The French Bulldog is a highly popular dog breed but is linked with many serious health issues. A holistic view of breed health in French Bulldogs would assist efforts to appreciate the overall health strengths and weaknesses in the French Bulldog and to take appropriate steps to mitigate these.Based on random sampling of French Bulldogs and non-French Bulldogs under primary veterinary care during 2016 within the VetCompass Programme, a cohort study design was used to estimate the one-year (2016) period prevalence of the most commonly diagnosed disorders in each group. Risk factor analysis used multivariable logistic regression modelling methods.p < 0.001) and lighter  (p < 0.001) than non-French Bulldogs. Of 43 common specific-level disorders across both groups, French Bulldogs had significantly increased adjusted odds of 20/43 (46.5 %) disorders and significantly reduced adjusted odds of 11/43 (25.6 %) disorders compared to non-French Bulldogs. Highly predisposed disorders in French Bulldogs included stenotic nares , Brachycephalic Obstructive Airway Syndrome , aural discharge , skin fold dermatitis  and dystocia . At a grouped-level of diagnostic precision, French Bulldogs had increased adjusted odds of 12/32 (37.5 %) disorders and reduced adjusted odds of 6/32 (18.8 %) disorders compared to non-French Bulldogs.The analysis included 2,781 French Bulldogs and 21,850 non-French Bulldogs. French Bulldogs were younger   and lighter (12.45 kg versus 13.80 kg) than non-French Bulldogs. French Bulldogs had increased risk of 20/43 (46.5 %) specific disorders and decreased risk of 11/43 (25.6 %) specific disorders compared to non-French Bulldogs. The disorders with greatest relative risk in French Bulldogs compared to non-French Bulldogs were narrowed nostrils (x 42.14), Brachycephalic Obstructive Airway Syndrome (x 30.89), ear discharge (x 14.40), skin fold dermatitis (x 11.18) and difficulty giving birth [dystocia] (x 9.13). When the disorders were grouped into broad disease categories, French Bulldogs had increased risk of 12/32 (37.5 %) disorder groups and reduced risk of 6/32 (18.8 %) disorder groups compared to non-French Bulldogs.This study suggests that the health of French Bulldogs is very different, and largely much poorer, that the health of the wider non-French Bulldog population. Many of these differences are closely associated with the extreme body shape that defines the French Bulldog breed. Shifting the body shape of French Bulldogs to become more moderate, and hence less extreme, is proposed as a logical opportunity to reduce the current serious and common health issues in the French Bulldog breed. ConcernDisorder predisposition describes increased susceptibility and can result from genetic (hereditary) or other risk factors  [disorder protection describes an affinity to evade a specific condition [ronment) . Conversondition , 10. Preondition . Given tondition , it is uondition , upper rondition , cornealondition , prolapsondition  and stenondition . French ondition , 19 dystondition , elbow dondition , patellaondition , skin foondition , screw tondition  and demoondition . Howeverondition . A fulleondition .Support for the generation of new information on disorder predispositions and protections is currently of special interest to The Kennel Club in the UK in order to support its programme of Breed Health and Conservation Plans (BHCP) . The BreSecondary application of first opinion veterinary clinical data as a research resource that can give useful insights into the health of companion animals is now well established . A growiMethods.The study population included all dogs under primary veterinary care at clinics participating in the VetCompass Programme during 2016. Dogs under veterinary care were defined as those with either (a) at least one electronic patient record (EPR)  recorded during 2016 or (b) at least one EPR recorded during both 2015 and 2017. VetCompass collates de-identified EPR data from primary-care veterinary practices in the UK for epidemiological research . Data fiA cohort study design was used to estimate and compare the one-year (2016) period prevalence of the most commonly diagnosed disorders in a randomly selected sample of French Bulldogs and a randomly selected sample of all remaining dogs. Power calculations estimated that 2,184 French Bulldogs and 21,832 non-French Bulldogs were required to detect an odds ratio of ≥ 1.5 for a disorder occurring in 2 % of the non-French Bulldogs, with 80 % power and 95 % confidence and assuming a 10:1 ratio of non-French Bulldogs to French Bulldogs in the study population . Ethics approval was obtained from the RVC Ethics and Welfare Committee (reference number SR2018-1652).Breed information entered by the participating practices was cleaned and mapped to a VetCompass breed list derived and extended from the VeNom Coding breed list . Dogs reThe list of unique animal identification numbers for all dogs under veterinary care in 2016 was randomly ordered and the clinical records of randomly selected subsets of French Bulldogs and non-French Bulldogs were reviewed in detail to extract the most definitive diagnoses recorded for all disorders with evidence of existence during 2016 . Electiva priori factor of interest and the models additionally included age (years), sex-neuter status, at/above or below mean bodyweight, insurance status and veterinary group. Model fit was assessed with the Hosmer-Lemeshow Test [Following data checking for internal validity and cleaning in Excel , analyses were conducted using SPSS version 24.0 (IBM Corp). The sex-neuter status, age, adult bodyweight and insurance status for French Bulldogs and non-French Bulldogs under veterinary care during 2016 were described. One-year period prevalence values were reported separately for French Bulldogs and non-French Bulldogs to describe the probability of diagnosis at least once during 2016. The final combined list of common disorders aimed to weight each breed group equally by including all disorders that featured among the 30 most common disorders in French Bulldogs and the 30 most common disorders in non-French Bulldogs. This approach generated a combined list of 43 specific-level disorders and 32 grouped-level disorders overall. Continuous variables were non-normally distributed and were summarised using median, interquartile range (IQR) and range. Mann-Whitney U test, chi-square test and Fisher’s exact test were used as appropriate for univariable statistical comparisons . Multivahow Test . StatistThe study population of 905,544 dogs under veterinary care during 2016 in the UK included 16,397 (1.81 %) French Bulldogs and 889,147 (98.19 %) non-French Bulldogs. Randomly selected samples of 2,781/16,397 (16.96 %) French Bulldogs and 21,850/889,147 (2.46 %) non-French Bulldogs were included in the analysis. Data completeness were: breed 99.7 %, age 98.7 %, sex-neuter status 99.7 %, insurance status 100.0 % and bodyweight 64.5 %.p < 0.001). The median bodyweight of French Bulldogs  was lighter than for non-French Bulldogs  (p < 0.001).Descriptive results were reported on 2,781 French Bulldogs and 21,850 non-French Bulldogs  were diagnosed with ≥ 1 disorder during 2016 compared with 14,442/21,850 (66.1 %) of the non-French Bulldogs. After using multivariable methods to account for effects of age, sex-neuter status, at/above or below mean bodyweight, insurance status and veterinary group, French Bulldogs had a lower adjusted odds of diagnosis with ≥ 1 disorder than non-French Bulldogs .p < 0.001), Brachycephalic Obstructive Airway Syndrome , aural discharge , skin fold dermatitis  and dystocia . Conversely, French Bulldogs had significantly reduced adjusted odds of 11/43 (25.6 %) specific-level disorders compared to non-French Bulldogs. These protected disorders included: undesirable behaviour , post-operative wound , retained deciduous tooth , lameness  and obesity   specific-level disorders compared to non-French Bulldogs. These predisposed disorders included: stenotic nares , lower respiratory tract disorder  and congenital disorder . Conversely, French Bulldogs had significantly reduced adjusted odds of 6/32 (18.8 %) grouped-level disorders compared to non-French Bulldogs. These included: complication associated with clinical care , lethargy , dental disorder  and hernia   grouped-level disorders compared to non-French Bulldogs. These included: upper respiratory tract disorder , spinal cord disorder  is in the UK than the remaining dogs (4.48 years) in the wider population and highlights that results from direct (univariable) comparison of disorder risks between French Bulldogs and non-French Bulldogs are likely to be heavily confounded by age , 41. Connot predisposed to disease X) [There is substantial published literature supporting several serious health issues the French Bulldog , 44–46. sease X) . Hence, The welfare impacts associated with the many intrinsic health problems of French Bulldogs have been seriously compounded by a dramatic rise in the popularity of the breed, especially over the past decade. During 2020, the French Bulldog recorded their highest puppy registration figures with The Kennel Club since records began, with UK registrations rising by 17 per cent compared to 2019 . The posHealth is challenging to define as a concept, with disorders  being easier to objectively characterise and report . Even inThe propensity (degree) of difference between the overall health of a breed compared with the overall health of all remaining dogs could be used as one indicator of the degree of divergence of individual breeds from the mainstream of current dogs. For breeds where many of these health deviations are related to conformational features, this would provide some evidence that these health deviations are unfortunately associated with extremes of conformation. A previous exploration of predispositions and protections in dogs reported that Labrador Retrievers differed to other dogs in 19/35 (54.3 %) of common disorders, showing predispositions in 12/35 (34.3 %) and protections in 7/35 20.0 %) . A study.0 % . A The current analysis explored differences in probability of diagnosis with at least one disorder during 2016 between French Bulldogs and non-French Bulldogs under primary veterinary care. Multivariable analysis methods were used to account for confounding from other characteristics that might differ between these breed groups such as age, sex-neuter status, at/above or below mean bodyweight, insurance status and veterinary group. Probability of diagnosis with at least one disorder is a relatively new metric to be explored for companion animals and there are several rationales that could potentially explain any differences that are found. In the current study, French Bulldogs showed 0.89 times the adjusted odds of diagnosis with at least one disorder compared with non-French Bulldogs. It is possible that higher odds of diagnosis with at least one disorder in the non-French Bulldogs could reflect poorer health or more complex healthcare needs in these dogs. Alternatively, higher odds of diagnosis may reflect greater recognition of disease by the owners of the non-French Bulldogs such that a higher proportion of veterinary healthcare for these dogs was related to illness rather than to routine prophylactic care.The current paper highlighted that French Bulldogs were also very different to other breeds in terms of disorders that were protected in the breed i.e., less frequent. There were 11/43 (25.6 %) specific-level disorders where French Bulldogs showed reduced odds, with 4 disorders showing odds ratios below 0.25 that could be categorised as ultra-protections. Much of the current literature on the associations between brachycephalic breeds and health has focused on aspects of reduced health in brachycephalic breeds such as French Bulldogs . HoweverThere is a growing literature that highlights the depth of the human-animal bond that exists for many owners of French Bulldogs and suggests that the relationships humans share with French Bulldogs are stronger than seen with other breeds of dog . ExploraThere is a large body of evidence to show that the overall syndrome of BOAS as well as its component disorders, including stenotic nares , 69, 71,Corneal ulceration was identified as an ultra-predisposition in the current study, with an adjusted odds ratio of 4.38 in French Bulldogs compared to non-French Bulldogs. Corneal ulceration describes epithelial damage that exposes the corneal stroma  and can ‘maximising good health, welfare and temperament overrides all other considerations for dogs’ [Skin fold dermatitis was the fourth highest predisposition of French Bulldogs in the current study, with an adjusted odds ratio of 11.18 compared with non-French Bulldogs. Skin fold dermatitis describes an inflammatory process following abrasion through friction, excessive moisture and reduced ventilation of opposing skin surfaces , 88. Skior dogs’ .The current study had some limitations related to the application of primary-care clinical records as a data resource for epidemiological research that have been reported previously , 34. In This study reports several recognised and novel predispositions and protections in French Bulldogs compared to other dogs in the UK. Based on these differences between the breed groups, the health of French Bulldogs is shown to have diverged substantially from the health of the wider non-French Bulldog dog population and many of these differences appear to be closely associated with common conformational extremes that define the French Bulldog breed. The study provides evidence suggesting that the overall health of French Bulldogs is poorer that the health of non-French Bulldogs but future studies that additionally account for severity and duration for these disorders would add greater nuance to this interpretation. Shifting the typical conformation of French Bulldogs towards a more moderate phenotype is proposed as a logical opportunity to reduce the health issues endemic in the French Bulldog breed.


