In the present study, we examined whether other colon-mutagenic non-carcinogens (CMNCs) induced colon tumors after treatment with DSS.Several rodent models with chemically induced colon cancer have been developed. Among these models, dextran sulfate sodium (DSS), a colitis inducer, combined with azoxymethane as a colon mutagenic carcinogen, is commonly used. We previously reported that although benzo anthracene, and N-ethyl-N-nitrosourea were selected as CMNCs. Male CD2F1 mice were orally administered CMNC for 5 consecutive days. After a 9-day dose-free period, mice were treated with 4% DSS in drinking water for 1 week. Three months after DSS treatment, colon samples were collected for histopathology and β-catenin immunohistochemistry analyses. All CMNCs in combination with DSS induced colonic adenocarcinomas at a high incidence/multiplicity in the distal and middle parts of the colon, coinciding with the location of colitis. Unlike in normal cells where β-catenin is exclusively located on the cell membrane, in adenocarcinoma cells, it was translocated to both the nucleus and cytoplasm or only to cytoplasm. The translocation of β-catenin is closely associated with colon carcinogenesis in rodents and humans. No colonic tumors or dysplastic lesions were found after exposure to either CMNC or DSS alone.We provided further evidence clearly showing that CMNCs can rapidly induce colonic tumors in mice with DSS-induced colitis, even if they are not colonic carcinogens. Colorectal cancer is one of the most common human cancers in the Western world . Rodent b]pyridine (PhIP) pyrene (BP), a colonic mutagen  anthracene (DMBA) induces mutations in the colon, bone marrow, liver, skin, and thymus in mice anthracene  and N-ethyl-N-nitrosourea  were obtained from Sigma-Aldrich Co. LLC . Dextran sulfate sodium  was purchased from MP Biochemicals, LLC .For administration, ENU was dissolved in water for injection at a concentration of 1.1 mg/mL, and AAT and DMBA were dissolved in salad oil  at concentrations of 12.5 and 2.5 mg/mL, respectively. DSS was dissolved in water at a concentration of 40 mg/mL (4%).Male Crj: CD2F1 (BALB/c × DBA/2) mice were obtained from Charles River Japan, Inc., Tokyo. All mice were housed in metal cages (one mouse per cage) and were fed a basal diet  and tap water ad libitum, under controlled conditions of temperature (23 ± 3 °C), humidity (55 ± 20%), and light (12-h light/12-h dark cycle). They were quarantined and acclimatized for 1 week. The animals were assigned by stratified randomization to the two groups according to their body weights; mice from both the DSS- and CMNC/DSS-groups and both the non-treatment and CMNC groups were assigned to the heavy and light groups, respectively, to minimize the mortality of light mice, given that they are likely to be more sensitive to DSS-induced colitis than heavy mice.Figure For each CMNC/DSS-group, mice (7-week old) were orally (by gavage) treated with each CMNC for 5 consecutive days, and starting 10 days after the last dose, mice were administered 4% DSS in drinking water for 7 days. Twelve weeks later, the mice were necropsied under anesthesia to collect the colorectum from the cecocolic junction to anus for histopathology and immunohistochemistry.The in-life phase of the experiment was performed at Sunplanet Co., Ltd. of the Eisai Co., Ltd. group, and the protocol was approved by the Institutional Animal Care and Use Committee and carried out according to the Sunplanet animal experimentation regulations., Pascal [During necropsy, the large intestine was immediately excised, flushed with saline, infused with 10% neutral buffered formalin, cut open longitudinally along the antimesenteric border, and grossly observed. Thereafter, the tissues were stored in 10% neutral buffered formalin, cut into four parts of equal length from the proximal to distal ends, processed, and embedded in paraffin. Each colon sample was embedded to expose both longitudinally cleaved edges. All longitudinal sections were stained with hematoxylin and eosin (H&E) and histopathologically observed. The lesions of dysplasia, adenoma, and adenocarcinoma were classified according to the criteria that were described in detail in our previous report , which w, Pascal  and Ward, Pascal . DysplasParaffin-embedded sections of mouse colons with adenocarcinomas from each CMNC/DSS group were subjected to immunohistochemical staining of β-catenin. Immunohistochemical staining was performed according to the procedure described in our previous report . Monocloi.p. dose at 300 mg/kg, corresponding to 40% of LD50  [i.p. dose at 20 mg/kg [i.p. doses at 22.2 mg/kg/day (once a week for 5 weeks) [The doses of AAT (125 mg/kg/day), DMBA (25 mg/kg/day), and ENU (11 mg/kg/day) tested in this study were determined based on our preliminary study (data not shown) or the studies to measure the mutant frequency in mice; for AAT, a single al dose) , 27, for20 mg/kg  and for 5 weeks) .t-test for paired samples.The incidences and multiplicities were compared using Fisher’s exact probability test and Welch’s In DSS-treated mice, with or without CMNC, bloody and/or soft stools were observed for 1 or 2 days before the last DSS treatment. Stool changes resolved by 5 days after DSS treatment cessation and were attributed to colitis. In the CMNC/DSS groups, three mice that developed tumors showed bloody stools from 9 weeks after the last DSS treatment.The gross findings are shown in Fig. In the CMNC/DSS- and DSS-groups, the large intestine was shorter in length, and the intestinal wall showed irregular thickening. Histopathologically, colitis with or without erosion or ulceration was noted in the distal and middle parts of the colon. In animals with colitis, there was occasional accumulation of foamy macrophages in the lamina propria.Table The expression of the β-catenin protein in adenocarcinomas is shown in Fig. We previously reported that in mice administered BP, a CMNC, the formation of colon tumors was rapidly induced after DSS treatment , 24. In APC genes or activation of the Wnt/β-catenin signaling pathway [All tumors whose formation was induced by the three CMNC/DSS were histologically diagnosed as tubular adenomas or well- to moderately differentiated adenocarcinomas. These tumors predominantly appeared in the middle and distal parts of the colon, coinciding with the location of DSS-induced colitis. These findings were consistent with those reported for DSS in combination with BP or CMCs such as AOM, DMH, and PhIP , 7–12. I pathway , 40–43.MeIQx, a heterocyclic amine found in well-cooked meat, is mutagenic but not carcinogenic in the colon of mice . One stuIn rodent chemical-induced colon cancer models, CMCs, particularly AOM, are commonly used in combination with DSS. Our present and previous studies , 24 provFigure APCMin/+ mice  or even APC+/+ mice (wild-type at the Apc locus) are intraperitoneally treated with ENU, although the ENU does not induce colonic tumors when adult mice, generally used in toxicity studies, are orally treated [The colon becomes the site of tumor induction when juvenile  treated , 35, 51. treated .APCMin/+ mice are treated with ENU [Colon tumors are induced when adult with ENU . This fiSince the present study with the three colonic mutagens was performed under the same experimental conditions, the potency of their carcinogenicity in this model may be correlated and can be compared. The most powerful initiation activity was estimated to be that of ENU (0.33), followed by that of DMBA (0.060) and AAT (0.033), by calculating the multiplicity of adenocarcinoma divided by the dose (mg/kg/day).The purpose of the present study was to provide evidence on the hypothesis that CMNCs act as initiators of carcinogenesis in a DSS-induced colitis model. Our study may help better understand the effects of environmental mutagens on inflammation-related cancer. Increasing attention has been paid to the involvement of inflammation in the initiation, promotion, and progression of tumors –56. PatiIn our previous study, BP of a CMNC rapidly induced the formation of colonic tumors in mice after DSS treatment. In the present study, we clearly showed further evidence that the other three CMNCs  also rapidly induced the formation of colonic tumors in mice after DSS treatment. These findings indicate that colonic mutagens can cause colonic tumors in the presence of colitis due to DSS, regardless of whether they are carcinogenic in the colon.


