isolates were resistant to Clindamycin, while it was about 38.9% for Moxifloxacin (30/77). Only 11.7% of isolates (9/77) were resistant to rifampin. All isolates were susceptible to metronidazole. There were no inner colonies suggestive of heteroresistance within the zones of inhibition around the metronidazole E- test strips (Table % proved C. difficile infection (CDI) is regarded as a widespread issue worldwide because of its increasing morbidity and mortality. The range of this infection is variable from mild diarrhea to pseudomembranous colitis especially among the elderly population who have been exposed to antibiotics [C. difficile strains. There are limited epidemiological studies on C. difficile in Iran. The prevalence of CDI in our study was lower than those reported in Western countries and China [C. difficile samples associated with higher mortality and recurrence rate of CDI [C. difficile strains in Asia.Currently, ibiotics . CDI epind China , 26. Thend China . In a sind China .In Europe of CDI . We foune of CDI . This ma−B+ strains, yet the most prevalent STs were ST-2, ST-54, ST-37, and ST-35 in China and ST-1 in France. This might be due to different geographical locations where the study was carried out [Our phylogenetic analysis showed that ST-54 and ST-2 were the most prevalent strains. Therefore we proposed a low genetic diversity of toxigenic strains in Isfahan, Iran. Other similar studies in Europe, the Middle East, and North America previously identified ST2 as a common clinical strain all around the world . Studiesried out , 10, 26.+B+ strains (ST-54). Recent studies have reported an increasing number of infections due to A-B+ strains especially ST-37 in Asia though such strains do not produce a binary toxin [C. difficile culture and toxin testing in many hospitals in Iran, awareness of circulating strains and their prevalence is not high enough.Most of CDI in the current study were found to be due to Ary toxin . Due to C.difficile strains commonly revealed high susceptibility to these most common choices for CDI treatment [C. difficile frequently contaminated hands of HCWs after caring for patients with CDI (p < 0.01). Other studies showed that skin contamination persisted in many patients after resolution of diarrhea and was easily acquired on investigators hands [C. difficile isolates with the same RTs in gastrointestinal imaging devices and stool specimens [We could not establish a correlation between the hospitals and detected genotypes. Our isolates were genotyped into 4 STs, which were not specific to Iran, a finding that suggests the worldwide spread of some lineages. All strains of ST54 isolates were toxin type A + B+ and all strains ST2 were toxin type A-B+. In addition, there was no correlation between the genotype and CDI risk factors in our study. Based on our multivariate regression model results, patients with CDI were significantly older and had more comorbidities than the non-CDI group. Several previous studies have noted the association between recent hospitalization, advanced age, severe diseases and a higher risk of acquiring CDI , 30, 31.reatment . In two reatment . The strrs hands  The samepecimens . While aC. difficile isolates, which led to undermining the true prevalence and diversity of C. difficile STs. Due to the quick discharge of many of our patients; we were not able to analyze treatment and outcome characteristics of all patients with CDI.There were a number of limitations to our study including difficulties in the sequencing of all Since the incidence of CDI was relatively high at the provincial level, a countrywide CDI surveillance (with a long period and large population size) is warranted to analyze other risk factors of CDI and contamination.clostridium difficile was observed in our patients and found to exist in their environment. More studies are recommended to monitor its epidemiological change and greater attempts must be made to encourage antibiotic stewardship by healthcare professionals and the public.According to the results, a relatively high infection rate of toxigenic and non-toxigenic strains of


Among 615 animals, 105  animals were positive for SFTSV RNA, and only one SFTSV strain was isolated from heart tissue of a yellow weasel. The phylogenetic analysis shows that the sequence from animals belonged to the same group with viral sequences obtained from humans. The animals maybe play a reservoir host in maintaining the life cycle of SFTSV in nature.Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease caused by severe fever with thrombocytopenia syndrome virus (SFTSV). SFTSV has been found in humans, ticks and animals, and SFTS has high mortality and increasing prevalence in East Asia. In the study, the samples  were collected from 374 domestic animals and 241 wild animals in Pingqiao District and Xinxian County of Xinyang in Henan Province, China. 275  animals were positive for anti-SFTSV antibodies, the anti-SFTSV antibodies positive ratios of domestic and wild animals were 43.58% (163/374) and 46.47% (112/241), respectively. There was no significant difference in domestic and wild animals, but significant differences were detected among different species of animals (The online version of this article (10.1186/s40249-019-0569-x) contains supplementary material, which is available to authorized users. Please see Additional file Severe fever with thrombocytopenia syndrome (SFTS) is an emerging hemorrhagic fever and its pathogen is severe fever with thrombocytopenia syndrome virus (SFTSV). The disease has major clinical presentations that include fever, thrombocytopenia, leukocytopenia, gastrointestinal symptoms, neurological symptoms and a bleeding tendency, as well as less specific clinical manifestations . The disSFTSV has a wide host range and infects in some animal species. The pooled seroprevalence of anti-SFTSV antibodies was 45.70% in goats and sheep, 36.70% in cattle, 29.50% in dogs, 9.60% in chickens, 3.20% in rodents, and 3.20% in pigs. SFTSV RNA was also detected in blood samples from several animal species, with a carriage rate varying from 0.23 to 26.31%, The highest carriage rate of SFTSV RNA was detected in cattle (up to 26.31%), followed by cats (17.46%), goats (9.10%), and rodents 8.44%), but there is no evidence that the virus can cause disease in animals [.44%, butIt is known that SFTSV can be detected in humans, various domestic animals and ticks. Although researchers had demonstrated in the laboratory that the SFTSV can be passed transstadially in the developmental stages of the ticks which can be as a host and reservoir of infection to spread SFTSV by biting humans and animals. But the prevalence of SFTSV infection among ticks collected from vegetation was quite low, suggesting that ticks alone may not be sufficient to maintain the virus in nature, so SFTSV must rely on other animals as storage hosts to circulate in nature . This stThe study was conducted in Pingqiao District and Xinxian County of Xinyang City in Henan Province, China, where had the most reported SFTS cases and was the most severe affected areas in China , 11. FroTotal SFTSV antibodies (including IgG and IgM) were detected in serum samples using a double-antigen sandwich ELISA kit  according to the manufacturer’s protocol. For this ELISA kit, 100 μl of serum samples were diluted to 1∶5, and positive and negative controls were added. Samples were incubated at 37 °C for 30 min, washed with phosphate-buffered saline (PBS), and 100 μl of horseradish peroxidase-conjugated nucleoprotein was added. Plates were developed by using a substrate solution after samples were incubated and washed. The chromogenic reaction was stopped by sulfuric acid, and absorbance was identified at 450 nm. The test results were determined to be valid if the criteria for the positive and the negative controls were fulfilled , 13.3) were ground by Tissuelyser . Total RNA was extracted from serum samples and tissue-grinding solution using a QIAamp viral RNA mini Kit , according to the manufacturer’s instructions. RNA was eluted in a final volume of 60 μl elution buffer and used immediately or stored at − 80 °C. RNA from each sample was examined by real-time RT-PCR Kit . The conditions for real-time RT-PCR reaction were as follows: 50 °C for 30 min, 95 °C for 15 min, 40 cycles of 95 °C for 15 s, and 60 °C for 45 s. Criteria for a positive result was cycle number (Ct) < 38, according to the instructions from the real-time RT-PCR Kit.The animal tissue samples (0.5–1 cm2 flask containing Vero E6 cell monolayers. Tubes were incubated at 37 °C for 14 days and changed media after 7 days. All cultures were monitored daily for the cytopathic effect (CPE). Each sample underwent at least three cell culture passages in Vero E6 cells before being considered negative [All positive samples  for SFTSV RNA were used to inoculate Vero E6 cells. After processing, 100 μl of samples was inoculated into a 25 cmnegative . The RT-http://mega.software.informer.com/5.0/) [The genomes of SFTSV isolates were compiled using the SeqMan program in the Lasergene software package . The percentage similarities of nucleotide identity were calculated using the Clustalx software . Molecular phylogenetic analysis was conducted by using the maximum likelihood (ML) method based on the Kimura 2-parameter model in the molecular evolutionary genetics analysis (MEGA) 5 software (available at: om/5.0/) . The treom/5.0/) . The avaχ2 test or Fisher’s exact test. A significant difference was considered with a P value less than 0.05.All statistical analyses were performed using SAS . Count data was analyzed by The research was approved by the Ethical Committee of Henan CDC (Reference number: 2016-KY-002-02). The collection of wild animals was permitted by Pingqiao District and Xinxian County Forestry Bureau. Animals were captured by hunters, who were supplied with safety protection.