Human-milk oligosaccharides (HMOs) are an abundant component of human milk that have health-related effects on breastfeeding infants. Since variation in HMO composition can be explained by maternal and environmental factors, understanding the diversity in HMOs across settings and identifying context-specific factors associated with HMO abundances is important.The aim was to describe the HMO profile of Bangladeshi women and to estimate the effect of maternal vitamin D supplementation on HMO composition.In a cross-sectional analysis of data and samples from the Maternal Vitamin D for Infant Growth trial in Dhaka, Bangladesh , 192 participants were randomly selected including 96 from each of the placebo and highest-dose vitamin D supplementation groups. In mid-feed breast milk samples collected at a mean (±SD) postpartum age of 93 ± 7 d, absolute and relative abundances of 19 HMOs were analyzed by HPLC. “Secretors” were defined as participants with 2′fucosyllactose concentrations >350 nmol/mL. Associations between HMO concentrations and selected maternal or environmental factors were estimated by multivariable linear regression, adjusting for vitamin D group allocation and secretor status. HMO profiles of Bangladeshi women were compared with data from other international cohorts.Overall, 34% (65/192) of participants were nonsecretors. Secretor status was associated with the concentrations of total HMOs and 79% (15/19) of individual HMOs. Vitamin D supplementation did not affect the total or individual concentration of any measured HMO. 3-Fucosyllactose concentration was significantly higher in breast milk samples collected in December to February compared with samples collected in March to May. HMO composition was similar to other previously reported cohorts.The HMO profile of Bangladeshi women is predominantly determined by secretor status. Context-specific HMO data may improve understanding of the effects of HMOs on the infant microbiome and health and guide the development of HMO-containing interventions. Human-milk oligosaccharide (HMO) profiles of Bangladeshi women are similar to those described in other countries. Vitamin D supplementation did not affect the Bangladeshi HMO profile. Human-milk oligosaccharides (HMOs) are an abundant and biologically important nonnutritional component of human milk. Numerous functionalities have been attributed to HMOs, including their ability to influence the composition of early-life intestinal microbiota by promoting the growth of beneficial bacteria , inhibitWhile more than 150 unique HMO structures have been reported , greaterNotably, South Asian women have not been included in international comparisons of HMO composition published to date. We aimed to describe the HMO profile of human milk collected from 192 women in Dhaka, Bangladesh, overall and by secretor status. By leveraging the randomized design of the Maternal Vitamin D for Infant Growth (MDIG) placebo-controlled trial, we also aimed to estimate the effect of maternal vitamin D supplementation on HMO composition and to provide insight into a potential mechanism by which seasonality may influence HMO profile.Data and specimens were drawn from the MDIG trial , a randoParticipants were enrolled at the Maternal Child Health Training Institute (MCHTI), a public hospital in Dhaka city that provides care to pregnant women and children in its catchment population . MDIG paIndividuals were eligible to be included if they provided written informed consent to participate in the MDIG trial and consent for future use of biological specimens, were randomly assigned to receive either placebo or the highest dose of vitamin D  from enrollment until 6 mo postpartum, contributed a breast milk sample at approximately 3 mo postpartum that had not already been entirely utilized for other analyses, and provided a maternal height and weight measurement at approximately 12 mo postpartum. Among 1300 MDIG participants, 135 (52%) in the placebo and 158 (61%) in the high-dose prenatal/postpartum vitamin D groups were eligible for inclusion in this cross-sectional analysis , medians (IQRs), and ranges. Correlation matrix heat maps of Pearson correlation coefficients (r) were used to visualize and estimate correlations between individual HMO concentrations, overall and by secretor status. Pearson r ≥ 0.6 or r ≤ 0.6 was considered to represent at least moderate correlations between pairs of HMOs. Total and individual HMO concentrations were compared with values published for women from Canada, Ethiopia, The Gambia, Ghana, Kenya, Peru, Spain, Sweden, and the United States  of participants were categorized as nonsecretors , with a geometric mean total concentration of 14,351.2  nmol/mL. Among nonsecretors, 2′FL accounted for 0.8% of the total HMOs in breast milk (compared to 46% in secretors) , and the geometric mean total concentration of 2′FL was 41.2 (95% CI: 31.6–53.7) nmol/mL [compared to 7768.9 (95% CI: 7241.2–8335.1) nmol/mL in secretors] (P < 0.001).Total HMO concentrations varied greatly among women  (cretors) , the absr = +0.60 and r = +0.75, respectively). The concentration of 2′FL was negatively correlated with LNFP2, sialyl-lacto-N-tetraose b (LSTb), and FDSLNH (Pearson r = −0.80 to r = −0.63) (r = −0.62 to r = −0.58) and the concentrations of lacto-N-neotetraose (LNnT) and lacto-N-tetrose (LNT) were positively correlated (Pearson r = +0.63)   . Concent= +0.63) . Among nctively) .Supplemental Table 2). Secretor status was significantly associated with total HMO concentration and the concentrations of 15 of 19 (79%) individual HMOs . Both negative and positive associations between secretor status and individual HMOs were observed . Month of milk collection (December–February vs. March–May) was significantly and positively associated with the concentration of 3FL , was comparable to average concentrations that have been previously reported for women in other cohorts worldwide , 18. TheFUT2 gene that are responsible for the nonsecretor phenotype have been shown to vary between different ethnic populations  compared with breast milk collected from women in other international cohorts [ranging from 0.8% in rural Gambia and 0.9% in southeastern Washington, United States, to 2% rural Ethiopia and 3% in Sweden  in preterm infants , 38. SinAs reported elsewhere , 18, 41,A key limitation of this study was that breast milk samples were analyzed from only a single time point during lactation (3 mo postpartum), so an analysis of the effect of lactation stage on HMO composition in Bangladeshi women was not possible. In addition, the study population was recruited from 1 hospital that serves an urban community in Dhaka that may not be representative of Bangladesh in general. Greater variance in HMO profiles may have been observed by including women from more diverse socioeconomic and environmental settings.Bacteroides (It is well documented that HMOs promote the colonization and growth of beneficial bacteria, including some species of bifidobacteria  and membteroides , and thateroides , 45. In teroides  and mateteroides , 48 and teroides  fecal miteroides . HoweverIn conclusion, the description of the HMO profile of lactating women in Bangladesh provides a basis for future research of HMOs in this setting and may guide the development of novel and targeted HMO-containing interventions.nzab137_Supplemental_FilesClick here for additional data file.