Aridity, which is increasing worldwide due to climate change, affects the biodiversity and functions of dryland ecosystems. Whether aridification leads to gradual (or abrupt) and systemic (or specific) changes in the biogeography of abundant and rare microbial species is largely unknown. Here, we investigated stress-adaptive changes  and biogeographic patterns of abundant and rare bacterial communities in different habitats, including agricultural field, forest, wetland, grassland, and desert, in desert oasis transition zones in northern China. We observed abrupt changes at the breakpoint of aridity values (0.92), characterized by diversity (α-diversity and β-diversity), species coexistence, community assembly processes, and phylogenetic niche conservatism. Specifically, when aridity was <0.92, increasing aridity led to more deterministic assembly and species coexistences for the abundant subcommunity, whereas the reverse was observed for the rare subcommunity. The phylogenetic niche conservatism for both subcommunities increased slowly with aridity. When aridity was >0.92, the systemic responses of abundant and rare taxa changed dramatically in a consistent direction, such that both subcommunities rapidly tended to have a more deterministic assembly, species coexistence, and stronger phylogenetic niche conservatism with increasing aridity. In addition, the change rates of abundant taxa were higher than those of rare taxa, indicating the more sensitive responses of abundant taxa along aridity variation. This finding has important implications for understanding the impact of aridity on the structure and function of abundant and rare soil taxa and how diversity maintenance is associated with soil microbiota responding to global change. The abrupt threshold of soil bacteria found can be used for buffering and for building effective adaptation and mitigation measures aimed at maintaining the capacity of drylands for basic ecosystem functioning.IMPORTANCE Aridity, which is increasing worldwide due to climate change, affects the biodiversity and functions of dryland ecosystems. We provided the first statistical evidence for abrupt changes of species coexistence, ecological processes, and niche conservation of abundant and rare soil bacteria triggered by diversity to abrupt increases in aridity. The abrupt threshold of soil bacterial community response to aridity is spatially heterogeneous at the local scale and should be specified according to local conditions for buffering and for building effective adaptation and mitigation measures aimed at maintaining the capacity of drylands for basic ecosystem functioning. Research on microbial biogeography is indispensable to deciphering the mechanisms that generate and maintain microbial diversity and to predict how soil processes respond to climate change –3. Great–8–Drylands, areas characterized by aridity  values of >0.65 , cover mDisentangling the mechanisms underlying microbial community assembly and species coexistence is a central issue in microbial ecology , 21–24. 21–Phylogenetic distribution of microbial functional traits could aide in the prediction of microbial community response to global change . Despite32–Here, we aimed to answer whether biogeography and community assembly of abundant and rare soil bacteria exhibited nonlinear responses with increasing aridity. We addressed this question using the high-throughput sequencing data sets , 37 of sAs expected, abundant taxa constituted a relatively low proportion of operational taxonomic units (OTUs)  but accounted for 53.5% of the average relative abundance in each sample. Conversely, rare taxa constituted a high proportion of the OTUs , while they contributed to an average of only 12.4% of the relative abundance in each sample. To disentangle the potential main contributors of α-diversity of abundant and rare taxa in terrestrial ecosystems, we applied random forest (RF) analysis . The res10.1128/mSystems.01309-21.1FIG S1P < 0.05; **, P < 0.01; ***, P < 0.001. Download FIG S1, TIF file, 1.2 MB.Heatmaps of correlation (Spearman’s) coefficients between microbial α-diversity all individual soil and climate factors of abundant and rare subcommunities in different habitats and soil depths. The shading from white to red represents low-to-high positive correlation, while the shading from white to blue represents low-to-high negative correlation. *, Copyright © 2022 Pan et al.2022Pan et al.https://creativecommons.org/licenses/by/4.0/Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the We observed that the changes in bacterial α-diversity for abundant and rare taxa with aridity exhibited a nonlinear trend . Specifi10.1128/mSystems.01309-21.2FIG S2P < 0.001). Download FIG S2, TIF file, 2.2 MB.Aridity-driven patterns of α diversity of abundant and rare subcommunities in different habitats and soil depths. Asterisks denote significant differences  (P < 0.01) (P < 0.05)  based on MNTD metric (βMNTD) indicated that aridity had the strongest effects on the community structure of abundant and rare taxa . The cor< 0.001)  and soil < 0.01)  on eithe < 0.01) . The inc < 0.01) . Additio < 0.05) .10.1128/mSystems.01309-21.3FIG S3P < 0.05; **, P < 0.01; ***, P < 0.001. Download FIG S3, TIF file, 1.3 MB.Heatmaps of correlation (Spearman’s) coefficients between β-diversity for all individual soil and climate factors of abundant and rare subcommunities in different habitats and soil depths. The shading from white to red represents low-to-high positive correlation, while the shading from white to blue represents low-to-high negative correlation. *, Copyright © 2022 Pan et al.2022Pan et al.https://creativecommons.org/licenses/by/4.0/Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the 10.1128/mSystems.01309-21.4FIG S4P < 0.001. Download FIG S4, TIF file, 2.9 MB.β-Diversity trends under different habitats and soil depths of abundant and rare subcommunities. Nonmetric multidimensional scaling (NMDS) based on MNTD metric (βMNTD) analysis results showing the differentiations of β-diversity for abundant and rare subcommunities at an aridity level of 0.92 in different habitats (a) and soil depths (b). (c) The distance–decay relationships (DDRs) based on βMNTD between community similarity of abundant and rare subcommunities. The similarities of communities were tested by Adonis. ***, Copyright © 2022 Pan et al.2022Pan et al.https://creativecommons.org/licenses/by/4.0/Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the 10.1128/mSystems.01309-21.5FIG S5P < 0.001. Download FIG S5, TIF file, 2.9 MB.Changes of community dissimilarity (NMDS1) of abundant and rare taxa along aridity gradients in different habitats and soil depths. ***, Copyright © 2022 Pan et al.2022Pan et al.https://creativecommons.org/licenses/by/4.0/Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the The ecological processes shaping bacterial community assembly were explored using composition  based on null-model analysis. RF analysis showed that aridity was identified as the most important contributor to the assembly of both the abundant and rare subcommunities . The relGiven the previous phase transitions, we then built metacommunity co-occurrence networks based on correlation relationships to estimate whether species coexistence patterns of abundant and rare taxa exhibited abrupt changes with increasing aridity. The network analyses showed that higher aridity stress (aridity of >0.92) led to a more complex network for abundant taxa but less obvious changes for rare taxa . We foun10.1128/mSystems.01309-21.6FIG S6P < 0.05; **, P < 0.01; ***, P < 0.001. Download FIG S6, TIF file, 2.4 MB.Piecewise regression fitting of network topological parameters with increasing aridity in 14 average clusters of all samples of abundant and rare subcommunities. Solid lines in green and orange represent the fitted linear OLS model with aridity values of <0.92 and >0.92, respectively. The dashed line represents the potential trends between topological features and increasing aridity fitted by locally weighted regression (Loess) under the aridity gradient. *, Copyright © 2022 Pan et al.2022Pan et al.https://creativecommons.org/licenses/by/4.0/Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the P < 0.001)  compared with the corresponding rare taxa, confirming their higher level of trait conservatism . As note< 0.001) .We further examined the relationships between biodiversity and ecosystem function redundancy index (FDR) of abundant and rare taxa revealed a positive abrupt change along aridity gradients, but only that of abundant taxa was significant . Strong Understanding the interrelated responses of biodiversity, ecological processes, and niche conservatism to increasing aridity is crucial for improving forecasts of ecosystem responses to climate change. There is modeling and empirical evidence that multiple ecosystem functional and structural characteristics undergo abrupt discontinuous transitions and follow a series of sequential ecological thresholds in relation to increases in aridity , 20, 38.Our results showed that soil bacterial α-diversity of abundant and rare taxa responded to increases in aridity in a nonlinear manner, consistent with previous studies that investigated on broader scales –42. The –In the dryland ecosystem, weak correlation of phylogenetic DDRs, but strong correlation between community dissimilarity and increasing aridity, were observed for both abundant and rare taxa, indicating microclimatic heterogeneity caused by aridity outweighs the effect of spatial isolation on microbial diffusion limitation. Our results showed that community dissimilarity