χ2 = 0.1884, P > 0.05), The positive ratio of the mammals  was higher than that of birds  . The higher positivity rate of the antibodies in domestic animals ware cattle , sheep  and dogs , the lowest positive rate in domestic animals is pigs . In the wild animals, yellow weasels  and hares  were higher than other animals, there are three animals (squirrels and wild boars and badgers) the positive rates were zero. There were significant differences in different species of animal   were positive for anti-SFTSV antibodies; the positive ratios of domestic and wild animals were 43.58% (163/374) and 46.47% (112/241), respectively, there was no significant difference between domestic and wild animals . There were no significant differences in the positive rates of SFTSV RNA among animal species , but the positive rate was higher in the domestic cattle , chickens  and sheep , and in the wild animals yellow weasels , pheasants , hares  and rock pigeons . There were significant differences in the positive rates among organs of animals , the positive rate was the highest in spleen , and the lowest in kidney  . Additionally, 105 out of 615 (17.07%) animals were positive for SFTSV RNA, in which at least one organ was positive according to real-time RT-PCR. The brains were negative for SFTSV RNA in all animals. The positive rate of domestic animals and wild animals were 15.76% (59/374) and 19.09% (46/241), respectively. There were no significant differences between domestic animals and wild animals (https://blast.ncbi.nlm.nih.gov/Blast.cgi). BLAST results showed that this isolate strain was related closely to known sequences, with 96.64 to 99.91% nucleotide identity for the complete L segments, 96.15 to 99.67% nucleotide identity for the complete M segments, and 98.51 to 99.89% nucleotide identity for the complete S segments.One strain SFTSV was isolated and confirmed from heart tissue of a yellow weasel in this study by real-time RT-PCR. The genomes of the SFTSV isolates were sequenced and submitted to GenBank . The nucleotide sequences of this SFTSV were aligned using the basic local alignment search tool (BLAST) at the National Centre for Biotechnology Information (NCBI) . The SFTSV strain from animals belonged to Group A with viral strains obtained from humans in Henan Province Fig..Fig. 1PhSerological epidemiology of SFTSV was surveyed among domesticated animals in many previous studies. SFTSV antibody positive rate had a larger difference in the same animal species among different epidemic areas, but sheep, cattle, dogs and chickens had very high positive rate and high levels of SFTSV antibodies –20. The The results of this study showed that SFTSV-carrying rate was 17.07% among domestic animals and wild animals in epidemic areas in Henan, China, by real-time RT-PCR, and one SFTSV strain was isolated from a yellow weasel. The PCR positive rate of all animals was higher than all previous studies because the collection of sample types was different from them. In this study, the serum, heart, liver, lung, kidney, spleen and brain tissue samples were collected from animals. One organ from an animal was positive by real-time RT-PCR, the animal was judged as carrying SFTSV, but SFTSV RNA was only detected in serum samples from animals in previous studies. A total of 6637 blood samples from 11 animal species were testing for SFTSV RNA in twelve published articles, while the carriage rates of SFTSV RNA ranged from 0.23 to 26.31% [The previous animal experiments showed that newborn mice, mitomycin-treated mice, and type I IFN-deficient mice are available as models for the fatal illness caused by SFTSV infection –25. ImmuNatural infection study showed goats were infected by ticks in the SFTS-endemic region. The goats were viremia over a very short period (less than 24 h) after viral infection, soon occupied by a timely mounting antibody response which effectively controlled the infection. The whole cohort did not show any specific clinical signs of illness, and all survived infection , 30. TheThis study has two limitations. First, animal selection lacked uniformity in number, especially some wild animals were lesser and captured difficultly in nature. Second, animal species can’t be randomly selected to capture.The most animals were infected by SFTSV and some carry SFTSV in epidemic areas in China. 44.72% animals were positive for anti-SFTSV antibodies and 17.07% animals were positive for SFTSV RNA in Xinyang in Henan Province. The animals maybe play a reservoir host in maintaining the life cycle of SFTSV in nature.Additional file 1:Multilingual abstracts in the five official working languages of the United Nations. (PDF 402 kb)Additional file 2:Table S1. SFTSV RNA positivity as detected in the different animal species from published articles. (DOC 37 kb)


Gastrointestinal stromal tumors (GISTs), which are the most common mesenchymal tumors of the digestive system, are treated varyingly according to the malignancy. The purpose of this study is to develop and validate a nomogram for preoperative prediction of the malignant potential in patients with GIST.n = 308) and validation set (n = 132). CT signs and texture features of each patient were analyzed and predictive model were developed using the least absolute shrinkage and selection operator (lasso) regression. Then a nomogram based on selected parameters was developed. The predictive effectiveness of nomogram was evaluated by the area under receiver operating characteristic (ROC) curve (AUC). Concordance index (C-index) and calibration plots were formulated to evaluate the reliability and accuracy of the nomogram by bootstrapping based on internal (training set) and external  validity. The clinical application value of the nomogram was determined through the decision curve analysis (DCA).A total of 440 patients with pathologically confirmed GIST after surgery in our hospital from January 2011 to July 2019 were retrospectively analyzed. They were randomly divided into the training set  and 284 ones with high-malignant potential (intermediate and high risk) are enrolled in this study. The prediction nomogram consisting of size, cystoid variation and meanValue had an excellent discrimination both in training and validation sets ): 0.935 , 0.933 ; C-indices (95% CI): 0.941 , 0.935 ; sensitivity: 81.4, 90.6%; specificity: 75.0, 75.7%; accuracy: 88.0, 88.6%, respectively). The calibration curves indicated a good consistency between the actual observation and nomogram prediction for differentiating GIST malignancy. Decision curve analysis demonstrated that the nomogram was clinically useful.This study presents a prediction nomogram that incorporates the CT signs and texture parameter, which can be conveniently used to facilitate the preoperative individualized prediction of malignancy in GIST patients. Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the digestive system with malignant potential regardless of its size, accounting for 1–3% of all gastrointestinal tumors . GISTs aComputed tomography (CT) is widely recognized as the main imaging method for the diagnosis, characterization and evaluation of curative effect in GIST patients due to its convenient operation, good image quality and moderate price . The sigHence, the aim of this study was to develop and validate a preoperative nomogram, incorporating both the CT signs and texture features, for prediction of the malignant potential in patients with GISTs.This study was approved by the ethics committee of our hospital. The requirement for informed consent was waived for this retrospective study. Records for GIST patients attending our hospital from January 2011 to July 2019 were obtained. The inclusion criteria including the following: 1) patients who underwent surgery for GISTs with curative intent; 2) information of postoperative pathologically confirmed GISTs risk category available; 3) standard contrast-enhanced CT less than 30 days before surgery. The exclusion criteria including the following: 1) previous history of GISTs or other cancer; 2) preoperative therapy ; 3) poor image quality affects lesion segmentation.n = 308, 164 males and 144 females; mean age, 57.8 ± 10.54 years; range, 29–87 years) and validation set  after simple randomization at a ratio of 7 to 3.A total of 440 patients with pathologically confirmed GISTs who underwent surgical resection were enrolled: 233 males and 207 females; mean age, 58.4 ± 10.87 years; range, 29–87 years. Patients were divided into training set . Patients were regularly fasted for 4 to 6 h before the CT examination and encouraged to drink 500–800 mL of water 30 min before the scan and 1000 mL immediately before the scan to fill the gastrointestinal tract. The CT parameters were as follows and used with a standard reconstruction algorithm: tube voltage, 120 kV; tube current, 250–300 mA; slice thickness and interval, 1.5 mm. Patients were in a supine position, and the scan range included all lesion areas. After the unenhanced CT, a total of 80–120 mL (1.5 mL/kg) of iodinated contrast material  was injected with a pump injector  at a flow rate of 3 mL/s into the antecubital vein. The arterial-phase, portal venous-phase and delayed-phase scans were performed at 25 to 30 s, 50 to 60 s and 120 s after the injection of the contrast medium, respectively. The images were uploaded to picture archiving and communication system (PACS)  workstations.Two radiologists with 3 (reader 1) and 13 (reader 2) years of diagnosis experience reviewed and assessed the following 8 CT signs of each lesion without knowing the pathology determined by consensus: the size , location (gastric and non-gastric), growth pattern , shape (regular or irregular), boundary (clear or unclear) of lesions, and the presence of calcification, cystic necrosis and metastasis.www.lifexsoft.org) with portal venous-phase CT images. The above two radiologists  selected the largest slice of the tumor at three-dimensional (3D) images to delineate the region of interest (ROI) by consensus  parameters. A list of the corresponding features is provided in Additional file Orlhac .http://www.r-project.org). Independent t-tests or