Osteoarthritis is the main cause for total knee arthroplasty (TKA), followed by rheumatoid arthritis. Previous studies have reported conflicting results concerning the risk of surgical site infection after TKA for rheumatoid arthritis and osteoarthritis patients. Thus, this study aimed to examine whether rheumatoid arthritis patients had a higher risk of acute surgical site infection after TKA compared to osteoarthritis patients. We conducted a retrospective cohort study using Taiwan’s National Health Insurance Research Database of the whole population from 2012 to 2015, and collected the medical records of osteoarthritis patients or rheumatoid arthritis patients who underwent TKA. To evaluate the risk of acute surgical site infection in rheumatoid arthritis patients, propensity score matching was implemented for osteoarthritis patients. Acute surgical site infection was observed in 2.58% of TKA cases in rheumatoid arthritis patients and 2.66% of TKA cases in osteoarthritis patients. Rheumatoid arthritis and osteoarthritis patients had comparable risk for 90-day  and 1-year  surgical site infection. In conclusion, patients with rheumatoid arthritis were not at higher risk of acute surgical site infection after TKA compared to osteoarthritis patients. The current treatment strategy for patients with RA is safe and appropriate if they require TKA. RA is the most common inflammatory arthritis type. Its incidence rate in Taiwan was 15.2 per 100,000 people in 20072. The outcome of TKA in RA patients is similar to the outcome in OA patients3. However, surgical site infection is a major concern and influences long-term TKA survival. The rate of surgical site infection is < 2%4, and the rate reported in Taiwan was 0.6% in 20175. This complication mostly occurs within 1 year after TKA. Pulido et al. reported that 27% of infections were diagnosed within 30 days, whereas 65% of infections occurred within 1 year after arthroplasty6. Postoperative infection may result in significant morbidity and mortality and may account for massive healthcare expenditure. Several risk factors contribute to such catastrophic consequences, including obesity, diabetes mellitus, wound drainage or dehiscence, blood transfusion, coagulopathy, malignancy, immunodepression status, or rheumatoid arthritis9.Total knee arthroplasty (TKA) is currently considered the most successful treatment for end-stage arthritis of the knee and has a low complication rate. The main cause of end-stage arthritis is osteoarthritis (OA), which accounts for 90% to 97% of the primary indication for TKA, followed by rheumatoid arthritis (RA)11. Comparisons of the TKA surgical site infection rate between RA and OA patients have been an interesting topic in this area14. Regarding this, two nationwide population studies reported increased surgical site infection in RA patients compared to OA patients16. Lee et al. also concluded that RA patients had a significantly higher rate of deep surgical site infection than OA patients did, but their superficial infection rates were similar17. However, other studies reported no increase in infection rate in RA patients compared to OA patients19. Thus, this topic remains controversial and warrants further investigation. In light of the current evidence, our aim is to examine whether the acute surgical site infection rate after TKA in RA patients is higher than that in OA patients.It has been suggested that RA patients are more vulnerable to infections due to the consumption of immunosuppressive drugs20. We also retrieved basic information on contracted medical facilities from the NHIRD. For research purposes, these datasets can be linked by the patient’s or hospital’s scrambled identification number.We conducted a retrospective population-based cohort study using Taiwan’s National Health Insurance Research Database (NHIRD). The NHIRD contains comprehensive claims data, including outpatient visits, patient admissions, and drug prescription details for > 99% of Taiwan’s population. In this study, we identified study samples from the whole population of the NHIRD from 1 January 2012 to 31 December 2015. The NHIRD contains demographic characteristics, surgical procedures, and diagnostic codes in accordance with the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The validity of ICD-9-CM diagnosis is reliable in several diseasesThis study was conducted in accordance with the Declaration of Helsinki and was approved by the institutional review board at our hospital. The approved period of investigation was from January 2012 to December 2015. The requirement for obtaining informed consent from patients was waived due to the retrospective nature of the study .http://epitools.ausvet.com.au). For a cohort study with preassumed 5% of infection rate in OA patients, relative risk of 1.616, 95% confidence level, and 80% power, the minimum sample size was estimated as 1057 per group. OA was identified by ICD-9-CM code 715.0 and RA by code 714.0. TKA was identified by ICD-9-CM procedure code 81.54  was 82% for the algorithm using our criteria: ICD-9-CM code 714.0 from inpatient records along with ever-used pre-operative DMARDs, anti-tumor necrosis factor-α (anti-TNF-α), or steroids. Thus, to enhance the accuracy of identifying RA patients, we collected medication information including nonsteroidal anti-inflammatory drugs, DMARDs, anti-TNF-α, and steroids according to the Anatomical Therapeutic Chemical code. For example, methotrexate as a DMARD was labeled as L01BA01; etanercept as an anti-TNF-α product was labeled as L04AB01, and methylprednisolone as a steroid was labeled as H02AB04. We ruled out RA patients not receiving pre-operative DMARDs, anti-TNF-α, or steroid treatment, as well as patients treated with pre-operative DMARDs or anti-TNF-α but without an RA diagnosis , postoperative infection (998.3 and 998.59), and pyogenic arthritis and osteomyelitis  following TKA. Procedural codes include the operation performed for the infection  , comorbidities, and surgery-related factors. Comorbidities were hypertension, diabetes mellitus, hyperlipidemia, and other diseases that might be associated with surgical site infection. These diseases were determined at baseline, 6 months prior to TKA and were identified by ICD-9-CM codes, including hypertension 401–405), diabetes mellitus (250), hyperlipidemia (272), chronic obstructive pulmonary disease (490–496), urinary tract infection (599.0), congestive heart failure (428), cancer (140–239), chronic renal disease (585), peripheral vascular disease (443.9), anemia (280–285), valvular heart disease , and ischemic heart disease (410–414). Patients without complete comorbidity data were excluded  matching based on the theoretical model for estimates of PS in the logistic regression model. Under PS matching, RA patients were matched with OA patients in a 1:3 ratio. PS was calculated using logistic regression with covariates, including sex, age, comorbidities, and operation year. RA and OA patients were matched based on greedy matching with caliper set at 0.2 times the standard deviation of PS. The chi-squared test, Fisher’s exact test, and an independent sample t-test were utilized for the comparison of characteristics of the RA and OA patients before and after PS matching. The standardized mean difference (SMD) was calculated after matching, in which SMD < 10% indicates appropriate matching. We used a multivariable regression analysis to compare perioperative infection risk between RA and OA patients. After matching, unmatched OA patients were ruled out. We performed two analyses to estimate the acute infection risk of RA patients after TKA—namely, PS weighting with standardized mortality ratio weighting (SMRW) and conditional logistic regression for PS-matched data. According to SMRW, the weight for the RA group was 1, while the weight for the OA group was the ratio of PS and 1-PS. Two corrected methods were arranged: Model 1—correction with diagnosis (RA/OA); Model 2—correction with diagnosis (RA/OA), sex, age, hypertension, hyperlipidemia, diabetes mellitus, length of stay, blood transfusion, and hospital level. Other comorbidities were not included in the correction because of a low sample size, making their data not usable in logistic regression.Moreover, a sensitivity analysis was conducted by repeating the above analyses to observe the risk of surgical site infection using data obtained 1 year after TKA. We ruled out incomplete data between January and December of 2015. All statistical analyses were performed with SAS version 9.4 statistics software .This study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board at Hualien Tzu Chi Hospital .Patient consent was waived due to the retrospective nature of the study.A total of 64,341 patients who had undergone TKA between July 2012 and September 2015 were involved in this study, of whom 1.8% (n = 1126) were diagnosed with RA. The characteristics of the population are listed in Table p < 0.001), with female predominance in both groups . As for comorbidities at 6 months before TKA, the OA group had a higher incidence of hypertension (59.40% versus 41.21%), diabetes mellitus (25.37% versus 13.32%), hyperlipidemia (25.46% versus 13.14%), and ischemic artery disease (14.17% versus 7.02%) than the RA group did. More patients in the RA group experienced anemia (5.95% versus 1.44%). No significant differences were found in chronic obstructive pulmonary disease, urinary tract infection, congestive heart failure, cancer, chronic renal disease, peripheral vascular disease, or valvular heart disease occurrence. The RA patients also had higher rates of blood transfusion than the OA patients . NSAIDs were consumed the most by RA patients (98.31%), followed by DMARDs (90.85%), steroids (80.02%), anti-TNF-α (15.81%). NSAIDs were also consumed the most by OA patients, while DMARDs and anti-TNF-α were not applicable in this group. The rate of acute perioperative infection was comparable between the two groups .On average, the RA patients were younger than the OA patients .After PS matching with RA:OA = 1:3 (Table p = 0.812). After PS matching with RA:OA = 1:3, no significant difference in 1-year surgical site infection was noted between the two groups . After PS weighting with SMRW and conditional logistic regression, the risk of acute infection between the two groups was found to be similar according to the two analyses and two correction methods  between the two groups18. LoVerde et al. matched RA (n = 159) with OA (n = 318) patients in a 1:2 ratio and discovered a slightly higher superficial infection rate in the OA group than that in the RA group (OA: 9.4% versus RA: 5%), with marginal significance (p = 0.09)19. The results of both studies are compatible with our result, considering the original data, according to which RA and OA patients have a similar infection rate within 90 days after TKA.In this population-based cohort study, we found no significant difference in acute TKA surgical site infection risk between RA and OA patients while controlling for potential confounders. When the follow-up period was extended to 1 year after TKA, the results remained similar. Previous studies showed conflicting results when comparing RA and OA patients in terms of surgical site infection. Chesney et al. enrolled 1509 RA or OA patients who had undergone TKA. The superficial and deep infection rates did not show a significant difference (p < 0.001)7. In a systemic review, Lee et al. reported that superficial postoperative infection occurred in 15 of 258 RA patients and in 77 of 1609 OA patients (5.8% versus 4.7%), and deep infection occurred in 229 of 7651 RA patients and in 642 of 68,628 OA patients (3% versus 0.9%). Only the deep infection rate showed a significant difference (p < 0.001)17. Ravi et al. also concluded that RA patients have a higher infection rate than OA patients do after TKA 13. Our study results are not consistent with the results of the above studies, which may be due to the methodological differences. For example, one Danish nationwide cohort study considered prosthetic joint infection as infection that occurred at 1 year after operation15, while Ravi et al. defined postoperative infection as infection that occurred within 2 years13.Moreover, Zhu et al. discussed the risk factors of surgical site infection after total joint replacement. RA itself and the use of immunosuppressive drugs could both increase the infection rate 27.RA patients use three kinds of anti-rheumatic drugs to control disease activity: DMARDs, anti-TNF-α, and steroids. These drugs have been suspected to provoke infectious events28. These patients are more susceptible to postoperative anemia and are more likely to require a blood transfusion. Blood transfusions may increase the risk of infection by triggering transfusion-related immunomodulation30. However, in our study, RA patients had a higher rate of anemia and a higher blood transfusion rate after operation, and infection rate seemed to be unaffected, even after PS matching.RA patients tend to develop anemia because of bone marrow suppression due to chronic disease or medication use31. However, Gabriel reported poor agreement between the diagnostic coding for RA in a database and the diagnosis based on clinical criteria in medical records32. Bongartz et al. also concluded that 31% of the patients registered as having RA did not meet the ACR criteria for this diagnosis33. Such a high rate of misclassification may threaten our cohort study, which uses the database diagnosis as the sole source of diagnostic classification. We not only enrolled RA patients by searching for the ICD-9-CM code in the database but also collected anti-rheumatic drug use information using the Anatomical Therapeutic Chemical code to enhance the accuracy of RA diagnosis in order to diminish selection bias.The establishment of RA should be diagnosed according to the new ACR/EULAR RA criteriaThere are some limitations in this study. First, we collected data from the NHIRD, which has no detailed information on other potential confounders, including disease activity, obesity, length of surgery time, blood loss or other non-measurable factors . Additionally, the NHIRD has no information regarding whether infections are superficial or deep. Therefore, we cannot analyze these risk factors or outcomes in this study. Second, the generally low surgical site infection rate may underpower our conclusion, and this may not be addressed by extending the accrual period and, potentially, the follow-up window. However, in the clinical setting, such a low infection rate is what clinicians expect in patients receiving TKA. Finally, we did not have complete records of the medications taken by patients and were unable to make assertions about the adequacy and adjustment of anti-rheumatic medication in the perioperative period.According to this thorough collection from the database of the whole population in Taiwan, RA patients do not have a higher risk of acute or even 1-year postoperative surgical site infection after TKA compared to OA patients. The current treatment strategy for patients with RA is safe and appropriate if they require TKA.Supplementary Table S1.