also exhibited a segmented increase pattern with increasing aridity. The nonlinear response of soil nematode was also observed in the 3,200-km east-west-oriented grassland transect in northern China . The posIn our study, abundant taxa showed stronger phylogenetic signals for ecological preferences than rare taxa, which indicated that related species in abundant taxa have more similar ecological preferences over environmental gradients. Recent studies in a variety of ecosystems  support our findings , 49, 50.55–Understanding the community assembly mechanisms to increasing aridity is crucial to revealing the stability and tolerance of biodiversity and function for future climate change , 15, 20.61–In addition, we found that the node-level topological features of abundant taxa decreased significantly with increasing aridity, while the topological features of rare taxa were not significant under lower aridity stress. Both increased rapidly under higher aridity stress, indicating that the abundant taxa were strongly filtered across the aridity gradient, while rare taxa were only selected by the environment under higher aridity stress. We observed faster response rates of abundant taxa with increasing aridity than that of rare ones, indicating that abundant taxa are more sensitive to the intensification aridity than rare taxa. Thus, abundant species could act as the indicators for predicting the response of ecosystem attributes to aridity extremes, and rare taxa might be the microbial seed bank to enhance the resistance or resilience of soil microbiota and play a potential role in maintaining ecosystem stability under serious global aridification. This might be the ecological implications for the investigation of aridity threshold for rare and abundant taxa. It must be acknowledged that our results found the critical aridity level for soil bacterial community collapse to be >0.9, which is higher than the threshold of soil fungus disruption (aridity levels of >0.7) based on global data sets in the recent report . This maTo the best of our knowledge, we systematically provided the first statistical evidence of abrupt adaptation of species coexistence, ecological process, and niche conservation for abundant and rare soil bacteria triggered by diversity to abrupt increases in aridity. Our results underscore that abundant microbial taxa show better ecological adaptation than rare taxa in terrestrial ecosystems to increases in aridity. This finding has important implications for understanding the impact of aridity on the structure and function of abundant and rare soil taxa and how diversity maintenance is associated with soil microbiota responding to global change. Eventually, the abrupt threshold of soil bacteria found can be used for buffering and for building effective adaptation and mitigation measures aimed at maintaining the capacity of drylands for basic ecosystem functioning.Zea mays L. , Calligonum spp., Stipa spp., Leymus spp., Achnatherum spp. , and Populus spp. (forest) cover most of these habitats. Long-term wind erosion and aridity caused by semiarid climate has formed a soil with loose structure and low organic matter in the Hexi Corridor.Soil samples were collected along the Hexi Corridor in the northwestern portion of Gansu Province and to the west of the Yellow River in China , as described by Jiao et al. . In totahttp://data.cma.cn). Aridity index  was extracted from the CGIAR-CSI Global-Aridity and Global-PET database , latitude (Lat), and elevation, were recorded using a handheld GPS unit . MAT and MAP  data for each sampling site were obtained from a national climate database (database . Aridity4), nitrate-nitrogen (NO3), microbial biomass nitrogen (MBN), total phosphorus (TP), available phosphorus (AP), total potassium (TK), available potassium (AK), and cation exchange capacity (CEC), were measured through standard testing methods, as described previously (GTGCCAGCMGCCGCGG) and the reverse primer 907R (CCGTCAATTCMTTTRAGTTT) , dissolved organic carbon (DOC), microbial biomass carbon (MBC), total nitrogen (TN), ammonia-nitrogen   were useTRAGTTT) . Paired-TRAGTTT) . Counts TRAGTTT) . In totaOTUs that contained fewer than 20 reads were removed to avoid random effects on the identification of rare taxa . To accoThresholds can occur only if nonlinear regression is a better fit for the data. We considered a threshold the point in aridity when a given variable sharply changes its value (breaking point) . Thus, fWe applied Blomberg's K statistics to characterize the depths of trait conservatism for aridity response in abundant and rare bacterial taxa, as calculated with the “multiPhylosignal” function in the “picante” package of R. The K values quantified the correlation between species and phylogeny, similar to the estimation of phylogenetic intensity of Brownian motion: higher K values (>1) mean deeper phylogenetic signals and niche conservatism, whereas lower K values (≈0) indicate a convergent or random pattern of evolution. In addition, niche breadths of abundant and rare taxa were calculated with the “niche.width” function in the “spaa” package of R according to Levins , 79.P values for multiple testing using false discovery rate of less than 0.01 were used to construct these networks. To describe the topology of the networks, we calculated a set of metrics, average degree, average path length, clustering coefficient, density, diameter, heterogeneity, and centralization, through the “microeco” package  we determined the Spearman's correlation between the microbial diversity in abundance, habitat type, soil depth, and environmental factors, and (ii) RF analysis was applied to identify the main factors including soil and climate variables influencing the microbial diversity and community assembly process. The mean squared error (MSE) values of each variable were sorted to characterize the relative importance, and the larger values indicated higher importance . FinallyNormalized stochasticity ratio (NST) was utilized to quantify the relative importance of responding to increases in aridity in the process of community assembly dynamic of abundant and rare taxa . The NSTThe functional redundancy index (FRI) was used to describe functional profiling of rare and abundant taxa. The absolute FRI was based on the proportion of abundant and rare taxa with a predicted function using the ‘‘FAPROTAX” package in R .http://bigd.big.ac.cn/gsa.The raw sequence data reported in this paper have been deposited in the Genome Sequence Archive  and in t10.1128/mSystems.01309-21.7FIG S7FIG S7, TIF file, 1.5 MB.Changes of relative abundances of most dominant phyla at both ends of the aridity threshold for abundant and rare taxa. Download Copyright © 2022 Pan et al.2022Pan et al.https://creativecommons.org/licenses/by/4.0/Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the


Single-tablet regimens (STRs) should be considered for patients with HIV/AIDS to increase medication compliance and improve clinical outcomes. This study compared variations in the prescription trends between STRs and multiple-tablet regimens (MTRs) for treatment-naïve patients with HIV/AIDS after the approval of the new STRs, a proxy indicator for improvement in medication adherence. The medical and pharmacy claim data were retrospectively obtained from the Health Insurance Review and Assessment service, which contains basic information on the patients’ sociodemographic characteristics and treatment information for the entire Korean population. From 2013 to 2018, a total of 6737 patients with HIV/AIDS were included. Most patients were men  and insured through the National Health Insurance . The mean number of pills in their antiretroviral treatment regimens decreased from 2.8 ± 1.2 in 2013 to 1.2 ± 1.0 in 2018. After the first STR (EVG/c/TDF/FTC) was approved in 2014, prescription transitions from MTR to STR were observed among more than 38% of patients. In 2018, most treatment-naïve patients were prescribed STRs (91.2%). There was a time lag for STR prescription trends in non-metropolitan hospitals compared with those in metropolitan cities. Our data provide a valuable perspective for evaluating ART regimen prescription patterns on a national scale. This achievement was made possible in part thanks to the Joint United Nations Program on HIV/AIDS2. The goal of the program, called the 90–90–90 target, was to diagnose 90% of all HIV-positive persons, provide antiretroviral therapy (ART) for 90% of those diagnosed with HIV/AIDS, and achieve viral suppression for 90% of patients on medication by 20202.Over the 30 years since the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) was first recognized, the HIV/AIDS epidemic has remarkably transitioned from a fatal disease to a chronic illness with patients living with HIV/AIDS4. Early ART regimens were based on the administration of more than 20 pills, 3 times a day. Standard ART recommendations stipulate that the regimen contains at least 3 active drugs from 2 or more classes. In most cases, this consists of partial regimens combining 2 nucleoside reverse transcriptase inhibitors (NRTIs)—zidovudine (ZDV)/lamivudine (3TC), abacavir (ABC)/lamivudine (3TC), or tenofovir (TDF)/emtricitabine (FTC)—and 1 of the following: boosted protease inhibitor (PI) (lopinavir/ritonavir), nonnucleoside reverse transcriptase inhibitors (NNRTIs) (efavirenz or rilpivirine), or integrase strand transfer inhibitors (INSTIs) 6. Such multiple-tablet regimens are certainly not easy for adherence by patients with HIV/AIDS. Regimen characteristics, such as the complexity of the treatment regimen, long treatment duration, and