Mann-Whitney U tests were applied for continuous variables across the groups, and Fisher’s exact tests or χ2 tests were used to assess differences in patient categorical variables. A two-sided P value of < 0.05 was used as the criterion to indicate a statistically significant difference.Statistical analysis was performed on R software  regression with 10-folds cross validation which was used to select the most useful features in previous studies , 20 to aP > 0.05 indicated insignificant deviance from the theoretical perfect calibration. Concordance index (C-index) was formulated to evaluate the reliability and accuracy of the nomogram by bootstrapping (1000 bootstrap resamples) based on internal (training set) and external  validity.The prediction performance of nomogram was evaluated by the area under the receiver operating characteristic (ROC) curve (AUC) on both the training and validation sets, with the AUC, sensitivity, specificity and accuracy with 95% confidence intervals (95% CIs) were calculated. Calibration curve was plotted to assess the calibration of the nomogram with the Hosmer-Lemeshow goodness-of-fit test. The clinical application value of the nomogram was determined through the decision curve analysis (DCA) by quantifying the net benefit to the patient under different threshold probabilities.p > 0.05) in either the training or validation sets, consistent with the report [Totally 440 GIST patients comprising of 156 low-malignant and 284 high-malignant potential are enrolled in this study. Clinical and demographic characteristics in the training and validation sets are summarized and compared in Table e report .Table 2p < 0.05). Thus, the mean measurement values of the two radiologists were used for further analysis.A total of 8 CT signs and 16 texture features were extracted from 440 GIST patients’ CT portal-phase images, and the agreement between the two radiologists  was excellent for texture features   Table .Table 3The prediction nomogram had an excellent discrimination capacity for discriminating the low- from high-malignant potential GIST in training set (AUC 95% CI) =0.935 , sensitivity = 81.4%, specificity = 75.0%, accuracy = 88.0%) and validation set (AUC (95% CI) =0.933 , sensitivity = 90.6%, specificity = 75.7%, accuracy = 88.6%), as shown in Fig. % CI =0.9p values > 0.05, respectively)  Fig. a, b. TheThe DCA for the prediction nomogram was presented in Fig. In this study, a prediction nomogram was developed and validated for the preoperative individualized prediction of the malignant potential in GIST patients. The prediction nomogram consisting of 2 CT signs (size and cystoid variation) and 1 texture parameters , which was easily available preoperatively, successfully stratified GIST patients according to their malignant potential.GISTs have become the model of targeted therapy for solid tumors with the in-depth study of molecular pathology, and the choice of treatment for GISTs is closely related to their risk stratification . GISTs ap values < 0.001, respectively) , 0.920 , respectively) . NeverthHowever, the present study had several limitations although the results were encouraging. First, this study was a single-center retrospective study, and it is necessary to design a new multi-center study for further evaluation and verification of the results. Second, the sample selection was biased in this retrospective study, and a prospective study is required to confirm and validate the nomogram. Third, the texture features extracted in this study were based only on portal venous-phase CT images. Whether the use of other periods, such as arterial-, delayed-phase images or the combination of them will increase the predictive efficiency in the malignant potential of GISTs needs further study.A prediction nomogram based on CT and texture analysis was constructed and validated in our study, which was conveniently used to facilitate the preoperative individualized prediction of malignant potential in GIST patients.Additional file 1: Table S1. Specific categories of texture parameters.


Patients with appendicular endometriosis (AE) constitute <1% cases of all pelvic endometriosis cases. AE presents with pain in right iliac fossa and symptomatically mimics appendicitis and definitive diagnosis is possible only after histopathological examination of excised appendix.In this case report, we present a rare case of appendicular endometriosis in a young woman suffering from pain in right iliac fossa and periumbilical region (on/off) for the past one year. She had a past history of infertility. Blood investigations were normal and CT scan of abdomen demonstrated findings suggestive of appendicitis. Laparoscopic appendicectomy was performed, which revealed 2 cm tumor-like mass (1.5 cm diameter) present at the tip of appendix involving the mesoappendix. There was no ascites, peritoneal or omental deposits or any signs of inﬂammation. Post-operative recovery was good. Dissected appendix specimen was sent for histopathological examination which confirmed endometriosis of appendix.Gastrointestinal endometriosis (GE) accounts for 3–37% of all endometriosis cases, whereas AE is present in only ∼3% of all GE cases and constitutes <1% of all the endometriosis cases. AE frequently involves tip and body of the appendix. The layers of appendix most commonly affected are muscular and seromuscular (∼2/3rd cases), followed by the serosa (∼1/3rd cases).Thus, appendicular endometriosis is a rare entity and should be included in differential diagnosis in young women presenting with pain in right iliac fossa and having history of infertility. In majoThe presence of endometrial glands and stroma outside the uterine cavity is known as endometriosis . It rema2A 35-year-old female came to the surgical out-patient department of our hospital with chief complaints of intermittent pain in the periumbilical region and right iliac fossa for one year. Pain was not associated with other complaints or menstruation. There was a history of infertility and no other significant past medical history. The physical examination was unremarkable. The routine blood investigations were normal. USG abdomen and pelvis revealed well-defined nodular lesion (1.5 × 1.3 × 1.6 cm) in right iliac fossa, and mild hypoechoic circumferential wall thickening in the terminal ileum and ileo-caecal junction (3–5 mm thick). Contrast enhanced computed tomography (CT) of abdomen revealed well-defined long tubular structure  with lobulated tip along the postero-medial wall of caecum, mild pericaecal stranding and thickened right lateral conal fascia – suggesting of acute appendicitis . AdditioIntra-operatively, there was presence of a 2 cm tumor-like mass at the tip of appendix involving the mesoappendix, while base of the appendix was normal. There was no ascites, peritoneal or omental deposits or any signs of inﬂammation. The entire appendix measuring 2.5 × 2 × 5 cm was dissected and excised . Caecum 3Endometriosis is described as an estrogen-dependent, chronic inflammatory disorder. Presence of viable endometrial tissue outside the uterus is the characteristic finding. It frequently involves the reproductive organs and peritoneum. It may also affect the GIT, omentum, mesentery and surgical scars, while the distant and rare sites includes the lungs, kidneys, nasal cavity and skin. Gastrointestinal endometriosis (GE) accounts for 3–37% of all endometriosis cases, whereas AE is present in only ∼3% of all GE cases and constitutes <1% of all the endometriosis cases .The most frequent symptoms includes dysmenorrhea followed by chronic non-menstrual lower abdominal pain. Other symptoms are infertility, painful coitus, pain during defecation, painful bladder symptoms and dysuria, bowel symptoms , and ovarian mass . ChronicNone of the available diagnostic procedures  help in the preoperatively diagnosis of AE. A definitive diagnosis is possible only after histopathological examination of the excised appendix. Since laparoscopy provides a direct clue due to visualisation of features under magnification, it may be considered as a standard diagnostic method. However, when a young woman presents with complaints of chronic pelvic non-menstrual pain, and past history of infertility and pelvic endometriosis, diagnosis of AE must be suspected. Similarly, our patient was young and had a history of chronic lower abdominal pain and infertility, which helps in the diagnosis. Also, CT scan revealed findings suggestive of acute appendicitis.AE frequently involves tip and body of the appendix. The layers of appendix most commonly affected are muscular and seromuscular (∼2/3rd cases), followed by the serosa (∼1/3rd cases). American Society for Reproductive Medicine has proposed a staging system, which categorises the endometriosis in to 4 stages: Stage I to IV i.e., minimal, mild, moderate and severe . This stSurgical excision of affected tissue/organ is generally needed for the most efficient and exhaustive treatment of endometriosis. As per the recent guidelines, appendicectomy should be performed laparoscopically, unless contraindicated . The man4Appendicular endometriosis is a rare entity and almost always diagnosed after surgical excision of the appendix followed by histopathological examination. However, it should always be included in differential diagnosis when a young woman presents with complaint of chronic right iliac fossa pain mimicking appendicitis and has a history of infertility.The authors declare that they have no conflict of interest.This study did not receive any funding.The study was approved by Ethics Committee of Hospital Sahloul Sousse.Written informed consent was obtained from the patient.Study concept or design – AS, HA.Data collection – HA, WF, RG.Data interpretation – MBL, WF, RG.Literature review – WF, ABA, SL.Drafting of the paper – HA, MA, SL.Editing of the paper – AB, AS, AM.As this was a case report and not a clinical trial, this study does not require registration.Houssem Ammar.Not commissioned, externally peer-reviewed.