Amongst the contributing factors of depression, vitamin D deficiency has increasingly drawn attention in recent years. This paper seeks to examine the association between serum vitamin D level and depression in patients with obesity.n = 174) and those without depression considering the effect of potential confounders. Participants were selected from males and females aged 18 to 60 years old visiting the outpatient obesity clinic of Rasoul-e Akram hospital, Tehran, Iran. The diagnosis of depressive disorder was made based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. Additional clinical and laboratory data were collected from hospital electronic records. Mann–Whitney U test (nonparametric), Student’s t-test (parametric), and Chi-squared test were used to analyze the differences between the two groups. To examine age and gender differences in the relationship between vitamin D deficiency and depression, stratified analyses were conducted by age and gender groups.In this comparative observational study, serum 25-hydroxyvitamin D [25(OH)D] levels were compared between obese individuals with depression (P <  0.001). Vitamin D insufficiency/deficiency was detected in 78 and 67% of the depressed and non-depressed groups, respectively, which was significantly different (P = 0.03). The associations between depression and the serum 25(OH) D levels were observed regardless of gender and age. The overall average vitamin D levels were not significantly different between total males and females . The average level of vitamin D was higher in the older age group (40–60 years) compared to younger participants (18–39 years) .The mean 25(OH) D levels were significantly different between depressed and non-depressed groups (20 ± 15 vs. 27 ± 13, The present study provides additional evidence for the hypothesis that low vitamin D serum concentration is associated with depression in obese adults, and highlights the need for further research to determine whether this association is causal. Obesity is increasingly recognized as a serious public health concern. More than 650 million people throughout the world suffer from overweight and obesity . There iVitamin D, also known as cholecalciferol, is a unique neuro-steroid hormone that is vital for numerous brain functions. This hormone binds to receptors in numerous brain regions including the hippocampus and cingulate cortex, which are involved in the pathogenesis of depression and other mental illnesses . Many clStrong evidence of aberrations in the vitamin D-endocrine system as well as low serum 25(OH) D levels have been seen in obese individuals , 11. It Despite a biologically potential role of vitamin D in the development of depression, very few studies have investigated this association in overweight and obese subjects, with conflicting findings. While two studies indicated the benefits of vitamin D supplementation on depressive symptoms in obese adults , 15, a rThe discrepancy among these results has given rise to the need for further research. In this regard, this study seeks to examine the association between serum vitamin D level and depression in obese patients.This comparative observational study was conducted at Rasoul-e Akram hospital, an Iran University of Medical Sciences affiliate located in Tehran, Iran.2 (kg/m2), greater than or equal to 30 kg/m2, normal TSH, normal FBS, normal PTH level, no history of sleep apnea, neither past nor present substance use, no history of calcium supplement or vitamin D use for at least 1 month before study enrollment. Additional criteria for the non-depressed group included: not meeting criteria for another mental disorder and no history of psychiatric medication use. Patients with recent illnesses or incomplete medical records were excluded from the study.The study population consisted of males and females aged 18 to 60 years old visiting out-patient obesity clinic from April 2019 to October 2020. The participants were selected using convenience sampling. Based on the presence or absence of depressive symptoms, participants were categorized into two separate groups. The diagnosis of depressive disorder was made by expert psychiatrists using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (SCID-5) . All parAll laboratory evaluations were performed in the morning after an overnight fast using reliable assays. The serum 25(OH) D measurements were classified according to definitions established by the Endocrine Society: 30–100 ng/ml was considered normal, with insufficient 25(OH) D levels or hypovitaminosis D sub-grouped into two: vitamin D insufficiency (20–29 ng/ml) and vitamin D deficiency (< 20 ng/ml) . Considep-value of < 0.05 was considered statistically significant.Categorical data were expressed as counts and percentages. Continuous variables were presented as mean and standard deviation (SD). The Statistical Package for Social Sciences, version 22 was used for all statistical analyses . The normal distribution of the variables was examined using Kolmogorov- Smirnov test. Mann–Whitney U test (nonparametric), Student’s t-test (parametric), and Chi-squared test were used to analyze the differences between two groups. To examine age and gender differences in the relationship between vitamin D deficiency and depression, stratified analyses were conducted by age and gender groups. A P <  0.001) and age (P <  0 .001), i.e., the depressed group had a significantly higher proportion of females (92% vs. 75%) and a higher mean age than the non-depressed group (42 ± 10 vs. 37 ± 10). Moreover, vitamin D insufficiency/deficiency was detected in 77 and 67% of the depressed and non-depressed groups, respectively, which was significantly different (P = 0.03). The mean BMI was not significantly different between the groups (P = 0.05). The mean vitamin D levels were not significantly different between males and females .A total of 174 depressed patients and 173 non-depressed individuals were studied. The baseline characteristics of the participants are summarized in Table P <  0.001). Moreover, the results obtained from separate analyses on variable levels of gender, showed that the mean vitamin D level for the depressed men was significantly lower than non-depressed men . Similarly, depressed women had a notably lower mean vitamin D level compared to non-depressed women . Therefore, the association between depression and the serum 25(OH) D levels was observed regardless of gender.As can be seen from Table P = 0.28). Likewise, the mean vitamin D level in non-depressed men did not differ significantly from non-depressed women . The overall average vitamin D levels were also not significantly different between total males and females .As shown in Table P < 0.001). In the same way, depressed participants aged 40–60 years had a notably lower mean vitamin D level compared to non-depressed aged 40–60 . Therefore, the association between depression and the serum 25(OH) D levels was observed regardless of age. The overall average vitamin D levels were also significantly different between age groups 18–39 and 40–60 .Regarding age groups, our finding revealed that the mean vitamin D level for the depressed participants aged 18–39 years was significantly lower than that of non-depressed aged 18–39 years  D levels and incident depression in obese patients. The relation between low levels of vitamin D and depression was already established in normal-weight individuals by past research . HoweverMultiple mechanisms are involved in the interaction between vitamin D deficiency, obesity, and depression. It has been proposed that an inverse relationship exists between vitamin D serum levels and BMI . As was Indeed, the possibility of reverse causality should also be noted. In other words, certain features associated with depression and obesity might have limited the vitamin D sources and increased the risk of vitamin D deficiency in the depressed participants of this study, as compared with the non-depressed group. For example, depressed individuals with obesity may avoid outdoor activity and sunlight exposure for long periods due to body image concerns, social withdrawal, anhedonia, particular personality traits, and pathological fatigue , 23. FurHowever, more recently, literature has emerged that offers contradictory findings on these associations. In contrast to the mentioned studies, in a randomized controlled study, Mousa et al.  showed tDifferent findings may be attributed to the differences in the study population , diverse methodology (different vitamin D supplementation doses and duration), and different baseline levels of serum 25(OH) D concentrations. Moreover, the mentioned studies applied self-reported psychiatric rating scales for evaluation of depression rather than a clinician-rated assessment and therefore were prone to multiple potential biases. In addition, some of the previous studies did not adjust for potential confounders, such as thyroid dysfunction, comorbid diabetes mellitus, sleep apnea, low physical activity, and substance use that may play a role in developing depression in the obese population .2D, decreased skin production of vitamin D, and substrate deficiency of vitamin D [As mentioned before, in this study depressed patients had significantly lower mean vitamin D levels than the non-depressed group; however, the distribution of gender groups in our study was quite imbalanced (overrepresentation of women). Considering biological and psychosocial differences between males and females, we also examined the relationship between vitamin D status and depression in men and women separately. In both genders, the mean vitamin D levels were significantly lower in the depressed group compared to nondepressed individuals. The finding is in the lines of earlier literature that found no significant interaction effect of gender on the association between vitamin D status and depression , 27. Furitamin D . It seemitamin D .Several limitations to this study need to be acknowledged. First, the sample size was relatively small. Therefore, larger studies will be needed to confirm our observations. Second, the depressed and non-depressed groups were not matched based on age, gender, and season of collecting vitamin D. Recent evidence suggests that the circulating levels of 25(OH) D can be affected by acute illness, diurnal rhythm, and season of blood draw , 35. HowIn summary, the present study provides additional evidence for the hypothesis that low vitamin D serum concentration is associated with depression in obese adults, and highlights the need for further research to find out whether this association is causal.