frequent medication changes, have been associated with medication non-adherence7. Therefore, the World Health Organization (WHO) has recommended using simplified fixed-dose combination regimens for common chronic diseases, such as hypertension, tuberculosis, and HIV infection. Today, once-a-day antiretroviral treatment is recognized as the standard medication for people living with HIV/AIDS8.The key to viral suppression is maintaining a potent and sustainable regimen to which people living with HIV/AIDS can easily adhere. In this sense, guidelines from the United States Department of Health and Human Services and the European AIDS Clinical Society recommend ART with combination regimens and emphasize adherence to the ART for all individuals infected with HIV/AIDS10. The first STR that combined TDF, FTC, and efavirenz (EFV) became available globally in 2006. Many medical professionals believed that the STRs would not only reduce the patients’ pill burden and improve their quality of life but also improve medication adherence and, consequently, the probability of virologic suppression. Retention in care and virologic suppression has been achieved in the patients started on STRs12. Patients on STRs were more likely to achieve good medication adherence and had fewer hospital admissions than patients on multi-tablet regimens (MTRs)13. Increases in STR prescriptions were significantly associated with medication adherence14, which led to improved quality of life and better clinical outcomes among patients with HIV/AIDS15. Given that adherence is an essential feature in the prevention of the emergence and replication of drug-resistant strains of HIV, STRs have become an important tool to manage appropriate medication adherence19.The fixed-dose combinations represented by single-tablet regimens (STRs) should be considered for patients with HIV/AIDS to increase medication compliance and, consequently, improve their clinical outcomes20. About 1100 new patients with HIV/AIDS cases have emerged every year since 2013. To optimize ART for patients, the STR strategy was proposed in Korea, too. The first STR combining TDF, FTC, cobicistat (c), and elvitegravir (EVG) was approved in 2014 in Korea. During the 10 years between 2007 and 2018, the time when this research was conducted, there were 4 STRs available: (1) elvitegravir (EVG)/cobicistat (c)/tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) (approved in March 2014); (2) rilpivirine (RPV)/TDF/FTC (approved in December 2014); (3) dolutegravir (DTG)/ABC/3TC (approved in November 2015); and (4) EVG/C/tenofovir alafenamide fumarate (TAF)/FTC (approved in February 2017). This study compared variations in the prescription trends between STRs and MTRs for treatment-naïve patients with HIV/AIDS after the approval of the new STRs, a proxy indicator for improvement in medication adherence, using the national insurance claims data in Korea.In Korea, the incidence of HIV/AIDS has consistently increased since the first case of HIV/AIDS infection in 1985Table Since the approval of the first STR, EVG/c/TDF/FTC, in 2014, four STRs have become available sequentially (Supplementary Table After the first STR (EVG/c/TDF/FTC) was approved in 2014, prescription transitions from MTR to STR were observed by more than 38% of patients, whereas NNRTI-based and PI-based MTR rates were reduced by 18.6% and 19.9%, respectively, in 2014. The proportion of patients initiating ART with STRs increased to 86.7% in 2016 after DTG/ABC/3TC was approved. In 2018, most patients who started ART were prescribed STR  as their first HIV/AIDS treatment medication  with one INSTI-based agent (EVG). In the same year, the second single-complex combination, RPV/TDF/FTC, was approved. It contains an NNRTI (RPV) with the same combination of 2 NRTIs (TDF and FTC). Notwithstanding, EVG/c/TDF/FTC, the first approved STR, was the most frequently prescribed STR from 2014 to 2015. INSTI-based regimens containing the novel ingredients DTG or EVG replaced previously preferred MTRs. EVG/c/TDF/FTC has been replaced by EVG/c/TAF/FTC since 2017. Notably, there were no RPV/TDF/FTC prescriptions for treatment-naïve patients after its approval in 2014. Eventually, RPV/TDF/FTC, which had not been claimed for reimbursements for 2 years, was deleted from the National Formulary list in 201725. On the other hand, elvitegravir (EVG) is a recently developed INSTI, and it has been recognized for its excellent efficacy and tolerability. Additionally, it is rarely associated with treatment resistance. EVG/c/TDF/FTC can be prescribed to all patients regardless of HIV-RNA levels, and thus, clinicians have selected EVG/c/TDF/FTC for various patient groups. Furthermore, RPV/TDF/FTC must be taken with at least 400 cal of food, whereas EVG/c/TDF/FTC prescriptions have no restrictions on concomitant food intake26. These disadvantages associated with specific ART regimens can affect the choices of clinicians who consider medication adherence and convenience.Physicians favored EVG/c/TDF/FTC over RPV/TDF/FTC because of the latter’s limited and complex indications. Moreover, RPV/TDF/FTC has been associated with high virologic failure rates and drug-resistant mutations, with failures occurring among patients with baseline HIV-RNA viral loads > 100,000 copies/mL or CD4 cell counts < 200 mm25. EVG/c/TAF/FTC, which was approved in 2017 in Korea, reduced the adverse effects of the previously approved EVG/c/TDF/FTC. TAF is a tenofovir prodrug that results in a 90% reduction in plasma tenofovir concentrations compared with TDF, and it is, therefore, associated with fewer tenofovir-related adverse effects in the kidneys and bone19. As soon as DTG/3TC/ABC was approved, its prescription rate increased rapidly because of its better therapeutic effects; however, no such increase was observed for EVG/c/TAF/FTC. These findings imply that both convenience and improvements in therapeutic scope are important considerations for physicians and patients deciding on ART regimens.We observed a remarkable change in ART prescription patterns after the launch of DTG/ABC/3TC and EVG/c/TAF/FTC. Dolutegravir (DTG) is a second-generation INSTI and is highly active against drug-resistant HIV strains, including strains resistant to first-generation INSTIs. DTG/ABC/3TC is recommended for once-daily treatment and can be taken more easily, with or without food27. There is a higher proportion of young people in metropolitan areas, so new STRs, which can be taken more easily and have fewer adverse effects, may be preferred by younger patients in these areas. The general pattern of ART prescription trend changes was similar in non-metropolitan areas relative to that observed in metropolitan areas—declining MTR prescriptions and increased uptake of STR—albeit with a time lag in non-metropolitan areas.STR prescription rates were higher in metropolitan areas than elsewhere between 2014 to 2016. This pattern may be due to demographic factors29. Second, we were unable to evaluate whether the ART choices were the clinically optimal regimen , as we only relied on insurance claims data for reimbursement purposes.This study had some limitations. First, we did not include clinical outcomes showing how the STRs increased patient compliance, influenced virologic suppression, or reduced tolerance. However, previous studies have demonstrated STRs are important determinants of medication adherenceDespite these caveats, our data provide a valuable perspective for evaluating ART regimen prescription patterns on a national scale, compared with studies using data on ART regimens from medical records in selected clinics. Our results imply that the preferences among the single fixed-dose combination options are determined not only based on administration convenience  but also fewer adverse effects. Although newer regimens are preferred, a new effective ingredient (DTG) was selected more frequently than an alternative component (TAF), despite the latter’s smaller adverse effect profile.As HIV/AIDS patients get older over time, they are likely to develop comorbidities. Therefore, additional studies are warranted to clarify the relationship between medication adherence and clinical outcomes, including the adverse effects of ART medication and comorbidities, such as diabetes and dyslipidemia. We need to continue efforts to optimize ART adherence to manage HIV/AIDS as a chronic disease, particularly for patients with multiple comorbidities and psychosocial difficulties.31. Furthermore, all medical institutions and local pharmacies are compulsory participants of the National Health Insurance and National Medical Aid programs. All medical expenditures within the National Health Insurance and National Medical Aid programs are monitored for reimbursement by the HIRA. The HIRA claims database contains basic information on patients’ sociodemographic characteristics and information on diagnoses, prescriptions, or diagnostic procedures, and it covers the entire Korean population of approximately 50 million individuals32.The medical and pharmacy claims database was retrospectively obtained from the Health Insurance Review and Assessment (HIRA) service. In Korea, 97% of the total population are the mandatory beneficiaries of National Health Insurance, and the remaining 3% are recipients of the National Medical Aid program, the public assistance system for health services for people in the lowest economic bracket33. With the internal code in the first visit, out-of-pocket payments are waived for patients with HIV. Those who were prescribed at least 1 ART prescription during 2007–2018  remained. Third, we excluded