PRNP), which encodes the prion protein (PrP). The recent emergence of chronic wasting disease (CWD) in Europe has highlighted the need to investigate PRNP gene diversity in European deer species, to better predict their susceptibility to CWD. Here we report a large genetic survey of six British deer species, including red (Cervus elaphus), sika (Cervus nippon), roe (Capreolus capreolus), fallow (Dama dama), muntjac (Muntiacus reevesii), and Chinese water deer (Hydropotes inermis), which establishes PRNP haplotype and genotype frequencies. Two smaller data sets from red deer in Norway and the Czech Republic are also included for comparison. Overall red deer show the most PRNP variation, with non-synonymous/coding polymorphisms at codons 98, 168, 226 and 247, which vary markedly in frequency between different regions. Polymorphisms P168S and I247L were only found in Scottish and Czech populations, respectively. T98A was found in all populations except Norway and the south of England. Significant regional differences in genotype frequencies were observed within both British and European red deer populations. Other deer species showed less variation, particularly roe and fallow deer, in which identical PRNP gene sequences were found in all individuals analysed. Based on comparison with PRNP sequences of North American cervids affected by CWD and limited experimental challenge data, these results suggest that a high proportion of wild deer in Great Britain may be susceptible to CWD.Susceptibility to prion diseases is largely determined by the sequence of the prion protein gene ( Odocoileus hemionus hemionus) and black-tailed deer (Odocoileus hemionus columbianus) in Colorado wildlife facilities [Cervus canadensis) white-tailed deer (Odocoileus virginianus), moose  and a single captive red deer (Cervus elaphus) [Chronic wasting disease (CWD) is a prion disease of cervid species that is widespread in North America and has recently emerged in Europe. It belongs to a family of diseases termed transmissible spongiform encephalopathies (TSEs), which cause progressive and invariably fatal neurodegenerative disorders in humans and animals. CWD was first described in the 1960s as a wasting syndrome of captive mule deer (elaphus) , 3. It ielaphus) , as wellelaphus) .Rangifer tarandus) was identified in Norway in March 2016 [Member States of the European Union (EU) and Norway were believed to be free of CWD based on a survey conducted between 2006 and 2009 on 3274 farmed and 10 049 wild deer [rch 2016 –11.C) into a protease-resistant form (PrPSc). The sequence of the open reading frame (ORF) of the gene encoding the prion protein (PRNP) is strongly associated with susceptibility to prion diseases. This association has been exploited in breeding programmes such as the National Scrapie Plan in the UK, which selectively bred for disease resistant PRNP genotypes to reduce the incidence of classical scrapie in sheep [PRNP genetics have been widely studied in North America, where both natural and experimental infection of deer species has allowed for the identification of PRNP polymorphisms that are associated with reduced incidence of disease and/or slower disease progression. The first identified was M132L in wapiti, which encodes a methionine to leucine change at codon 132. Genotype surveys of CWD affected deer populations have produced conflicting evidence regarding the association of codon 132 variation with incidence of disease [PRNP polymorphisms associated with CWD susceptibility include S225F in mule deer, [PRNP polymorphisms have been associated with reduced susceptibility to CWD, none of them appear to confer complete resistance.The development of prion diseases is associated with misfolding of the prion protein  that show evidence of association with reduced susceptibility or resistance to CWD have the potential to be used in breeding programmes for captive and farmed deer. The primary aims of this study were (i) to perform a comprehensive survey of the protein-coding sequence of the PRNP gene in the six major free-ranging or wild species of deer found in Great Britain (GB) and (ii) to compare the PRNP genotype distributions in British and European populations of red deer, as red deer are one of the most numerous wild species in both GB and mainland Europe, and are also an economically important game species due to revenue generated via hunting, tourism and venison production [The extent of oduction .A total of 1003 samples collected from wild deer in GB  were analysed. Archived DNA samples were provided by JP, SPE and SLS for red deer, sika deer, and red/sika hybrids, and by KB for roe deer. The procedures for sample collection and genomic DNA preparation for these archives have been described previously –38. AddiIn total, samples from 480 red deer were analysed, of which 388 were from the archived collection, and 92 samples were collected by BDS deer stalkers. Samples from 83 sika deer were analysed, 73 samples were archived DNA, and 10 stalker collected samples from the South of England. All samples collected by members of the BDS were identified by animal phenotype only, whereas archived DNA samples of red and sika deer were selected both on phenotypical appearance and microsatellite genotyping data , wherebyn = 78), Northern England (Lake District) (n = 32), Southern Scotland (n = 23), Argyll (n = 47), Central Highlands (n = 142), Northern Highlands (n = 114) and Hebrides (n = 44)   and wild sika (n = 20) collected in five regions of the Czech Republic [Genotype analysis was also performed on 50 wild red deer collected from six counties in Norway, and 66 archived DNA samples from wild red deer  according to manufacturer’s instructions.Genomic DNA was extracted from small sections of ear-tip tissue, digested with proteinase K (PK) at 37 °C overnight, followed by standard phenol/chloroform purification, ethanol precipitation and re-suspension in 1XTE buffer, as described previously . NorwegiPRNP (771 bp) was amplified by PCR using AmpliTaq Gold 360 master mix (Thermo Fisher Scientific) and primer pairs − 143d (ATGGAATGTGAAGAACATTTATGACCTA) or − 213d (AGGTCAACTTTGTCCTTGGAGGAG) with + 139u (TAAGCGCCAAGGGTATTAGCAT) or AR2 (GCAAGAAATGAGACACCACCAC) for British and Czech red, roe and sika deer, − 213d and AR3 (ACCACTACAGGGCTGCAGGTA) for fallow and Chinese water deer, and − 213d and AR2 (GCAAGAAATGAGACACCACCAC) for muntjac deer. PCR conditions were 95 °C for 5 min followed by 40 cycles of 95 °C for 30 s, 61 °C for 30 s and 72 °C for 1 min, and a final 72 °C for 10 min. PCR fragments were sequenced by sanger sequencing using primer + 70u (GCTGCAGGTAGATACTCCCTC) and BigDye® reagents  as recommended by the manufacturer. Sequence data were analysed using Chromas and DNAStar Lasergene version 14.The ORF of cervid ® reagents  as recommended by the manufacturer. Sequence data were analysed using Seqscape v3.0 software, Sequence Scanner v2.0 (Applied Biosystems) and MEGA7 version 7.0.26 [The ORF was amplified using PCR primers Ce19_F (ATTTTGCAGATAAGTCATC) and Ce 778_R (AGAAGATAATGAAAACAGGAAG) . PCR conn 7.0.26 .The Chi square test was used to compare haplotype frequencies between different regions and countries.Capreolus capreolus MK103016; Dama dama MK103017; Cervus nippon MK103018, MK103019; Muntiacus reeveesi MK103020–MK103023; Hydropotes inermis MK103024–MK103026; Cervus elaphus with 247L MK103027.Sequences were deposited in Genbank with the following accession numbers: PRNP gene is highly conserved among cervid species, and non-synonymous polymorphisms identified in individual species are usually reported as variations from a consensus sequence [PRNP sequence polymorphisms identified in the deer species examined in our survey are summarized in Table The ORF encoded by exon 3 of the sequence . Followi98-P168-E226 (TPE), T98-P168-Q226 (TPQ), A98-P168-Q226 (APQ) and A98-S168-Q226 (ASQ).Four single nucleotide polymorphisms (SNPs) were identified in 480 British red deer samples: a synonymous SNP at codon 136 , and three non-synonymous polymorphisms at codons 98 , 168  and 226  giving rise to amino acid changes threonine to alanine (T98A), proline to serine (P168S) and glutamine to glutamic acid (Q226E), respectively. Linkage was found between positions 408 and 676 (codons 136 and 226), such that the haplotypes were either 408t-676c or 408c-676g. The SNPs resulting in substitutions at positions 98 and 168 occurred exclusively on a Q226 background and the following four haplotypes were inferred: T247).Only the TPE and TPQ haplotypes were identified in Norwegian red deer. The synonymous codon 136 polymorphism was observed in the same haplotype linkage as described above. Czech red deer had TPE, TPQ and APQ haplotypes, as well as a novel non-synonymous SNP at codon 247 (a/c nucleotide position 739) leading to a conservative isoleucine to leucine substitution which occurred in linkage with APQ (APQ-Ln = 73), Czech sika (n = 20), English sika (n = 8/10) were all homozygous for the TPQ haplotype. Both British and Czech sika had a synonymous polymorphism at codon 133  at frequencies of 0.08% and 0.1% respectively. Of the nine genetically determined sika-red hybrids from Argyll (0.091 ≤ Q ≤ 0.772) three were homozygous TPQ/TPQ, four were heterozygous TPE/TPQ, and two were heterozygous for the APQ haplotype (APQ/TPQ and APQ/TPE). The two animals heterozygous for the APQ haplotype were characterised as red deer-like , as were two of four TPE/TPQ heterozygotes . Of the 10 English animals