New vertebral compression fractures (NVCFs) are adverse events after vertebral augmentation of osteoporotic vertebral compression fractures (OVCFs). Predicting the risk of vertebral compression fractures (VCFs) accurately after surgery is still a significant challenge for spinal surgeons. The aim of our study was to identify risk factors of NCVFs after vertebral augmentation of OVCFs and develop a nomogram.We retrospectively reviewed the medical records of patients with OVCFs who underwent percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP). Patients were divided into the NVCFs group and control group, base on the patients with or without NVCFs within 2 years follow-up period after surgery. A training cohort of 403 patients diagnosed in our hospital from June 2014 to December 2016 was used for model development. The independent predictive factors of postoperative VCFs were determined by least absolute shrinkage and selection operator (LASSO) logistic regression, univariate analysis and multivariate logistic regression analysis. We provided a nomogram for predicting the risk of NVCFs based on independent predictive factors and used the receiver operating characteristic curve (ROC), calibration curve, and decision curve analyses (DCA) to evaluated the prognostic performance. After internal validation, the nomogram was further evaluated in a validation cohort of 159 patients included between January 2017 and June 2018.p = 0.003). The percentages of patients with previous fracture history were 26.53 and 12.71% in the NVCFs and control group, respectively (p = 0.010). The volume of bone cement were 4.43 ± 0.88 mL and 4.02 ± 1.13 mL in the NVCFs and Control group, respectively (p = 0.014). The differences have statistical significance in the bone cement leakage, bone cement dispersion, contact with endplate, anti-osteoporotic treatment, post-op Cobb angle and Cobb angle restoration characteristics between the two groups. The model was established by multivariate logistic regression analysis to obtain independent predictors. In the training and validation cohort, the AUC of the nomogram were 0.882 , 0.824-0.940) and 0.869 (95% CI: 0.811-0.927), respectively. The C index of the nomogram was 0.886 in the training cohort and 0.893 in the validation cohort, demonstrating good discrimination. In the training and validation cohort, the optimal calibration curves demonstrated the coincidence between prediction and actual status, and the decision curve analysis demonstrated that the full model had the highest clinical net benefit across the entire range of threshold probabilities.Of the 403 patients in the training cohort, 49(12.16%) were NVCFs at an average of 16.7 (1 to 23) months within the 2 years follow-up period. Of the 159 patients in the validation cohort, 17(10.69%) were NVCFs at an average of 8.7 (1 to 15) months within the 2 years follow-up period. In the training cohort, the proportions of elderly patients older than 80 years were 32.65 and 13.56% in the NVCFs and control group, respectively (A nomogram for predicting NVCFs after vertebral augmentation was established and validated. For patients evaluated by this model with predictive high risk of developing postoperative VCFs, postoperative management strategies such as enhance osteoporosis-related health education and management should be considered. Osteoporotic vertebral compression fractures (OVCFs) mainly cause sudden severe pain, progressive kyphosis, decreased quality of life, and increased mortality –3. AlthoHowever, with the improvement and popularization of vertebroplasty technology, there are an increasing number of related complications. Postoperative new vertebral compression fractures (NVCFs) are the most common complication, which reduce the quality of life and increase the economic burden on society , 11. PreFrom June 2014 to June 2018, a total of 892 patients in our institution were diagnosed with OVCFs. The inclusion criteria are as follows: 1.All patients underwent a PVP or PKP procedure. 2.The patient had obvious back pain[visual analogue scale (VAS) > 6], and limited physical activity, especially in cases of turning over or getting up. 3.The diagnosis of osteoporosis can be established if one of either A or B below is fulfilled: A. T score ≤ − 2.5 at spine/hip at Dual energy X-ray absorptiometry (DEXA); B.Sagittal L1-Hounsfield unit (HU) value≤110 on Computed tomography (CT) scan. The HU threshold with high specificity (about 90%) was used to detect osteoporosis: L1 ≤ 110HU.We measured the HU value of L2 instead of L1 when patients had moderate-to-severe vertebral fractures of L1. 4.Patients with low-energy trauma. 5.The signal change of the lumbar fracture by lumbar magnetic resonance imaging (MRI) suggesting a hyperintense T2 signal and a hypointense T1 signal, or a whole-body bone scan performed a active bone metabolism. The exclusion criteria are as follows: 1.Patients with OVCFs caused by tumor, infection, or tuberculosis. 2.Patients had coagulation dysfunction, combined systemic disease, and inability to tolerate the procedure. 3.Systemic or local infection. 4.Spinal cord compression and obvious neural symptoms such as numbness and/or muscle weakness. 5.Perform hybrid stabilizations including percutaneous posterior stabilization. 6.Unstable fracture with the involvement of the posterior elements. 7.Incomplete follow-up data. The exact indication for PVP or PKP surgery is osteoporosis vertebral compression fractures that patients with back pain were not relieved by conservative treatment, or were affected by daily life seriously. Of these 892 patients, 245 who did not meet the inclusion criteria or meet any of the exclusion criteria were excluded. During the follow-up period, 49 patients were lost to follow-up; 36 patients have died of causes unrelated to PVP/PKP. Finally, our study screened a total of 562 patients who met the criteria. From June 2014 to December 2016, 403 patients were included in the training cohort. In addition, a validation cohort of 159 patients from January 2017 to June 2018 was recruited, with the same standards as the training cohort. Patients were divided into the NVCFs group and control group, base on the patients with or without NVCFs within 2 years follow-up period after surgery. All methods are carried out in accordance with relevant guidelines and regulations. This study was approved by themedical ethics committee of the People’s Hospital of Ningxia Hui Autonomous Region . All participants gave written informed consent.The patients received PVP/PKP in the prone position under the guidance of C-arm fluoroscopy. After local anesthesia (1% lidocaine), puncture through the pedicle, fluoroscopy lateral radiographs show that a working channel is established when the bone needle was percutaneously inserted into the posterior one-third of the fractured vertebral body, according to Jensen’s technique . After tAll patients were given oral calcium and vitamin D postoperatively. If some patients have no fever or other discomfort, they will receive intravenous infusion of Zoledronic Acid  on the first day once a year thereafter for 3 years. Patients were reviewed on the postoperative 24 h for anteroposterior and lateral spinal radiographs and discharged 2 to 3 days after surgery. Postoperative follow-up examinations were at 1 months, 3 months, 6 months, 1 year, and 2 years in the outpatient clinic. If the patient did not return for follow-up, a telephone call was made to interview the patient. When thinking of the most pragmatic and cost-efficient method of review, anteroposterior and lateral spine X-ray were taken in an upright position from all patients. Spine MRI should be considered when patient has reappeared back pain, and a vertebral fracture is possible. MRI investigations might be more useful for making an early diagnosis of the new vertebral fracture. Participants were followed for up to 2 years with NVCFs after vertebral augmentation as the end point.Primary diagnostic criteria of NVCFs after PVP/PKP were as follows: 1.The back pain reappeared after postoperative pain relief, and limited physical activity, especially in cases of turning over or getting up. 2.The signal change of the lumbar fracture by lumbar MRI suggesting a hyperintense T2 signal and a hypointense T1 signal. Newly developed OVCFs was diagnosed as NVCFs in a different vertebral body compared to the last follow-up image on plain radiography, MRI, or bone scan. Adjacent segment fracture was defined as newly developed VCFs within 1 level above or below from the index fracture. Distant segment fracture was defined as 2 or more levels away from the index fracture.General information: gender, population, age, body mass index (BMI), and fractured vertebral body segments. (2) Surgical factors: surgical method (PVP/PKP), average bone cement dosage, bone cement leakage, bone cement dispersion, contact between bone cement and endplate, regular anti-osteoporosis treatment. (3) Comorbidities: history of diabetes, hypertension, and fractures. Bone cement has crossed the midline of the vertebral body on spine x-ray plain film is defined as good bone cement diffusion, otherwise as poor. Overcoming various obstacles in the treatment process and taking their anti-osteoporosis drugs on time according to the treatment regimen are defined as regular anti-osteoporosis treatment, otherwise as irregular. The anterior vertebral height (AVH) and Cobb angle  of the fractured vertebral body were measured before surgery and 24 h after surgery. The anterior vertebral height ratio (AVHR) was calculated as percentile of anterior vertebral height of the compressed vertebra against the mean anterior vertebral height of adjacent upper and lower vertebra. The anterior vertebral height recovery ratio (AVHRR) was defined as postoperative AVHR - preoperative AVHR. Cobb angle was defined as the angle formed by the upper and lower endplates of the fractured vertebral body. Cobb angle restoration was defined as preoperative Cobb angle - postoperative Cobb angle. A lordotic angle was assigned a positive value, and a kyphotic angle was assigned a negative value.P < 0.05 in the univariate analysis were subjected to multivariate logistic regression analysis, and the variables with P < 0.05 were considered as possible predictors. Based on multivariate logistic regression analysis, a nomogram was created by R softwarea in the training cohort.Categorical variables were expressed as rates, and the chi-square test was used for comparison between groups. Continuous variables are presented as mean values ±standard deviation, and independent samples t-test or analysis of variance (ANOVA) was used for comparison between groups. The texture feature selection using least absolute shrinkage and selection operator (LASSO) regression model is used for data dimensionality reduction and feature selection. The variables with p < 0.05.A receiver operating characteristic (ROC) curve was drawn. The area under the curve (AUC) value was calculated to evaluate the sensitivity and the specificity. Calibration plots were generated to examine the performance characteristics of the predictive nomogram. Decision curve analysis (DCA) was assessed whether the model improves forecasted net income. After that, the nomogram constructed in the training cohort was further verified in validation cohort according to the same method as above. The data were statistically analyzed using SPSS version 24 and R version 3.6.1. Differences were defined as statistically significant at Of the 403 patients in the training cohort, 4912.16%) were NVCFs at an average of 16.7 (1 to 23) months within the 2 years follow-up period (Table 2.16% werp = 0.003) (Table p = 0.010) (Table p = 0.014)  Table . The per4) Table . In addiThe model was established by multivariate logistic regression analysis to obtain independent predictors Fig. . Among tBased on the results of multivariate logistic regression analysis, we construct the nomogram with age, bone cement dosage, bone cement leakage, bone cement dispersion, contact between bone cement and endplate, and anti-osteoporosis treatment Fig. . In ordeIn the training cohort, DCA showed that if the threshold probability of patients and doctors is greater than 2% and less than 96%, using the nomogram to predict the risk of NVCFs is more beneficial than the program Fig. C. SimilaVertebral augmentation, as a minimally invasive technique, is considered a treatment option for OVCFs. NVCFs is the most common complication reported in patients with OVCFs and remains a vexing problem for both clinicians and patients.However, there are many factors may influence NVCFs development, including sex, age, BMI, BMD, diffusion of bone cement, and volume of cement factors. Through multivariate logistic regression analysis, we found that advanced age, excessive(> 4.5)/insufficient(< 4 ml) bone cement volume, bone cement leakage, poor bone cement dispersion, bone cement not contacting the endplate, and without available anti-osteoporotic treatment are the independent risk factors of NVCFs after vertebral augmentation for OVCFs. Then, we develop a nomogram based on six independent predictors. Nomograms are visual statistical models that can better improve clinical decision-making –15. Our In line with previous studies , six indMany scholars agree that the surgical factors and progression of osteoporosis are correlated with postoperative VCFs . RegardiKwon et al . reportedThe differences between the NVCFs and control group in the postoperative Cobb angle and restoration of the Cobb angle were statistically significant. The postoperative Cobb angle in the NVCFs group (15.27 ± 4.07 °) was lower than that in the control group 17.32 ± 3.70 °). Kang et al . found th ± 3.70 °The present study found that poor bone cement dispersion in the vertebral body and failure to contact the upper and lower endplates are risk factors for postoperative VCFs. A biomechanical study reported by Chevalier et al . showed tOur study established a nomogram model based on a large cohort, and successfully verified it in a validation cohort. All variables included in the nomogram are easy to determine. By calculating the points for each of the six variables, a spine surgeon can easily estimate the risk of NVCFs after a surgery. Based on the evaluation results, preoperative and postoperative management strategies can be implemented to decrease the risk of NVCFs. Similarly, for low-risk patients, some preventive measures may be reduced to reduce the economic burden.Our research also has some limitations. First, this was a retrospective study; therefore; there may be an inherent selection bias. However, we included as many preoperative and surgical factors as possible based on a large sample to minimize deviation. Second, although this nomogram has been verified in the validation cohort, we must realize that the incidence of postoperative VCFs reported in different hospitals, regions, and countries differs, which may limit this nomogram to a small number of hospital applications. Third, because some data were lost in the retrospective study, bone mineral density was not considered in the multivariate regression analysis. Fourth, 4 of the 6 identified parameters were determined intraoperatively, although many pre- and intraoperative parameters were incorporated in the current study. It is inappropriate to assess the risk of postoperative VCFs before surgery, and the eventuality of augmenting adjacent segments must be made intraoperatively. The sensitivity and specificity of the nomogram may be further improved through multi-center retrospective validation studies or prospective randomized clinical trials, which will provide high-level evidence for future clinical applications.Our study found that advanced age, the volume of bone cement (< 4 or > 4.5 ml), bone cement leakage, poor bone cement dispersion, non-contact betwen bone cement and endplate, and irregular anti-osteoporotic treatment are the independent risk factors of NVCFs after vertebral augmentation of OVCFs. The nomogram containing the above six predictors can accurately predict the risk of VCFs after surgery.