individuals who started ART before 2013 (n = 6240), given that the first STR, EVG/c/TDF/FTC, was approved in March 2014 in Korea. Then, we excluded those under 20 years of age (n = 230), those who received ART prescriptions for pre-exposure prophylaxis (PrEP) or incomplete prescriptions  (n = 208), and those who switched regimens within 2 weeks from the ART initiation (n = 233). Among the remaining 13,648 patients, 6737 patients were considered as HIV/AIDS treatment-naïve and included in the final sample for the present study , over 10 years, between 2007 and 2018 . Second, among these, we excluded individuals who did not have a specified internal code for HIV/AIDS, indicating rare diseases, i.e., V103, in the first medical claim with an HIV/AIDS diagnosis  or ART prescription (n = 1585)34. We separately identified ART initiation dates at outpatient visits and during hospital admissions. Index regimens were grouped as an STR versus MTR based on the number of pills in the regimen. Based on the treatment guidelines for initial ART administration to consist of 2 NRTIs combined with a third agent, we categorized MTR types, such as NNRTI, boosted PI or PI-based, INSTI, and NRTI-sparing (boosted protease inhibitor plus INSTI)28. The medical institutions were categorized as tertiary general hospitals, which are designated by government accreditation every three years based on the proportion of severe diseases versus others. Hospital locations were grouped as metropolitan areas, including the capital city, versus other regions35.Sociodemographic characteristics were accessed at the initial ART prescription, which was used as the index date for each subject. The analyzed sociodemographic characteristics included sex, age, and national health insurance premium level as a proxy for income. Age at the index date was categorized by 10-year intervals starting at 20 years of age2 test. All analyses were performed using Stata 15 .All descriptive results are given as total numbers and percentages. Comparisons of percentages were performed using the χThis study was approved by the Institutional Review Board of Yonsei University, which waived the requirement for informed consent due to the study’s use of existing secondary claims data obtained from HIRA . The study was performed in accordance with relevant guidelines and regulations.Supplementary Figure 1.Supplementary Figure 2.Supplementary Table 1.Supplementary Legends.


High normal levels of thyroid-stimulating hormone (TSH) have been reported to be associated with chronic kidney disease (CKD) among euthyroid individuals. However, there has been only limited research on the association between TSH and proteinuria, a major risk factor for the progression of renal disease.A cross-sectional study of 1595 euthyroid individuals was conducted. All participants were within the normal range for free triiodothyronine (T3), free thyroxine (T4), and TSH. Analyses were stratified by thyroid cyst status to test the hypothesis that the absence of thyroid cysts, an indicator of latent thyroid damage, is associated with declining ability to synthesis thyroid hormone.For participants with thyroid cysts, a significant inverse association between TSH and proteinuria was observed  of log-transformed TSH for proteinuria 0.40 ). In participants without thyroid cysts, a significant positive association between those two factors was observed ).Among euthyroid individuals in the general population, being in the normal range of TSH was found to have an ambivalent association with proteinuria. Thyroid cyst status could be an effect modifier for those associations. High normal levels of thyroid-stimulating hormone (TSH) have been reported to be associated with decreased glomerular filtration rate (GFR)  and chroProteinuria is a major risk factor for the progression of renal disease . TherefoAnti-thyroid peroxidase antibody (TPO-Ab) is inversely associated with thyroid cysts in individuals with normal thyroid function . Since tIn addition, demands for thyroid hormone might decrease with aging . Since iFurthermore, thyroglobulin plays a crucial role in the activation and synthesis of free triiodothyronine (T3) and free T4 . The fluUpon demand, TSH is secreted in the pituitary ground and activates the thyroid to increase peripheral free T3 and free T4 levels. Therefore, if the thyroid is functioning appropriately, TSH levels indicate the ability to synthesize thyroid hormone. However, if thyroid function declines, TSH levels indicate thyroid hormone deficiency, a risk factor for proteinuria.Since individuals with thyroid cysts might benefit from the activation and production of thyroid hormones , 9, we hThe aim of the present study was to clarify the associations between TSH and proteinuria stratified by thyroid cyst status by studying a Japanese general population with free T3, free T4, and TSH levels in the normal range.To clarify the influence of benign thyroid disease such as cysts and nodules on health, a thyroid survey was started in 2014. In 2014, 1883 individuals aged 40–74 years participated in this survey. Based on this survey, we found that thyroid cysts could have clinical relevance, even though they were generally regarded as clinically insignificant , 8, 9. SIn this cross-sectional study, the study population comprised 1883 Japanese individuals aged 40–74 years from the town of Saza in western Japan. These individuals underwent an annual medical check-up in 2014 as recommended by the Japanese government.n = 60); had missing data thyroid function such as TSH, free T3, and free T4 levels (n = 17); or who were out of the normal range for T3 (2.1–4.1 pg/mL), T4 (1.0–1.7 ng/dL) (n = 77). Individuals out of the normal range for TSH (0.39–4.01 μIU/mL) were also excluded (n = 126).To avoid the influence of thyroid disease, individuals were excluded if they had a history of thyroid disease (n = 1) or blood pressure (n = 1) were also excluded. Individuals were also excluded if data from serum tests (n = 4) or drinking and smoking status (n = 2) were missing. The study included 1595 participants, with a mean age of 60.5 years (standard deviation (SD), 9.1; range 40–74).Individuals without data on body mass index (BMI) (2). Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were recorded at rest.Trained interviewers obtained information on clinical characteristics. Body weight and height were measured with an automatic body composition analyzer  to calculate BMI  at the LSI Medience Corporation . Normal ranges for free T3 (2.1–4.1 pg/mL), free T4 (1.0–1.7 ng/dL), and TSH (0.39–4.01 μIU/mL) based on this method were reported . HemogloThe presence of thyroid cysts was determined by experienced ultrasound technicians using a LOGIQ Book XP with a 10-MHz transducer . For the present study, a thyroid cyst was defined as a structure with a maximum diameter of ≥ 2.0 mm and no solid components , 8, 9.Spot urine dipstick was used to assess for the presence of proteinuria. Proteinuria was diagnosed as +1 or above.In order to validate the study population in the present study, goodness of fit was evaluated using the Hosmer-Lemeshow test.To evaluate the secretory capacity of the pituitary gland, Jostel’s TSH index (TSHI) was calculated . To evalCharacteristics of the study population were expressed as means ± SD, except for sex, daily drinker or current smoker status, and TSH. Sex and daily drinker or current smoker status were expressed as percentages. Since TSH values had a skewed distribution, log-transformed TSH values were used for analysis. TSH values were expressed as medians . We also evaluated sex- and age-adjusted values of thyroid hormones (free T3 and free T4) associated with the status of thyroid cysts using analysis of covariance (ANCOVA).Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) to determine the association between proteinuria and thyroid cysts and between proteinuria and TSH.2), smoking status , drinking status , SBP (mmHg), HbA1c (%), TG (mg/dL), and HDLc (mg/dL). We also stratified analyses by thyroid cyst status. For sensitivity analysis, we conducted sex-specific analyses using age-adjusted models. We also evaluated associations between log-transformed TSH values and proteinuria in participants without reduced renal function (defined as GFR ≥ 60 mL/min/1.73 m2). All statistical analyses were performed with SAS for Windows . P values < 0.05 were regarded as statistically significant.Two adjustment models were used. Model 1 adjusted for sex and age. Model 2 adjusted for variables in model 1 and potential confounding factors directly associated with thyroid function: BMI  were diagnosed as having thyroid cysts and 86 (5.4%) were diagnosed with proteinuria.Table p = 0.980), whereas the least square mean (standard error) free T4 was 1.25 (0.004) ng/dL and 1.25 (0.01) ng/dL (p = 0.530), respectively.To avoid the influence of sex and age, adjusted values for free T3 and free T4 values in participants with and without thyroid cysts were calculated. The least square mean (standard error) free T3 was 3.17 (0.01) pg/mL in participants with thyroid cysts and 3.17 (0.001) pg/mL in participants without thyroid cysts  and 1.84  for men. The corresponding values for women were 0.31  and 2.36 .Results of additional analysis limited to participants without reduced renal function are shown in Table p values for this interaction were 0.001 in the sex- and age-adjusted model and < 0.001 in the fully adjusted model. Goodness of fit was validated for the present study population stratified by thyroid cyst status (p ≥ 0.05) (not shown in table).Investigations of the associations between log-transformed TSH