identified as sika by phenotype only, two were TPE/TPQ heterozygous and were therefore possibly sika-like hybrids.Scottish pure sika (PRNP ORF of British roe deer (n = 297) all encoded the haplotype described above as TPQ. Roe deer were monomorphic in PRNP sequence, with no variation in nucleotide sequence in any of the animals analysed. Likewise, fallow deer (n = 66) showed no variation in PRNP sequence and encoded the TPE haplotype with an additional amino acid substitution of asparagine for serine at codon 138 (TPE-N138).The PRNP ORF of all 41 muntjac deer analysed encoded serine at position 98, allowing their PRNP haplotype to be described as S98P168Q226 (SPQ). In addition, synonymous polymorphisms were identified at nucleotide positions 15 (c/t), 126 (g/a) and 606 (c/t) at varying frequencies. The PRNP coding region of 27 Chinese water deer revealed two amino acid sequence polymorphisms; a serine to asparagine substitution at codon 100  and a 24 bp deletion of the octapeptide repeat (ccccatggaggtggctggggtcag) which corresponds to the in-frame loss of the amino acid sequence PHGGGWGQ. In most species, a glycine-rich peptide sequence (octapeptide repeat) is present in five consecutive copies in the N terminal region of wild type PrPC, whilst Chinese water deer had a four octapeptide repeat haplotype. From the genotypes it was inferred that the deletion was linked to 100S (100S-Δ71–78). The haplotype frequencies were 0.21 for 100S, 0.25 for 100SΔ71–78, and 0.54 for 100 N. Seven animals were heterozygous for 100SΔ71–78, whilst three were homozygous S100Δ71–78/S100Δ71–78. The most common genotype in this sampling was N100/N100 (0.35).The PRNP sequence amongst the six deer species surveyed, with four haplotypes identified in the British population. Regional variation was evident within Great Britain in the distribution and frequency of the four PRNP haplotypes and resulting genotypes (Tables P < 0.05), as were the overall haplotype frequencies of England and Scotland (P < 0.05).Red deer showed the greatest variation in s Tables  and 3. F247 haplotypes were present at frequencies of 0.16 and 0.05, respectively. The APQ-L147 haplotype was only seen in the Czech red deer belonging to the Western lineage (n = 24) [P < 0.05), those in Spain and the Czech Republic were not.The haplotype frequencies in GB were also compared by Chi squared test with those in red deer from Norway and the Czech Republic, as well as previously published surveys of Scotland, Italy and Spain , 47 (Tab(n = 24) . The hapPRNP genetic variation in the wild (free-ranging) deer population of any European country and is the first to include free-ranging muntjac and Chinese water deer. The analysis included over 1003 animals from six different species of deer present in Britain, as well as red deer and sika deer from mainland Europe. Ten haplotypes were identified, five of which were present in red deer. The majority of polymorphisms identified in the ORF (exon 3) of the PRNP gene have been reported previously [This study represents the largest survey to date of eviously , 46–49, eviously , lions [eviously , and someviously . This isPRNP sequence, with four haplotypes identified in Great Britain, designated TPQ, TPE, APQ and ASQ. The TPQ, TPE and APQ haplotypes have been previously reported in surveys of Italian, Scottish  [Red deer showed the greatest variation in  and 10)  and Span and 10) . The ASQ and 10) . Non-syn and 10) , 52, as  and 10)  were notPRNP sequence variation stands at 1108 individuals. In every region or country surveyed, TPQ and TPE haplotypes were present at the highest frequencies , was identical to previously published sequences from Scandinavia [138 change is fixed in the fallow deer sequence and not polymorphic. The three haplotypes identified in 27 wild Chinese water deer is more than might be expected considering that the UK population was established relatively recently from small numbers of escapees from captive collections.In contrast to red deer, our roe deer samples showed no variation in their ividuals . Consideividuals . Howeverom Italy , Scandinom Italy  and Spaiom Italy . Similarndinavia  and Spaindinavia , as wellndinavia , 55. OurPRNP genotypes in European deer with those in North American cervid species with European data can be used to help predict their potential susceptibility to CWD, although confirmation of these predictions under natural or experimental challenge is essential. The TPQ haplotype, which we identified at high frequencies in British red (0.29), Roe (1.0), Sika (1.0) and Chinese Water deer (0.21), is identical to PRNP sequences found in North American cervids that are highly susceptible to CWD. Our analysis, and published data to date for European deer species, has not identified any PRNP polymorphisms that are associated with reduced CWD susceptibility in North American cervids, e.g. M132L, G96S [Comparison of the 2L, G96S . This suPRNP polymorphisms found only in British/European deer with susceptibility to CWD has yet to be determined. Amino acid substitutions at codon 98 are found in red (T98A) and muntjac (T98S) deer, and nearby codons 95 and 96 play a role in CWD susceptibility in white-tailed deer [PRNP sequences can be experimentally infected with North American CWD isolates [The association of non-synonymous led deer . Howeverisolates  and receisolates .Sc in an in vitro cell-free conversion assay [The substitution of serine for proline at codon 168 in red deer is of particular interest, as this position is located in the β2-α2 loop of the prion protein, an area critical for protein structure and stability . The muron assay . Howeveron assay , and a ron assay . The ASQPRNP haplotype TPQ-L247 identified in Czech red deer may be less likely to influence susceptibility as it represents a conservative amino acid substitution within the C-terminal signal peptide which is cleaved from the mature prion protein [The novel  protein , howeverC, a part of the protein involved in pathogenic processes during prion disease. Nearby polymorphisms include S225F, which is associated with reduced CWD susceptibility in mule deer [226, QQ226 and EQ 226 genotypes, all animals became infected [In North America codon 226 encodes either E (e.g. wapiti) or Q (e.g. mule deer and white-tailed deer), whereas in European red deer both variants are present and heterozygous animals are common. Codon 226 is in the third α-helix of PrPule deer , and Q22ule deer , 62. Stuule deer , 64. Folinfected . The sma100 haplotype identified in Chinese water deer has not been reported in any other cervid but N100 is common to other mammalian prion proteins including bank vole, a species highly susceptible to CWD challenges [The TPQ-Nallenges . The facallenges .PRNP sequence variation in the six major deer species found in the wild in Great Britain and adds to our knowledge of PRNP variation in European deer species in general. Based on a comparison of the sequences with those found in North American cervids affected by CWD, it appears likely that a large proportion of the British deer population would be susceptible to CWD. The effect of specific PRNP haplotypes only found in European species, such as ASQ in Scottish red deer, on CWD susceptibility are still to be determined.In summary, this study has provided an analysis of


Although dietary patterns have been linked to chronic diseases such as cardiovascular disease, sparse data are available for a relationship between dietary patterns and incident chronic kidney disease (CKD) in West Asian populations. The aim of this study was to evaluate the association of population-based dietary pattern with the risk of incident CKD after 6.1 years of follow-up.2. Odds ratio (OR) using multivariable logistic regression was calculated for the association of incident CKD with the extracted dietary patterns.At baseline, habitual dietary intakes of 1630 participants of the Tehran Lipid and Glucose Study (TLGS) who were free of CKD was assessed by a valid and reliable food-frequency questionnaire. The following three major dietary patterns were identified using a principal components analysis: Lacto-vegetarian dietary pattern, traditional Iranian dietary pattern, and high fat, high sugar dietary pattern. Estimated glomerular filtration rate (eGFR) was calculated, using the Modification of Diet in Renal Disease (MDRD) Study equation and CKD was defined as eGFR < 60 mL/min/1.73mAfter adjusting for age, sex, smoking, total energy intake, physical activity, body mass index, diabetes, and hypertension the OR for participants in the highest compared with those in the lowest tertile of the lacto-vegetarian dietary pattern was 0.57 . In contrast, the high fat, high sugar dietary pattern was positively associated with the incidence of CKD . Traditional Iranian dietary pattern was not associated with incident CKD.The high fat, high sugar dietary pattern was associated with significantly increased (46%) odds of incident CKD, whereas a lacto-vegetarian dietary pattern may be protective against the occurrence of CKD by 43%.The online version of this article (10.1186/s12986-018-0322-7) contains supplementary material, which is available to authorized users. Chronic kidney disease (CKD) has recently emerged as a global health burden; its worldwide prevalence has been estimated to range between 8 and 16% which could cause millions of mortalities annually . Among tTo the best of our knowledge, there is no population-based study documented on dietary patterns