Cathepsin A (CTSA) is a lysosomal protease that regulates galactoside metabolism. The previous study has shown CTSA is abnormally expressed in various types of cancer. However, rarely the previous study has addressed the role of CTSA in hepatocellular carcinoma (HCC) and its prognostic value. To study the clinical value and potential function of CTSA in HCC, datasets from the Cancer Genome Atlas (TCGA) database and a 136 HCC patient cohort were analyzed. CTSA expression was found to be significantly higher in HCC patients compared with normal liver tissues, which was supported by immunohistochemistry (IHC) validation. Both gene ontology (GO) and The Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses demonstrated that CTSA co-expressed genes were involved in ATP hydrolysis coupled proton transport, carbohydrate metabolic process, lysosome organization, oxidative phosphorylation, other glycan degradation, etc. Survival analysis showed a significant reduction both in overall survival (OS) and recurrence-free survival (RFS) of patients with high CTSA expression from both the TCGA HCC cohort and 136 patients with the HCC cohort. Furthermore, CTSA overexpression has diagnostic value in distinguishing between HCC and normal liver tissue [Area under curve (AUC) = 0.864]. Moreover, Gene set enrichment analysis (GSEA) showed that CTSA expression correlated with the oxidative phosphorylation, proteasome, and lysosome, etc. in HCC tissues. These findings demonstrate that CTSA may as a potential diagnostic and prognostic biomarker in HCC. HCC causes a huge health burden globally, especially in East Asia and sub-Saharan Africa, and China accounts for about half of these deaths each year3. Although many researchers have made efforts to develop an effective therapy in recent decades, the 5-year survival has not significantly improved. Therefore, the identification of molecular biomarkers that can predict the prognosis of clinical treatment of HCC may substantially help the development of patient treatment strategies, and may even develop new targeted therapies for specific patients. The major risk factors for HCC are chronic infection with hepatitis B virus (HBV) and hepatitis C virus (HCV)5. Dietary aflatoxin exposure, chronic alcohol consumption, non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) are also linked to increased risk for HCC7. However, the complex signal transduction pathways and potential molecular pathogenesis involved in the occurrence and development of HCC are still unclear.Hepatocellular carcinoma (HCC) has a high mortality rate and is one of the cancers in which incidence gradually increased in recent years10. Previous studies have found that the overexpression of cathepsin B leads to the invasiveness and metastasis of breast cancer, pancreatic cancer, HCC, and colorectal cancer, by activating the ErbB oncogenic signaling pathway14. The cytosol concentration of cathepsin D was found to have a strong influence on metastasis in breast cancer16. In addition, cathepsin K was found to have a high correlation with the progression of prostate cancer and breast cancer18. Cathepsin A (CTSA) is a renowned serine protease cathepsin member of the cathepsin lysosomal protease family, which with a role in protecting β-galactosidase and neuraminidase-1 from intra-lysosomal proteolysis19. In recent years, CTSA overexpression has been observed in various types of human cancers such as breast cancer, lung cancer, and prostate cancer23. CTSA also has been identified as a potential biomarker for early diagnosis, prognosis and monitoring during cancer treatment. However, the mechanism of action of CTSA in the development and progression of HCC has not been previously reported.Cathepsin is a key lysosomal proteolytic enzyme, to the best of our knowledge, which is responsible for the degradation of many intra-cellular or extra-cellular substrates. Cathepsins were expressed in various types and stages of human cancer and were reported to be related to cancer progression and drug resistance26. The relationship between the prognosis of HCC and CTSA expression was verified by Immunohistochemistry (IHC). The potential function of CTSA in HCC was analyzed by screening CTSA co-expressed genes using cBioPortal and LinkedOmics, as well as gene ontology (GO) and The Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses performed using the Database for Annotation, Visualization and Integrated Discovery (DAVID)27. Then, we performed gene set enrichment analysis (GSEA) analysis to determine the enriched genes and whether a series of previously-defined 9 stages of HCC progress-related gene sets were enriched in different phenotypes28.In this study, the gene expression profiling interactive analysis (GEPIA), The Cancer Genome Atlas (TCGA), The Human Protein Atlas databases were used to investigate the expression of CTSA in HCC and normal liver tissues to determine the relationship between prognosis of HCC and CTSA expressionhttp://gepia.cancer-pku.cn/) which is a web server for analyzing the RNA-Seq expression data from the TCGA and GTEx projects to explore the expression distribution and correlation of CTSA in a body map and different cancer tissues. The GEPIA and the UCSC Xena project (https://xenabrowser.net/datapages/) has recomputed all raw expression data from TCGA database and were used to detect the CTSA expression in different stages and types of HCC29. Then, the Kaplan–Meier Plotter  and GEPIA website to analyze the expression of CTSA and the prognosis of survival in HCC tissues30. The Human Protein Atlas database (https://www.proteinatlas.org/) were used to analyze the CTSA protein expression in HCC tissues and normal liver tissues by IHC. We used the Cancer Cell Line Encyclopedia project (CCLE)  to analyze the relationship of CTSA mRNA levels with DNA copy number in different liver cancer cell lines. We obtained the information about the alteration of the CTSA gene in cBioPortal for Cancer Genomics 31.Genotype Tissue Expression (GTEx) projects and TCGA database provide mRNA expression data in various types and stages of human cancers. We used GEPIA (https://xenabrowser.net/datapages/). We performed survival analysis to assess the clinical outcomes of patients with HCC after examination and transformation of variables evaluated in a Cox proportional hazards regression model. Overall survival (OS) was defined as the interval between surgery and mortality or between surgery and the last observation point. For surviving patients, the data were censored at the last follow-up. Recurrence-free survival (RFS) was defined as the interval between the date of surgery and the date of diagnosis of any type of relapse (intra-hepatic recurrence or extrahepatic metastasis)32. In order to evaluate the prognostic value of CTSA in HCC, 136 tumor specimens were collected during the continuous HCC tumors from September 2010 to December 2012, and the last follow-up was conducted on December 31, 2017. We used the Edmondson grading system33 and Child–Pugh classification to assess tumor differentiation and liver function, respectively. The 2010 International Union Against Cancer Tumor-Node-Metastasis (TNM) classification system were used to assess the tumor stages34.The patients must meet following criteria: liver function grade Child–Pugh class A, only one tumor lesion and absence of any metastasis, no cancer radiotherapy or chemotherapy prior to surgery, and pathology confirmed as primary HCC following surgery. The relevant clinicopathological data of HCC patients were obtained from the medical record of hospital database, and pathological data were assessed by two pathologists. Survival information was accessed from medical records, telephone interviews as well as the Social Security Death Index. This study was approved by the Human Research Ethics Committee of 900 Hospital of the Joint Logistics Team . All experiments were performed in accordance with relevant named guidelines and regulations. All participants were supplied with written information and gave written consent prior to collection of the specimens and informed consent was obtained from all the participants.We analyzed CTSA expression in HCC and adjacent peritumoral tissues from patients in TCGA database  (pH 9.0) for 20 min. Endogenous peroxidase was inhibited by incubation for 10 min in 3% H2O2 and washed in phosphate-buffered saline (PBS) three times. The sections were incubated with 10% normal goat serum for 30 min at room temperature (25 °C) without washing. A monoclonal rabbit Anti-CTSA antibody  were added dropwise to sections, incubated overnight at 4 °C, and washed in PBS three times. Then, sections were incubated with the secondary antibody  at 37 °C for 30 min and were washed by PBS three times. Next, the sections were stained with 3,3′-diaminobenzidine and a substrate-chromogen (Dako) for 2 min at room temperature, and counterstained with hematoxylin for 40 s. Finally, the sections were dehydrated in 95% alcohol and sealed with neutral balsam.22. A semi-quantitative IHC scoring system was used for the evaluation of CTSA protein level with a 5-point scale, as follows: 0, no positive cells; 1, < 25% positive cells; 2, 26–50% positive cells; 3, 51–75% positive cells; 4, > 75% positive cells. HCC tissue samples with a score of 0.1 or 2 were regarded as low CTSA expression, whereas a score of 3 or 4 was regarded as high CTSA expression.The sections were dropped by only the second antibody without the CTSA antibody was as the negative control. The 136 stained tissue sections were viewed using a CX41 microscope  and assessed by two separate pathologists with no prior knowledge of any patient information. The expression of CTSA was predominantly cytoplasmic or cytomembrane based on the Human Protein Atlas database and previous studies36. In this process, the critical value of the significant gene functions and pathways to be screened was set as P < 0.05. Then, the protein–protein interaction (PPI) network of CTSA co-expressed genes was constructed in the STRING database, and the minimum required interaction score was set as 0.9(highest confidence)37. Finally, The Cytoscape software was used to visualize the PPI network38.The hepatocellular carcinoma dataset in the cBioportal database and the LinkedOmics database were selected to analyze the correlated genes of CTSA expression using the function of co-expressed genes. Then, the overlapping genes with Pearson's Correlation greater than 0.35 obtained in the two databases were screened as CTSA co-expressed genes. Next, the Functional Annotation Tool in the DAVID database was used to perform GO and KEGG enrichment analysis on the co-expressed genes of CTSAhttps://xenabrowser.net/datapages/)39. Among them, there were 374 HCC specimens and 50 adjacent non-tumor tissue specimens. The 374 HCC specimens were divided into high expression group and low expression group taking the median of CTSA expression in HCC specimens as the