and thyroid cyst status and proteinuria revealed a significant interaction. The adjusted The major finding of the present study with euthyroid participants from a general population was that there is a significant inverse association between TSH and proteinuria in individuals with thyroid cysts and a significant positive association between those two factors in individuals without thyroid cysts. Thus, thyroid cyst status could affect the association between TSH and proteinuria.Among euthyroid individuals, high normal levels of TSH have been reported to be associated with decreased renal function , 2. A prThyroid hormones play a protective role in the kidney through the inhibition of nuclear factor-κB pathways, possibly by affecting the pro-inflammation and anti-inflammation balance that affects the development of CKD . AnotherProteinuria is a major risk factor of renal disease progression . ProteinTSH, by definition, stimulates the secretion of thyroid hormones. In the present study, for participants with thyroid cysts, TSH was found to be significantly inversely associated with proteinuria. For participants without thyroid cysts, TSH was found to be significantly positively associated with proteinuria. Because similar TSHI values were observed between euthyroid participants with and without thyroid cysts, pituitary function is not the best explanation for these paradoxical results.Previously, TPO-Ab titers were revealed to be inversely associated with thyroid cysts among 1432 Japanese individuals with normal thyroid function . When adjusted for known cardiovascular risk factors, the OR and 95% CI for thyroid cyst with respect to log-transformed TPO-Ab titer was 0.67  , latent However, in the present study, similar SPINA-GT and SPINA-GD were observed in individuals with versus without thyroid cysts. All participants in this study were within the normal range for free T3, free T4, and TSH. Therefore, different levels of thyroid hormone demand between euthyroid individuals with and without thyroid cysts might be the basis for those associations.Energy that is necessary for living is mainly produced in the mitochondria. Growth differentiation factor-15 (GDF-15), a potential biomarker of mitochondrial dysfunction, is elevated in aging and age-related disorders , 28. HowOn the other hand, since decreased thyroid function may lead to extended longevity , aging pTherefore, to maintain energy homeostasis and to adapt to age-related physical changes, the thyroid might make fine adjustments within the normal range of thyroid hormone and TSH levels. Thus, thyroid hormone demand, rather than serum levels of thyroid hormone and TSH, could be an important determinant for this adjustment.Individuals with thyroid cysts are typically older than those without thyroid cysts , 30, 31.Furthermore, in our previous study of 1020 participants in the normal range for free T3 and free T4 and not taking anti-hypertensive medications, the presence of a thyroid cyst was positively associated with isolated systolic hypertension but not with isolated diastolic hypertension; the fully adjusted OR and 95% CI was 1.78  for isolated systolic hypertension and 0.81  for isolated diastolic hypertension , euthyroIn addition, our previous study with 1724 euthyroid participants  also revealed that for those without thyroid cysts, TSH is significantly positively associated with hypertension  but this association was not observed for individuals with thyroid cysts [0.79 ] . Since eSince thyroid cysts might have a beneficial influence on activating thyroid hormone synthesis , 9 amongSince higher thyroid hormone activity could prevent the progression of CKD [18‑21], thyroid cysts could be inversely associated with proteinuria and reflect the absence of latent thyroid damage. However, in the present study, no significant associations between thyroid cyst status and proteinuria were observed.Aging is a well-known risk factor for cardiovascular disease and reduced renal function. Polycystic thyroid disease (PCTD) is a rare condition that is reported to be associated with subclinical or overt hypothyroidism. PCTD is more common in older individuals . Since aLevels of GDF-15, which is considered a marker of biological age , were elFrom a clinical perspective, the present study indicates that thyroid cysts could play an important beneficial role in thyroid hormone synthesis among participants with reduced demand of thyroid hormone. We evaluated thyroid function in a euthyroid population, i.e., individuals within the normal ranges for TSH, free T3, and free T4. We concluded that those three factors are not sufficient for evaluating thyroid function. Furthermore, in evaluating mortality, proteinuria has been reported to be more useful than GFR, especially in participants with higher GFR levels –38. WhenThis study has potential limitations that warrant consideration. First, we thought that thyroid cysts might influence the activity of thyroid hormones but not their plasma concentrations. However, we were unable to evaluate thyroid hormone activity with precision in this study. Since nitric oxide could act as an indicator of thyroid replacement therapy , furtherIn conclusion, among euthyroid individuals, being in the normal range of TSH is inversely associated with proteinuria among individuals with thyroid cysts, but positively associated with proteinuria in individuals without thyroid cysts. The presence of thyroid cysts could be an effect modifier for the association between TSH and proteinuria.


This study was planned for evaluating the safety and efficacy of SPAS (stent positioning assistance system) device in first-in-human procedures.  SPAS is a novel device that can be used for improved positioning of coronary stents.  Consecutive patients underwent percutaneous coronary intervention (PCI) with the SPAS device. Device-related adverse and serious adverse events were evaluated in addition to a dedicated questionnaire completed by operators immediately after using SPAS.  The SPAS device was deployed in 55 PCI procedures, comprising of heavily calcified lesions (33.3%), totally occluded (7.4%), and severely tortuous vessels (7.4%). In these procedures, nonbifurcation and nonostial (53.7%), bifurcation (22.2%), and edge-to-edge (24.1%) stenting techniques were employed. Analysis of the pooled scores for the five satisfaction-related questions gave an average score of 5.6 ± 1.5, with 40 (75.5%) operators providing an average satisfaction grade of >5; the average operator-rated SPAS device accuracy performance scores exceeded 6 out of 7 . The time spent for positioning the stent with the SPAS device averaged 41 ± 68.0 seconds. The SPAS device was rated as easy to use (6.1 ± 1.6) and reliable (6.1 ± 1.7). No device-related adverse events were reported.  This stent positioning device was evaluated in a consecutive cohort of standard and complex PCI procedures. The device was shown to be safe, easy, and precise to use, both in standard and complex cases. Despite ongoing innovations in stent delivery systems, the accuracy of stent positioning remains a significant challenge in clinical practice. Geographic miss (GM) is a descriptive terminology for a poorly deployed coronary stent or a stent missing a lesion during a percutaneous coronary intervention (PCI) procedure. GM includes longitudinal (injured or diseased segment not covered by the stent) or axial GM  mismatches .Longitudinal GM has been reported to occur in up to 30–45% of PCI procedures, despite satisfactory angiographic stent positioning , 3. It hCurrent heart catheterization rooms are equipped with enhanced X-ray systems that enable the interventional cardiologists to see precise images, high quality, and gated fluoroscopy and intravascular ultrasound (IVUS)/optical coherence tomography (OCT) . AdditioThere is a clear need for precise stent positioning, and avoiding GM.Ostial Pro®  enables more accurate stent placement, limited to aorto-ostial lesions . Rapid vRobotic-assisted percutaneous coronary intervention is a growing field, mainly due to the need of implementing a more precise delivery and deployment technique for PCI devices. This intervention has the potential of reducing the occurrence of LGM , 12. TheIn this first-in-human, multicenter, cross-sectional study, adult patients planned to undergo a standard PCI procedure with stenting. The PCI procedure was performed as per standard of care, with the Stent Positioning Assistance System (SPAS) device installed on the stent delivery system (SDS) of choice. Patients were then followed up during hospitalization and once by phone seven days after hospital discharge. User feedback was obtained via a questionnaire completed by the attending interventional cardiologist. In addition, all safety-related events were documented and reviewed. Stent positioning was assessed by X-ray images/videos in all patients and by optical coherence tomography (OCT) imaging in four patients. Operator information, stent device, and procedural details were also collected. Prior to the study, participating sites obtained Institutional Ethics Committee board approval. This study was conducted in accordance with good clinical practice (GCP) guidelines.Patients underwent a PCI procedure with the SPAS device. Eligible patients were ≥18 years of age with clinically significant coronary artery stenosis. Lesions in this study were unlimited and included bifurcation lesions, ostial lesions, and edge-to-edge stenting technique. Patients with highly calcified target lesions, unstable hemodynamics, visible intravascular thrombosis, or nonvisible distal part of the target vessel were