and CKD in the Middle East and North Africa (MENA) population. The association of extracted dietary pattern with kidney function has been examined in several studies among American , EuropeaEvaluating diet using a multi-dimensional and food-based approach may improve our understanding of which dietary pattern is most beneficial to prevent CKD; besides, this approach can facilitate future food-based dietary advice that is understood by the community. Therefore, we aimed to investigate the association of derived dietary patterns in our population with the incidence of CKD after 6.1-year follow-up.This study was conducted within the framework of the Tehran Lipid and Glucose Study (TLGS), an ongoing population-based cohort study, aimed to identify risk factors for non-communicable diseases (NCD) in a sample of residents from District No. 13 of Tehran [Among the 12,523 participants examined in the third survey of the TLGS, 3462 were randomly selected for dietary assessment. Characteristics of participants who completed the food frequency questionnaire (FFQ) were similar to those of the total population in the third survey of TLGS (2006–2008) , 15. Of n = 34). In addition, subjects who under- or over-reported energy intakes , (n = 113), those with missing data on covariates (n = 52) were excluded; some individuals fell into more than one exclusion category. To evaluate the incidence, we also excluded subjects who had CKD according to the Modification of Diet in Renal Disease (MDRD) equation and the national kidney foundation guidelines at baseline (n = 360). Finally, 1630 participants were followed until the survey fifth (2012–2015), with a median (25–75 interquartile range) 6.1 (5.6–6.5) years  by an expert interviewer. , 16. TraInformation on physical activity was collected at baseline using the Modifiable Activity Questionnaire (MAQ) to calculate metabolic equivalent task (MET) minutes per week. High reliability (98%) and moderate validity (47%) were found for the Persian translation of MAQ. We identified the active participants as those who had MET≥600 min/wk. , 18.2), body mass index (BMI) was calculated. Arterial blood pressure (BP) was measured manually, using a mercury sphygmomanometer with a suitable cuff size for each participant after a 15-min rest in the supine position. Systolic blood pressure (SBP) was determined by the onset of the tapping Korotkoff sound, while diastolic blood pressure (DBP) was determined as the disappearance of this sound. Blood pressure was measured twice and the average was considered as the participant’s BP.Weight was recorded to the nearest 100 g with subjects minimally clothed and without shoes, standing on digital scales . Height was measured and recorded to the nearest 0.5 cm, when the subjects were standing without shoes, with their shoulders in a normal position. Dividing weight (kg) by square of height  and 2-h plasma glucose  were assayed by an enzymatic colorimetric method using glucose oxidase, with both inter- and intra-assay coefficients of variation (CVs) being less than 2%. Serum triglycerides (TGs) were assayed using an enzymatic colorimetric method with glycerol phosphate oxidase. Inter- and intra-assay coefficients of variation (CV) for TG were 0.6 and 1.6% respectively. Serum creatinine was measured at the baseline and after 6 years of follow-up, according to the standard colorimetric Jaffe_Kinetic reaction method. Both intra- and inter-assay CVs were below 3.1%; all analyses were performed using commercial kits .2 of body surface area [Hypertension was defined as SBP/DBP ≥ 140/90 mm-Hg or current therapy for a definite diagnosis of hypertension . Diabeteace area . The abb−1.154 × (Age)−0.203 ×  × (1.210 if African − American)eGFR = 186 × (Serum creatinine)2 as not having CKD and eGFR< 60 ml/min/1.73 m2 as having CKD corresponding to stages 3–5 of CKD based on the Kidney Disease Outcomes and Quality Initiative guidelines.Patients were classified as follows based on their eGFR levels by the national kidney foundation guidelines : eGFR≥60We performed factor analysis  based on food items or groups to identify dietary patterns from the food frequency responses. This multivariate statistical technique  was used to reduce the complexity of diet into fewer independent factors. To simplify the interpretation, the factors were rotated by an orthogonal transformation (varimax rotation) to maintain uncorrelated factor variables called principal factor or pattern. The number of extracted factors to retain was determined by using the scree plot levels off . The factor scores of each dietary pattern for each individual was calculated by summing intakes of food items or groups weighted by their factor loading. Foods with loadings > 0.2 on a factor were used to describe dietary patterns. Dietary patterns were named according to the dominant foods in the respective patterns. Three extracted dietary pattern scores were categorized into tertiles.Continuous variables were reported as the age- or energy-adjusted mean ± standard error and categorical variables as percentages. We calculated age-adjusted mean values for participants’ characteristics and energy-adjusted mean values for participants’ dietary intake by using analysis of covariance (ANCOVA). Tests of a trend for continuous and categorical variables across tertiles of each dietary pattern  were conducted using the linear regression test, respectively.P values < 0.05 were considered statistically significant.Before running multivariable linear models, the interaction terms between covariates and dietary patterns on the incidence of CKD were examined. No interaction was observed between considered covariates and dietary patterns. To examine the association of incident CKD in each tertile of an extracted dietary pattern, multivariable logistic regression models were used and odds ratio (OR) and 95% confidence intervals (CIs) were calculated. In this analysis, the first tertile of each extracted dietary pattern was considered as the reference category. To calculate the trend of ORs across increasing tertiles of extracted dietary pattern, we considered the tertile categories as continuous variables. Age (continuous), sex , smoking (current/no), total energy intake (continuous), physical activity (high/moderate/low), BMI (continuous), diabetes (yes/no), and hypertension (yes/no) were adjusted. Statistical Package for Social Sciences (SPSS) was used for data analyses and 2.We performed several sensitivity analyses to test the robustness of the results: (1) we further adjusted for triglycerides; (2) we excluded subjects who have diabetes mellitus or hypertension at the baseline; (3) and we repeated the analysis after excluding certain population who was at stake for unstable creatinine concentrations including pregnant and lactating, extremes physical activity, BMI less than 18.5 and higher than 40 kg/m2. Mean ± SD eGFR for all participants at baseline and the end of follow up was, 73.7 ± 8.6 and 71.6 ± 11.2 ml/min/1.73 m 2.The mean ± SD age of participants (50.5% women) was 42.8 ± 11.2 years. After 6.1 years of follow-up, we documented 220 (13.5%) cases of incident CKD with a range of eGFR as 29–59 ml/min/1.73mThree different dietary patterns were extracted in this study based on factor analysis Table . The firParticipants in the highest tertile of the lacto vegetarian dietary pattern were younger and less likely to be male, smokers, and had lower prevalence of diabetes and hypertension, compared to the lowest tertile. The percentage of women decreased by increasing adherence to the traditional Iranian dietary pattern. Participants with higher adherence to high fat, high sugar dietary pattern tended to be older, had higher BMI, were less likely to smoke, had higher prevalence of diabetes and hypertension Table .Table 2AIn the energy-adjusted models, participants in the highest tertile of the lacto-vegetarian dietary pattern have less intake of total fat and sodium than those in lowest ones; they had also higher intakes of protein, carbohydrate, calcium, magnesium, potassium, and vitamin C. Participants who had higher adherence to the traditional Iranian dietary showed higher intakes of protein and carbohydrates and lower consumption of calcium, potassium, and vitamin C. The high fat, high sugar dietary pattern was characterized by higher intakes of total fat and saturated fatty acid and lower consumption of protein, carbohydrate, calcium, magnesium, potassium, and vitamin C Table .Table 3EIn Table Sensitivity analysis: Results were not substantially changed when we further adjusted for triglycerides. In the sensitivity analysis, that excluded subjects with hypertension and diabetes, the results showed no substantial changes . Furthermore, when we excluded participants at prone to unstable creatinine concentrations, adjusted ORs for participants in the highest compared with the lowest tertiles of lacto-vegetarian dietary pattern were 0.69 (95% CI: 0.48 to 0.97), and for high fat, high sugar dietary pattern were 1.43(1.03–1.99); again there were no substantial changes in the results. On analyzing the association of incident CKD with traditional; dietary pattern score, the odds of incident CKD continued to be statistically non-significant in the multivariable model  compared with the lowest quartile has a 77% increased rapid eGFR decline after 11 years of follow-up . ConsistFrom population-based studies that used factor analysis to identify dietary pattern, mostly two major dietary