critical point. We imported gene expression data into GSEA 4.1.0 software for enrichment analysis. In the process, we selected the KEGG gene sets (c2.cp.kegg.v7.0.symbols.gmt) as the functional gene set, the Number of permutations as 1000, and other parameters as the default settings. In the analysis of the results, the pathway of gene enrichment with a normal p-value < 0.05 and FDR q-value < 0.25 was selected.Normalized gene expression data was downloaded in the TCGA database from the UCSC Xena database  dataset in the cBioportal database to query the genetic alteration and the mutational hotspot of CTSA genes in HCC. Then, the overall survival rate was compared between HCC patients with CTSA mutations and without mutations.P < 0.05 was considered statistically significant unless otherwise stated.The statistical analysis was performed using Stata Statistical Software: SPSS 21  and GraphPad Prism 6.0 . Pearson’s chi-square test was used to compare the categorical variables. For normally distributed continuous variables, the Student’s t-test was used. Survival was estimated using Kaplan–Meier plots with log-rank test for differences. The diagnostic significance of CTSA for HCC was evaluated by the receiver operating characteristic (ROC) curve. P = 0.0081)  Fig. C.Figure P < 0.001, Fig. P = 0.001), tumor TNM stage (P = 0.004), serum alpha-fetoprotein (AFP) level (P = 0.001), neoplasm histology grades (P = 0.038), and adjacent hepatic inflammation in (P = 0.009) HCC patients. Age, gender, family cancer history, preoperative radiotherapy, preoperative pharmaceutical, and body mass index (BMI) were not related to CTSA mRNA expression (Table P = 0.014), tumor TNM staging (P < 0.001), and high expression of CTSA mRNA (P = 0.006) were risk factors of overall survival by performing Univariate Cox Regression analysis. The Multivariate Cox Regression analysis confirmed that TNM staging (HR (95%CI) 0.492 (0.346–0.700); P = 0.001) and high CTSA mRNA expression (HR (95%CI) 1.420 (1.001–2.013); P = 0.049) were independent risk factors for overall survival. For RFS, the vascular invasion (P < 0.001), tumor TNM staging (P < 0.001), Serum AFP level (P = 0.029), and high expression of CTSA mRNA (P = 0.003) were risk factors. Meanwhile, the vascular invasion (HR (95%CI) 1.651 (1.189–2.291); P = 0.003), TNM staging (HR (95%CI) 0.653 (0.465–0.919); P = 0.014) were independent risk factors of RFS confirmed by Multivariate Cox Regression  and found that its expression quantity in HCC tissues  was significantly higher than in the none-HCC group (n = 50) (P = 0.024), serum AFP level (P = 0.001), tumor location (P = 0.037), tumor differentiation (P = 0.031), tumor recurrence (P = 0.013), and survival (P = 0.036), but not related to age, gender, tumor size, vascular invasion, and tumor encapsulation (Table P = 0.033), TNM stage (P = 0.005), serum AFP level (P = 0.036), tumor differentiation (P = 0.008), vascular invasion (P = 0.048), and high expression of CTSA (P = 0.039) were risk factors affecting OS. The Multivariate analysis confirmed that tumor differentiation (HR (95%CI) 3.590 (1.093–11.795); P = 0.035) and high CTSA expression (HR (95%CI) 0.575 (0.336–0.983); P = 0.043) are independent risk factors affecting OS. For RFS, tumor differentiation (HR (95%CI) 2.938 (1.161–7.433); P = 0.023), vascular invasion (HR (95%CI) 2.075 (1.271–3.390); P = 0.004), tumor non-encapsulation (HR (95%CI) 0.288 (0.177–0.467); P < 0.001), and high CTSA expression (HR (95%CI) 0.583 (0.362–0.939); P = 0.027) were independent risk factors confirmed by the Multivariate analysis  in the cBioportal database and found that queried gene is altered in 25 (7%) of queried HCC patients, including 1 case of truncating mutation, 1 case of amplification, and 23 cases of mRNA high expression. We also analyzed the mutational hotspot of CTSA in 359 HCC patients and found that there was one mutational hotspot, L218Wfs*40/frameshift deletion mutation   (Fig. We selected the liver hepatocellular carcinoma dataset in the cBioportal database and the LinkedOmics database to analyze the correlated genes of CTSA expression using the function of co-expressed genes. A total of 19,899 genes related to CTSA protein expression in a cohort of 371 HCC patients from the LinkedOmics database expression were investigated. We exhibited a gene heat map and volcano plot with 8846 positively and 11,053 negatively correlated genes with CTSA protein expression (Fig. We performed GSEA enrichment analysis in the GSEA 4.1.0 software to investigate the potential pathway that CTSA may regulate the carcinogenesis and development of HCC using normalized gene expression data in the TCGA HCC dataset downloaded from the UCSC Xena database. The GSEA revealed that KEGG pathway associated with carcinogenesis and development including "oxidative phosphorylation", "proteasome", "lysosome", "glycerophospholipid metabolism", "other glycan degradation", "pentose phosphate pathway", and "amino sugar and nucleotide sugar metabolism" were identified as significantly altered in CTSA high group Fig. C. Furthe40, the 5-year survival percentage of HCC patients for all stages was only 18%, and cancer-related mortality ranks 5th among all cancers. Even though the methods of diagnosis and treatment have got rapid development, HCC still lacks effective diagnostic biomarkers. In the past few years, the role of various classes of cathepsins in the proliferation and metastasis of various types of human cancers has been extensively studied. The overexpression of cathepsin B promotes invasion and metastasis of breast cancer, pancreatic cancer, HCC, and colorectal cancer14. In addition, cathepsin B has been found to be involved in tumor initiation, migration, and drug resistance of glioblastoma stem cells and prostate cancer stem cells42. CTSA is a well-known serine protease cathepsin member of the cathepsin lysosomal protease family, which has been identified as a potential biomarker for early diagnosis, prognosis, and monitoring during cancer treatment43. A previous study showed that knockdown of CTSA suppressed the metastasis of prostate cancer by reducing the phosphorylation of the P38 MAPK pathway22. Another previous study had found that CTSA is highly expressed in hepatocellular carcinoma through the method of quantitative proteomics44, but its clinical prognostic value and gene function never been illustrated. This study is the first systematic investigation of diagnostic value, clinical significance, and the gene function of CTSA in HCC.HCC was a highly aggressive malignant tumor with high mortality and caused a huge health burden globally. According to data in 2019 released by the American Cancer Society44. Our research was consistent with it. The ROC curve using data from the TCGA database indicating that CTSA mRNA expression has a significant diagnostic value between HCC and normal liver tissues. IHC is a routine pathological examination after HCC resection. Our research showed that CTSA protein expression was significantly increased in HCC and was an independent risk factor for OS and RFS. Therefore, postoperative CTSA IHC examination can help predict the recurrence and prognosis of HCC patients.We analyzed the mRNA expression level of CTSA using the GEPIA database and TCGA database and found that its expression in HCC tissues was significantly higher than adjacent tissues. And this result was confirmed by IHC from the Human Protein Atlas database and 136 cases of clinical specimens. Furthermore, the high-level expression of CTSA mRNA was significantly correlated with poor OS and PFS of HCC patients in the GEPIA database, Kaplan–Meier plotters database, and TCGA database as well as the 136 HCC patients, indicating that CTSA may perform an important role in the development of HCC. To further investigate the clinical significance of CTSA in HCC, we analyzed the relationship between clinicopathological variables records and CTSA expression from the TCGA database and 136 HCC patients and found that the high mRNA expression of CTSA was significantly associated with vascular invasion, TNM staging, serum AFP level, neoplasm histology grades, adjacent hepatic inflammation, tumor recurrence, and survival. And the multivariate regression analysis confirmed that the high mRNA expression of CTSA was an independent risk factor for OS in HCC patients. High protein expression of CTSA was an independent risk factor for OS and RFS in HCC patients Table . PreviouIn order to explore the function of CTSA in the process of tumorigenesis and development of HCC, we identified the co-expressed genes using cBioPortal and LinkedOmic databases, and then performed GO and KEGG enrichment analysis used DAVID software on co-expressed genes. The results show that CTSA mainly involves in biological processes, such as ATP hydrolysis coupled proton transport, the Carbohydrate metabolic process, Ganglioside catabolic process, Lysosome organization, and Negative regulation of fibroblast proliferation, etc. KEGG as well as GSEA exhibited that the signaling pathway CTSA is involved in such as Lysosome, Oxidative phosphorylation, Metabolic pathways, etc., and should be further investigated in the future work. We further constructed a PPI network of CTSA co-expressed genes and screened out several genes including FTL, GRN, NPC2, HEXB, and PTGES2, which interact with CTSA. To the best of our knowledge, genes with similar expression patterns may be functionally related or even similar. The results of the Kaplan–Meier plotters database revealed that the high expression of these co-expressed gene mRNAs was related to the poor OS of HCC patients. Therefore, all our results indicate that CTSA may as an oncogene in the process of HCC tumorigenesis.To gain more insight into the role of CTSA in HCC, we further queried its genetic alteration in a cohort of 359 LIHC patients in the cBioPortal database. The results showed that approximately 7% of CTSA exhibited the alterations, and these alterations were significantly related to poor OS. We further explored the reasons for this genetic alteration. From the PPI network, we screened out 5 co-expressed genes that interact with CTSA, and the high expression of these co-expressed genes was associated with poor OS of HCC. It is reasonable to assume that these co-expressed genes have an impact on the CTSA alterations and may play an important role in the tumorigenesis and development of HCC.The mRNA and protein expression level of CTSA in HCC tissues was significantly higher than adjacent normal liver tissues. High CTSA expression level was associated with poor clinical outcomes of HCC patients. CTSA can be used as a biomarker of the prognostic value of HCC. CTSA may as an oncogene that regulated tumorigenesis and development through influencing pathways such as lysosome, oxidative phosphorylation, and metabolic pathways, etc. Postoperative CTSA IHC examination can help predict the recurrence and prognosis of HCC patients.