excluded. Diagnostic catheterization (referred for coronary artery bypass grafting (CABG) or nonsignificant coronary artery disease) was considered as screen failure.SPAS is a simple device aimed to aid the interventional cardiologist in controlling the stent position in the treated artery during PCI.As shown in Figures By introducing the stent from the back of the SPAS through the central main tunnel before, the rapid exchange system is advanced over the coronary wire and the stent is introduced to the lesion in the coronary artery. While fixating the SPAS and the guide wire , in order to tightly secure the SPAS on to the stent delivery system. Rather than pushing and pulling the stent inside the artery, the stent can be moved forward and backward to the desired location by rotation of the “rotator”; clockwise drives the stent forward, and counterclockwise retracts the stent as shown in Anatomical features, procedural characteristics, and using SPAS in different stenting techniques were evaluated after each PCI using SPAS for stent positioning. After each PCI procedure, operators completed the “Usability Questionnaire” as appears in the supplementary files.Operator feedback regarding usability of the SPAS device was gathered using a 7-point scale device usability questionnaire, where 7 points correspond to—“I absolutely agree”, and 1 point to—“I strongly disagree”. Success criterion was mean strong agreements with the questionnaire statements or average score >5 in each question.The primary safety endpoint was device-related adverse event and serious adverse event (SAE) rate during hospitalization. Adverse events (AE) were defined as any untoward medical occurrence in a study subject. Device deficiency (DD) was defined as an inadequacy of a medical device related to its identity, quality, durability, reliability, safety, or performance, such as malfunction, misuse or use error, and inadequate labeling. Adverse device effect (ADE) was defined as an AE related to the use of the investigational medical device. An SAE was defined as any untoward medical occurrence that at any dose results in death, is life-threatening, requires inpatient hospitalization or prolongation of existing hospitalization, results in persistent or significant disability/incapacity, or is a congenital anomaly/birth defect.Data were analyzed by SPSS statistic software version 25. All data were summarized descriptively, with sample size, absolute, and relative frequency for categorical variables and sample size, arithmetic mean, standard deviation, and median with its 25 and 75 percentiles for continuous variables. All tests were two-tailed with a significance level of 5%.2, and mean systolic blood pressure was 139 mmHg. Most common chronic diseases among subjects were hyperlipidemia (78.2%), hypertension (74.5%), diabetes mellitus (56.4%), and established previous ischemic heart disease (65.5%).In total, 55 patients participated in the study in two centers in Israel. The vast majority of patients (81.8%) were male. The average age was 61.9 ± 10.4 years. Mean BMI was 29.5 kg/mBaseline characteristics and clinical data before procedure are presented in Of the 55 procedures performed, 47 (85%) were performed via radial approach, four (7.4%) lesions were totally occluded, four (7.4%) involved severe tortuosity lesions, and 18 (33.3%) were moderately to highly calcified. Balloon predilatation was performed in 19 (35.2%) procedures. The different anatomical characteristics and stent positioning/implantation approach in each procedure were indicated by the interventional cardiologists in the questionnaire.The stenting techniques used are described in Supplementary Operators rated SPAS accuracy performance as 6.3 ± 1.2 in procedures employing nonbifurcational and nonostial stenting techniques (29/55 procedures). The mean SPAS performance score in procedures involving a moderately or highly calcified lesion (18/55) was 6.4 ± 1.5. Device performance in bifurcational (13/55) and edge-to-edge (13/55) procedures scored 6.5 ± 0.9 and 5.3 ± 2.0, respectively. High-performance ratings of 6.8 ± 0.5 were recorded for the aorto-ostial coronary artery stenting cases. The performance in the single bifurcation multiple-stent procedure was scored 7. In conclusion, performance scores for all techniques used met the success criteria; that is, mean scores exceeded 5.n = 22; 40.7%), operators preferred it to be at the discretion of the interventional cardiologist.In over half of the procedures , operators preferred the SPAS system preinstalled on the stent delivery system (SDS), while for the remaining procedures  and stenting complexity (5.3 ± 1.6). Ease of use and reliability scored mean 6.1 points, and operators were generally willing to use SPAS in the future (5.2 ± 1.9). Further analysis of the pooled scores for the five satisfaction-related questions gave a mean score of 5.6 ± 1.5, with 40 (75.5%) operators providing an average satisfaction grade of >5, meeting the success criteria. The time spent for positioning the stent with the SPAS device averaged 41 ± 68.0 seconds , and treated for stenosis of the left anterior descending artery. After PCI, the patient suffered from acute pulmonary edema, requiring prolonged hospitalization and urgent hemodialysis. The patient was treated with intravenous furosemide, which led to significant improvement. The event resolved after seven days and was considered unrelated to the SPAS device and study procedure.No serious adverse events related to SPAS were reported in usage in 55 patients. Two unrelated serious adverse events were reported during the study period. A 72-year-old male, heavy smoker, obese, hypertensive, with multivessel coronary artery disease, suffered from sepsis, which was later associated with a positive methicillin-susceptible This is the first-in-human evaluation of the safety and efficacy of a novel SPAS for precise positioning of coronary stents. The study included 55 different PCI procedures, from the entire spectrum of coronary intervention, including standard cases, bifurcation, ostial, calcified, and edge-to-edge stenting, and the SPAS system showed good results in safety and performer satisfaction. The unmet need for precise stent positioning in the coronary artery led to several inventions, including a robotic PCI system. The SPAS is a simple and affordable device that enables and facilitates stent placement with less than a millimeter precision.This study is the first in the field, single-armed and designed to evaluate the first use in human.Operators using the SPAS highly rated the performance in stenting accuracy, with the highest possible rating given to the single bifurcation and multiple-stent procedures, followed by the aorto-ostial coronary artery stenting procedures. Accuracy performance for all stenting techniques used, with the exception of edge-to-edge stenting, met the predefined success criteria (score >5).The performance scores were matched by OCT imaging findings performed in four patients who were randomly enrolled. Investigators decided to use this visualization method due to its high resolution and accurate length measurement. Full correspondence was found between the planned and actual implantation site in three cases and a deviation of 1 mm, that is, 2.5% of the stent length (40 mm) in one case . In concA large group of patients (32.7%) was classified by the operators as having calcified target lesions or vessels, despite an exclusion criterion. Nevertheless, the performance scores related to these patients and procedures showed that the operators scored high in allowing the SPAS device to position the stent accurately in the lesion area.After gaining familiarity with the SPAS device in 55 different PCI procedures, the seven interventional cardiologists who performed the stenting procedures stated that the SPAS has an “advantage in reducing stent installation time and stenting complexity”. They also indicated that the SPAS device improves the accuracy of stenting procedures. Furthermore, the SPAS was easy to use, and in most cases (66%), “it should be preinstalled on the SDS rather than leaving it to the discretion of the interventional cardiologist”.The SPAS device proved safe when used as indicated, with no device-related adverse events reported throughout the study period.Our study had limitations, as it is a first-in-human use of a novel device. The study is single-armed, with no control arm, reporting the experience of two centers performing PCI procedures. The interventional cardiologist received personal training for using SPAS in a bench-side PCI simulator, and the procedure evaluation was performed after the procedure. We had no control arm, and the cardiologist had to evaluate the SPAS compared with their personal experience.Further studies emphasizing comparison of the standard of care versus the usage of SPAS system are warranted, taking into consideration stent installation time, fluoroscopy time, X-ray exposure, iodine-contrast media delivered, number of stents used, and possibly the cost of the procedure.This is the first-in-human evaluation of the safety and efficacy of a novel stent positioning assistance system for precise positioning of coronary stents. The SPAS is a manual tool that brings manual PCI as close as possible to robotic-assisted PCI procedure, with a low cost and promising efficacy and safety. In our study, the SPAS device proved to be safe and easy to use with positive ratings in different PCI procedures including ostial lesions and calcified vessels. Further studies are needed for evaluating the clinical benefit of SPAS in large cohorts.