patterns were distinguished. The Prudent pattern is characterized by higher intakes of fruits, vegetables, legumes, whole grains, and sometimes poultry, and fish, whereas the Western pattern is characterized by higher intakes of saturated fats and processed and artificially sweetened foods, and salt. The former is consistently shown to have significant relation with lower risk of coronary heart disease, type 2 diabetes, and colorectal cancer, whereas the latter significantly elevated the risk of these diseases –38. In tOur findings revealed that there was no significant association between the traditional Iranian dietary pattern and incidence of CKD. Shi et al. observed that a traditional Southern dietary pattern  was associated with 4.5-fold increased odds of prevalence of CKD. Netletton et al. illustrated that a dietary pattern which is similar to ours, high intakes of legumes, tomatoes, refined grains, high-fat dairy, and red meat was positively associated with albumin to creatinine ratio (ACR) . The traAlthough the association of major patterns identified through factor analyses with kidney function has been examined in several studies among American , EuropeaLimitations of this investigation need to be mentioned; first, as in most epidemiologic studies, our definition of CKD is based on a limited number of isolated creatinine measurements that were not repeated within three months to confirm a chronic reduction in GFR. Besides, although using creatinine estimated eGFR has a limitation because serum creatinine varied day-to-day 15.5–19.6%), most epidemiologic studies used serum creatinine for the definition of the CKD as it is cheap, technically simple and therefore easily applied for a large population measurements .5–19.6%,. Second,In conclusion, the high fat, high sugar dietary pattern was associated with a 49% increased and Lacto vegetarian dietary pattern diet was associated with a 37% decreased odds of for incidence of CKD after 6.1 years of follow-up, findings consistent with the hypothesis that particular aspects of diet may be important intervention targets to prevent incident CKD and subsequent kidney dysfunction. This present study also provides further information regarding reductions in kidney function and dietary patterns that may be more easily interpreted and followed by the general public.Additional file 1:Table S1. Characteristics of participants who completed food frequency questionnaire (FFQ) in comparison to total population in the third phase of Tehran Lipid and Glucose Study (TLGS). (DOCX 13 kb)


The aim of the study was to describe school attendance and participation in physical education in school among children with juvenile idiopathic arthritis (JIA).Consecutive cases of JIA from defined geographical areas of Finland, Sweden and Norway with disease onset in 1997 to 2000 were followed for 8 years in a multi-center cohort study, aimed to be as close to population-based as possible. Clinical characteristics and information on school attendance and participation in physical education (PE) were registered.Participation in school and in PE was lowest initially and increased during the disease course. Eight years after disease onset 228/274 (83.2%) of the children reported no school absence due to JIA, while 16.8% reported absence during the last 2 months due to JIA. Full participation in PE was reported by 194/242 (80.2%), partly by 16.9%, and none by 2.9%. Lowest participation in PE was found among children with ERA and the undifferentiated categories. Absence in school and PE was associated with higher disease activity measures at the 8-year visit. School absence > 1 day at baseline predicted use of disease-modifying anti-rheumatic drugs, including biologics (DMARDs) (OR 1.2 (1.1–1.5)), and non-remission off medication (OR 1.4 (1.1–1.7) 8 years after disease onset.School absence at baseline predicted adverse long-term outcome. In children and adolescents with JIA participation in school activities is mostly high after 8 years of disease. For the minority with low participation, special attention is warranted to promote their full potential of social interaction and improve long-term outcome. Juvenile idiopathic arthritis (JIA) is an umbrella term for chronic childhood arthritis and a significant contributor to chronic disease in children and adolescents. Even in the era of modern treatment with improved outcome on biologic therapies, many children with JIA still experience flares and difficulties to attend daily life activities –3.Children’s right to education is a fundamental human right according to the United Nations . In addiWe have previously performed a longitudinal cohort study of JIA in a population-based setting in the Nordic countries . The datChildren with a follow-up visit 8 years after onset of arthritis were selected to our study on participation in the prospective multicenter Nordic JIA cohort , 13. TheClinical information including family history, assessment of disease activity, and self-reported questionnaires were registered per protocol at baseline, at one-year and then at 1–3-year interval and at a pediatric rheumatology study visit collecting more extensive data on remission and damage, approximately 8 years after disease onset . The part-test was used to compare means in continuous outcomes between groups. Univariate logistic regression was performed to assess variables cross-sectionally associated with the outcomes; school absence > 1 day and not participating fully in PE at baseline and at the eight-year visit. Univariate logistic regression was performed to assess school absence > 1 day at baseline as a predictor of adverse outcome in terms of using systemic medication during the disease course, not being in remission and school absence at the eight-year visit only for children that had relevant information available at both timepoints. For variables with p < 0.05 in the univariate logistic regression analyses, a multivariable logistic regression was performed adjusting for gender, age and other relevant variables. A p value < 0.05 was considered significant.Statistical analyses were performed using the STATA version 15 software . Descriptive statistics were used to summarize clinical characteristics of the population and disease activity measures. The chi-square and Fischer’s exact tests were used as appropriate for comparison of dichotomous variables, and the Mann-Whitney U-test for comparison of medians for skewed data. The Student’s n = 138) lacked information on participation in the first years of the study, and the Danish children (n = 93) lacked all information on participation. The corresponding number of children were 98 at the one-year visit median 13 (IQR 12–15) months, and 125 at the three-year visit median 37 (IQR 36–45) months after disease onset. Among the 347 children with eight-year follow-up, information on participation in school and/or PE was available in 285 (82.1%) children, including Finnish participants at the eight-year visit. Demographic and clinical characteristics of the children with and without information on participation is shown in Table Altogether 347 Norwegian, Swedish and Finnish children participated in the Nordic cohort with a long-term follow-up. Among these, 99 Swedish and Norwegian children aged 6 years or more with information on participation in school and/or PE were included in analyses at the baseline visit median 6 (IQR 6–8) months after disease onset, since the Finnish children n = 38 lackedp = 0.078, Fischer’s exact test, results not shown). Children with more than 1 day absence had significantly lower CHQ physical summary score (41.8 (IQR 32.1–50.4)) than children with full school attendance (53.4 (IQR 47.9–57.3)), while there were no differences in CHQ psychosocial summary score  children reported no school absence because of JIA within the last 2 months before the study visit, 39 (41.1%) reported more than 1 day, 24 (25.3%) reported more than 3 days, and 13 (13.7%) reported more than 5 days, as shown in Fig. p = 0.01). Higher BMI (p = 0.01) were associated with less participation in PE. Children that did not participate fully in physical education had significantly lower CHQ physical and also psychosocial summary scores, as shown in Table At baseline 6 months after disease onset 44/89 (49.4%) reported full participation in PE, partly participation was reported by 33 (37.1%), and 12 (13.5%) did not participate, as shown in Fig. In univariate analyses, lower school attendance at the eight-year visit was significantly associated with higher number of active and cumulative joints, higher level of pain and global disease impact on overall well-being assessed by the child/parent, higher global disease severity assessed by the physician, higher CHAQ score, lower physical summary score of the CHQ, higher JADAS10 score, ongoing DMARDs, and not being in remission off medication Table . These aAll characteristics associated with school absence mentioned above, were also associated with less participation in PE Table , and thep = 0.044) in the 92 children with both baseline and eight-year information available. School absence at baseline did also predict use of disease-modifying anti-rheumatic drugs, including biologics (DMARDs) (OR 1.2 (1.1–1.5), p = 0.011, n = 97), during the eight-year follow-up period. School absence more than 1 day at baseline was also a significant predictor of not being in remission off medication (OR 1.4 (1.1–1.7), p = 0.007, n = 94) in a