The tuberous sclerosis-associated neuropsychiatric disorders (TAND) have not previously been studied in China. We aimed to assess the psychiatric level of individuals with TAND using the Mini International Neuropsychiatric Interview for Children (MINI-KID) in China.P < 0.0001). Notably, 69.47% (66/95) had two or more psychiatric disorders. Pervasive developmental disorder (PDD) was often co-morbid with other psychiatric disorders.A total of 83.16% of individuals (79/95) had at least one TAND, and 70.53% (67/95) had an intellectual disability. The MINI-KID tool diagnosed 16 neuropsychiatric diseases, the most common of which were attention-deficit/hyperactivity disorder (ADHD)  and social anxiety disorder . The number of children with psychiatric diseases in the tuberous sclerosis complex (TSC) group was significantly greater than the number in the typically developing group (This study used the structured and systematic MINI-KID scale to determine the diagnosis of psychiatric co-morbidities in a relatively large sample, suggesting a higher rate. By comparing the status of individuals with TSC with typically developing children, the results suggests that neuropsychiatric co-morbidities are significantly higher in individuals with TSC. Research has revealed the frequent presence of two, three or more neuropsychiatric diseases in individuals with TSC.The online version contains supplementary material available at 10.1186/s13023-021-01814-4. TSC1 (9q34) and TSC2 (16p13.3) genes [Tuberous sclerosis complex (TSC) is an autosomal dominant genetic disease characterized by the formation of hamartomas in multiple organ systems with various symptoms and degrees of severity. The currently known pathogenic genes are the TSC1 9q4 and TSCnd TSC2 1p13.3 gen3) genes . With th3) genes , very feAs a simple, reliable and effective interview, the MINI-International Neuropsychiatric Interview for Children (MINI-KID) was developed based on Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) and International Classification of Disease, 10th version (ICD-10) criteria for the assessment and diagnosis of psychiatric disorders . This stTSC1/TSC2 genes. The exclusion criterion was refusal to participate.This study was carried out from September 2019 to November 2019. Children with TSC were recruited from among all individuals with TSC aged 6–16 years who were treated in the Department of Neurology at the Children’s Hospital of Fudan University, National Children’s Medical Center. All individuals met the latest diagnostic criteria for tuberous sclerosis [We also recruited children with typical development as the control group in the health examination center of Children’s Hospital of Fudan University and matched them by age and sex. The criteria for children with typical development were as follows: (1) typical motor and language development; (2) no history of seizures or other neurological diseases; (3) no other chronic diseases ; and (4) no first-degree relatives with a family history of mental illness. The exclusion criterion was parental refusal to provide informed consent. Children with typical development were screened by the deputy chief physician and attending physician of the neurology department, who each had more than 5 years of experience.Written informed consent was received from all participating families. This study was approved by the ethics committee of Children’s Hospital of Fudan University.After providing informed consent, parents or guardians were invited to participate in interviews, and standardized questionnaires were used to obtain demographic and clinical data. The demographic data collected were the date of birth, sex, ethnicity, parental education level, family income, and residence. The cognitive assessment was conducted using the Wechsler Intelligence Scale for Children in Chinese (WISC-C). The clinical data collected were growth and development, family history, age at onset of epilepsy, duration of epilepsy, current number of antiepileptic drugs, frequency of seizures, spasm, and TSC clinical manifestations.Parents or guardians of the children with TSC were interviewed using the MINI-KID (parent version) for children and adolescents. The Chinese version of the MINI-KID (parent version) 5.0 was translated by Liu Y.X. and other researchers from Peking University Institute of Mental Health in 2010. The study by Liu Y.X. and other studies have confirmed that the Chinese version of the MINI-KID (parent version) has good reliability and validity  and thatThe MINI-KID is a structured diagnostic scale designed according to the DSM-IV and the ICD-10. The scale has 25 modules to diagnose 24 mental illnesses and suicidal tendencies in children and adolescents between the ages of 6 and 16 years . Each moAll parents of children participating in this study were administered the questionnaire face-to-face after signing the informed consent form.P value < 0.05 was statistically significant. All analyses were performed using JMP Pro 15.0.0 software .Continuous variables are presented as the means and standard deviations (SD). Continuous variables were analyzed using the ANOVA F-test, and categorical variables were analyzed using chi-square or Fisher's exact tests. Multivariate logistic regression models were performed with each TAND risk factors as an independent variable. Those known risk or protective factors for TAND were included in our regression analysis. We adjusted for sex , maternal education (years) (≤ 9/9–12/ > 12), paternal education (years) (≤ 9/9–12/ > 12), family income (RMB)  and residence  in the adjusted model. A two-sided Our TSC cohort included 291 individuals, of which 117 (40.21%) were 6–16 years old. Sixteen people declined to participate and 86.32% (101/117) parents signed the informed consent form, but 6 individuals did not complete all the questionnaires . Ninety-five individuals  completed the questionnaire, including 46 females (48.42%) and 49 males (51.58%), whose average age was 10.02 ± 3.10 years. All participants were of the Han ethnicity (Table TSC1:TSC2:NMI (no mutation identified) ratio was 27:58:10. More sporadic cases were identified than familial cases (n = 55 VS n = 40). Sixty-seven children had an intellectual disability (ID) (IQ ≤ 70) (70.53%), 34 (35.79%) had mild to moderate ID (IQ 35–70), and 33 (34.74%) had severe ID (IQ < 35). Of the 95 children, 76 had a history of epilepsy (80.00%), and 49 of the individuals with TSC and epilepsy developed drug-resistant epilepsy (64.47%). The average age at seizure onset was 2.50 ± 3.59 years, and the duration was 7.65 ± 4.37 years. Eighty-seven individuals had cortical tubers, 86 children had subependymal nodules (SENs), and 3 individuals had subependymal giant cell astrocytoma (SEGA).All 95 children were genetically tested, and the P < 0.05)  children with TSC developed TAND. Among children with TAND, the male: female ratio was 41:38. Sixteen neuropsychiatric diseases were diagnosed, the most common of which was attention-deficit/hyperactivity disorder (ADHD) , followed by social anxiety disorder , panic disorder , specific phobia , pervasive developmental disorder (PDD) , (mild) manic episodes , agoraphobia , tic disorder  and separation anxiety disorder   in the TSC2 gene mutation group and 70.00% (7/10) in the NMI group had neuropsychiatric disorders, but the difference was not significant (P = 0.546). The rates of psychiatric disorders in individuals with different genotypes are shown in Additional file A total of 85.19% 23/27) of individuals in the 3/27 of iP = 0.03), more frequent seizure frequency (more than once a month) (P = 0.04) and use of a greater number of antiepileptic drugs (≥ 2) (P = 0.04) were closely related to the occurrence of TAND   and without TAND group (n = 16). After adjustment for sex, parents’ education, family income (RMB)  and residence, the multivariate logistic regression models found that an earlier age of onset (< 2 years) P = 0.0, more fr) P = 0.0 and use To our knowledge, this cross-sectional study of TAND using the MINI-KID is the first to be conducted, and it is also the TAND cohort study with the largest sample performed in China. The rate of neuropsychiatric disorders in children with TSC is significantly higher than in individuals with typical neurodevelopment. Consistent with previous studies, TAND is present in childhood and adolescence , 17, 18.According to Prather and de Vries et al. , 20, autAlthough the rate of anxiety was very high in previous cohorts , 17, 18,Interestingly, in our study, we identified a number of psychiatric disorders that were uncommon or unreported in previous TAND studies, such as (mild) manic episodes, oppositional defiant disorder, and obsessive–compulsive disorder. We found and reported this phenomenon. We did not consider PDD as a confounder because these individuals had relevant clinical manifestations and did not meet the diagnostic criteria for PDD in the MINI-KID. These disorders are rare but had a sufficiently high rate to draw our attention to psychiatric disorders other than the common TAND.We sought to identify the risk factors associated with the occurrence of TAND and found that an earlier onset age (< 2 years), a longer seizure duration (≥ 2 years), more frequent seizures (more than 1 seizure per month), and the use of more antiepileptic drugs (≥ 2) are closely related to the occurrence of TAND. These findings are similar to previous studies , 17, 19.In view of the high prevalence of TAND in children with TSC, this study focused on drawing the attention of pediatric neurologists to TAND for the early screening and diagnosis of neuropsychiatric disorders. Individuals with a confirmed diagnosis will be referred to the relevant psychiatrist.The Neuropsychiatry Panel offers the TAND Checklist, a simple framework for a conversation about TAND , to makeThis study has several limitations. MINI-KID is a classification, not a comprehensive diagnosis; it is not based on ICD-11/DSM-5. It does not group co-occurring conditions and does not have a hierarchy for diagnostic classification. It only examines the psychiatric level of TAND and not the many other levels as outlined in the TAND construct and TAND Checklist. The present study was a cross-sectional study of a single center, and future multicenter prospective studies are needed to further verify the results. In addition, this study used only one method to explore the mental health of children with TSC and did not use the TAND Checklist for comparison. The study population included children aged 6–16 years and excluded younger children. At the National Children’s Medical Center, we may have a biased sample of children with TSC .This study used the structured and systematic MINI-KID scale to determine the diagnosis of psychiatric co-morbidities in a relatively large sample, suggesting their higher rate. By comparing the status of individuals with TSC with typically developing children, the results suggest a significantly higher rate of neuropsychiatric co-morbidities in individuals with TSC. Moreover, individuals with TSC often present with two, three or more neuropsychiatric diseases.Additional file 1. Distribution of neuropsychiatric disorders in individuals with TSC and typically developing controls.Additional file 2. Distribution of neuropsychiatric disorders in individuals with different genotypes.Additional file 3. Analysis of factors associated with the TAND incidence.Additional file 4. Risk factors associated with TAND.