univariate model. School absence at baseline remained significant for predicting the use of DMARDs (OR 1.2 (1.0–1.5)) and for not achieving remission (OR 1.3 (1.0–1.6)) when adjusting for gender, age, and the number of active joints during the first 6 months in a multivariable regression model (results not shown).School absence more than 1 day the preceding 2 months before the baseline visit predicted higher school absence at the eight-year visit (OR 1.2 (1.0–1.4), We assessed school attendance and participation in physical education in a prospective multi-center Nordic JIA cohort. School attendance increased during the disease course, and was generally high in children 8 years after disease onset in the Nordic JIA cohort. Participation in PE in school was also high, but we found less participation in PE in the ERA and undifferentiated categories. Higher pain scores and disease activity measures were significantly associated with higher school absence and less participation in PE at the eight-year visit. Moreover, school absence at baseline predicted use of DMARDs during the disease course, and not being in remission 8 years after disease onset.We did not find any other reports showing that baseline school absence predicts adverse outcomes, such as the need for DMARDs including biologic agents during the disease course and not being in long-term remission off medication. This finding was robust for adjustments for gender, age, and number of active joints in early disease, pointing to early school absence as a warning sign of a more severe disease over time.Our results indicate increased school absence in children with JIA compared to healthy school children, since the participants were asked to report JIA-related school absence. We did not ask for school absence not related to JIA. In Denmark, national statistics show a mean of 5.0% school absence in all school children . SixteenA lower attendance rate was found in children with JIA in a British cross-sectional study. Sturge et al. reported a mean school attendance rate for children with JIA of 92%, equivalent to 15 yearly absent days . AttendaA majority of the children in our cohort participated fully in physical education, and only 2.9% reported no participation. In two recent reports from the Nordic countries both Risum et al. and Nørgaard et al. found similarly high participation rates in physical education for children and adolescents with JIA in, respectively, a Norwegian and a Danish controlled cross-sectional study , 11. In The prospective, observational cohort design and population-based context are the strengths of this multicenter cohort study. The proportion of children lost to follow-up is small compared to other longitudinal studies –49. A noParticipation in school and PE is high in this eight-year follow-up of the Nordic JIA cohort, but lower participation in PE was found among children with ERA and the undifferentiated categories. Increased school absence at baseline predicted long-term adverse outcome in terms of use of DMARDs including biologic agents and not achieving remission off medications.Increased school absence and less participation in physical education 8 years after disease onset was also significantly associated with higher disease activity, functional disability and lower quality of life-measures. Attention is warranted to ongoing promotion of physical activity in children with JIA. School attendance needs continuous focus in JIA follow-up, especially in the vulnerable transition period for adolescents.


Primary lymphomas of the gastrointestinal tract are rare, accounting for only 1 to 4% of malignancies arising in the stomach, small intestine, or colon. The stomach is the most common extranodal site of lymphoma and gastric mucosa-associated lymphoid tissue (MALT) lymphoma accounts for 40% of primary gastric lymphoma. Gastric MALT lymphoma reaches its peak incidence between 50 to 60 years of age, therefore, it is rarely encountered in pediatric population. The presenting symptoms of gastric MALT lymphoma are usually nonspecific and primary perforation of gastric MALT lymphoma is uncommon.Helicobacter pylori eradication and radiotherapy were sequentially performed. Complete remission was achieved at two months after radiotherapy. To our best knowledge, she is the youngest patient with gastric MALT lymphoma reported in the literature.A 12 year-old female presented with iron deficient anemia developed gastric perforation. Emergency laparoscopic repair of the perforation was performed and tissue pathology showed gastric MALT lymphoma infiltration. Iron deficient anemia is a common presenting manifestation of malignancies in adulthood. In pediatric population, iron deficient anemia is usually caused by nutritional deficient or blood loss. In this case report, we present a teenaged female without previous gastric ulcer history who presented with a rare gastric tumor and an uncommon primary perforation. Even if there is an uncertainty about the exact diagnosis prior to the surgery, the strategy of stomach-preserving therapy by laparoscopy for primary perforation was successful and provided a good quality of life.The online version of this article (10.1186/s12887-019-1431-9) contains supplementary material, which is available to authorized users. Extranodal marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma), which was previously considered a low-grade lymphoma, is the predominant histological subtype of primary gastric lymphoma, representing 1–6% of primary gastric neoplasm, 5–7% of all non-Hodgkin lymphomas, 40–50% of all gastric lymphomas, and 50–60% of all extranodal lymphomas , 3. Howe13C urea breath test was a positive finding. Therefore, upper GI endoscopy was arranged.A 12-year-old girl was admitted with noticeable palor and dyspnea on exertion for the past two weeks. No specific medicine or family histories were reported. She visited local clinics and her hemogram showed a low hemoglobin value. Physical examination showed a palor and mild tachycardia (110 bpm). Laboratory data taken in our hospital showed a hemoglobin level of 5.9 g/dL; mean corpuscular volume of 75.4 fl; C-reactive protein level of 1.02 mg/L; serum ferritin of 2.9 ng/mL; serum iron level of 9 μg/dL; and total iron binding capacity at 458.2 μg/dL. She denied bloody stool or abdominal discomfort history. Iron tablet (100 mg bid) was prescribed. Stool examination showed a mild hemoccult-positive (1+). However, 8 h prior to scheduled exams, patient complained of sudden onset of severe tenderness with involuntary guarding and rebounding pain involving the entire abdomen. Interpretation of standing view and left lateral decubitus abdominal film detected free intraperitoneal air, and peritonitis was confirmed. Because of the abnormal image findings, surgical intervention was advised and in light of hemodynamic stability, a laparoscopic approach was performed. After initial exploration of the peritoneal cavity, a burst perforation, approximately 1 cm in diameter, was noted over lower gastric body , β2-microglobulin (148.0 μg/dL), hepatitis B virus (nonreactive), hepatitis C virus (negative), and human immunodeficiency virus (negative), was performed. Positron emission tomography-computed tomography (PET-CT) showed accumulation of fluorodeoxyglucose in the same area. CT, bone scan, and bone marrow biopsy were also performed, and no metastatic lesion was detected. The Lugano staging system was considered to be Stage IE.Helicobacter pylori infection eradication. Endoscopy was scheduled 4 weeks after operation and showed a deep and large ulcer over anterior wall of the body with convergence of thickened mucosal folds  plus 4 weeks esomeprazole (40 mg daily) were prescribed for A follow-up endoscopy was performed at 4 months after operation, and showed a broad-based healed scar with rugae interruption Fig. b. The hiSince MALT lymphoma is characterized as “low-grade” (or indolent) and has a natural history of slow progression, most cases occur in individuals 50 years or older, with disease being most common in the sixth decade –4. To ouH pylori has been identified as the cause of chronic gastritis with consequent acquisition of lymphatic tissue, and up to 98% of gastric MALT lymphoma are second to H pylori infection [H pylori eradication is the first-time treatment in any case irrespective of H pylori status and lymphoma stage [H pylori eradication should receive radiation or chemotherapy [ma stage , 8, and ma stage . Those potherapy . Surgeryotherapy , 8.The infiltration of MALT lymphoma is mostly confined to the mucosa, and only 10% of infiltration invade deeply beyond muscularis propria . TherefoH pylori negative or refractory to H pylori eradication [H pylori gastritis, 5% of metachronous gastric carcinoma occurred after remission of gastric MALT lymphoma and the risk of development of gastric carcinoma in patients with gastric MALT lymphoma were shown to be 6 times higher than in the general population [Radiotherapy usually offers a curative option to patients with dication . In the dication , 13. Howpulation , 14, 15.In pediatric population, iron deficient anemia is usually caused by nutritional deficient or blood loss. This case presents a relatively uncommon clinical problem. Even if there is an uncertainty about the exact diagnosis prior to the surgery, a stomach-preserving therapy by minimally invasive surgery is acceptable and should provide a good quality of life.Additional file 1:Timeline. (PDF 650 kb)