Taenia solium. Isolated spinal cysticercosis is rare, with limited cases having been reported in the literature. This entity poses great diagnostic and therapeutic challenges.Neurocysticercosis is a neuroinfectious disease caused by the larval stage of the tapeworm This retrospective study included seven patients pathologically diagnosed with spinal cysticercosis. The clinical manifestations, radiological features on magnetic resonance imaging (MRI), treatment, and outcomes were analyzed.This case series consisted of four male and three female patients, with an average age of 34.9 ± 10.9 years. Clinically, six patients manifested with localization-related myelopathy. There were four solid lesions, one cystic-solid lesion, and three cystic lesions. The solid and cystic-solid lesions showed characteristic MRI features: 1) within the lesion, there was a mural nodule with isointensity on T1WI and iso- to hyperintensity on T2WI; 2) the signals at the periphery of the mural nodule were variable, ranging from hypointense to hyperintense on T2WI; and 3) ring-like or cyst wall enhancement could be present, and dot-like enhancement could be noted in the mural nodule. Complete resection of the responsible lesion was achieved in all patients, and oral albendazole was administered in a patient with one more suspected homologous lesion. After a mean follow-up period of 56.7 ± 35.1 months, the patient’s symptoms mostly regressed.Spinal cysticercosis is an extremely rare cause of myelopathy. Characteristic MRI features can facilitate preoperative diagnosis. Clinicians should be aware of this entity, and it should be included in the differential diagnosis of myelopathy. Taenia solium is a common parasitic infection of the central nervous system in humans [Taenia solium inside the cerebral vesicles in 1697 [Taenia solium and the scolex of cysticercus were recognized [Taenia solium cysticerci [Cysticercosis caused by the larval stage of the tapeworm n humans . Accordi in 1697 . During cognized . In 1855cognized . In 1933sticerci . Due to This retrospective study included seven patients pathologically diagnosed with primary spinal cysticercosis at the Peking University Third Hospital and Beijing Tiantian Hospital between 2010 and 2020. The clinical and radiological profiles were collected and analyzed.Magnetic resonance imaging (MRI) profiles were available for all patients. The location, size, appearance, and signal characteristics of cysticercotic lesions on T1-weighted imaging (T1WI), T2-weighted imaging (T2WI), and contrast-enhanced imaging were analyzed.Surgical resection of the lesion was performed in all patients via a posterior midline approach with the assistance of neuroelectrophysiological monitoring. The surgical records documenting the intraoperative findings were analyzed. Postoperatively, one patient was treated with oral albendazole.Follow-up data for all patients were obtained during individual office visits or telephone interviews, with a mean follow-up time of 56.7 ± 35.1 months (range 10–91 months). The clinical outcomes were evaluated, focusing on the neurological functions and symptoms of the patients compared with their preoperative status.This case series consisted of four male and three female patients, with an average age of 34.9 ± 10.9 years . The onset symptoms included local pain (4/7), sensorimotor disturbance (6/7), and sphincter dysfunction (1/7). The duration of symptoms preceding the surgery ranged from 2 months to 3 years . All the cases were sporadic, and the patients denied any remarkable unhygienic diet or affected relatives. The clinical data are presented in Table A total of eight cysticercosis lesions were identified, involving the thoracic spinal cord in six cases, the lumbar region in three cases, and the sacral region in one case. The mean dimension of the lesions was 48.8 ± 56.5 mm . There were four solid lesions, one cystic-solid lesion, and three cystic lesions. The solid and cystic-solid lesions showed characteristic MRI features: 1) within the lesion, there was a mural nodule with isointensity on T1WI and iso- to hyperintensity on T2WI; 2) the signals at the periphery of the mural nodule were variable, ranging from hypointense to hyperintense on T2WI; 3) ring-like enhancement was seen in Case 1, cyst wall enhancement was demonstrated in Case 7, and dot-like enhancement was noted in the mural nodule in Case 2. The MRI features of the cystic lesion were nonspecific, showing hypointensity on T1WI and homogeneous hyperintensity on T2WI. The preoperative suspected diagnosis included cavernous malformation (3/7), ependymoma (1/7), enterogenous cyst (1/7), and arachnoid cyst (1/7). The radiological characteristics of spinal cysticercosis are summarized in Table Intraoperatively, cysticercotic lesions appeared grayish-yellow or grayish-white in color with a soft texture, and the blood supply was not abundant. The lesions were well demarcated with a clear plane from the surrounding spinal cord parenchyma, and complete resection of the responsible lesion was achieved in all patients.All patients recovered well postoperatively. In Case 3, in addition to the responsible lesion, spinal MRI showed an intramedullary solid poorly defined lesion at the T7-T8 levels, and the patient was treated with oral albendazole (15 mg/kg) for one month. No other adjuvant therapy was performed in any patient. Considering that cysticercosis is a systemic disease, brain MRI with or without CT was requested but revealed no abnormalities in all cases. After a mean follow-up period of 56.7 ± 35.1 months, the patient’s symptoms mostly regressed.en bloc fashion. Pathological examination revealed cysticercosis  in patients with a single cysticercosis lesion [The diagnosis of neurocysticercosis is extremely challenging. Clinical symptoms are nonspecific and location-dependent, and radiological examinations are usually not pathognomonic. Serologic tests can facilitate the diagnosis when a scolex is not visualized on neuroimaging, but the diagnostic value remains limited. Enzyme-linked immunoelectrotransfer blot (EITB) assay, based on the detection of antibodies specific for s lesion , 11. Adds lesion . Moreoves lesion .. performed a literature review that included 43 reported cases of intramedullary cysticercosis, and they found that all lesions appeared as fluid-filled cysts with hypointensity on T1WI and hyperintensity on T2WI, and most of the lesions were surrounded by parenchymal edema [For solitary spinal intramedullary cysticercosis, the preoperative diagnosis is largely dependent on radiological profiles. MRI has significantly increased the detection of spinal cysticercosis in which spinal intramedullary cysticercosis manifests as a nodular or cystic lesion. Within the lesion, the scolex appears as a mural nodule with isointensity on T1WI and iso- to hyperintensity on T2WI. After the administration of contrast medium, the cysticercotic lesions show no enhancement or dot-like enhancement in the scolex, while peripheral ring-like enhancement can be noted in some cases. We considered that the perifocal abnormal signals and ring-like enhancement were attributed to reactive gliosis. In 2013, Brutto et alal edema . In 2020al edema . Our stuBoth medical therapy and surgical treatment have been reported for the management of neurocysticercosis. The recommended regimens for pharmacotherapy are albendazole (15 mg/kg/day) and praziquantel (50 mg/kg/day) for 8 days to 2 weeks, and albendazole may be superior to praziquantel in usual dosing . HoweverSpinal cysticercosis is a rare cause of myelopathy. In most cases, the scolex can be seen as a mural nodule on MRI, and these characteristic imaging features can facilitate the preoperative diagnosis. Differential diagnosis of cysticercosis should be entertained in patients with spinal space-occupying lesions.


In addition, forest and freshwater areas were the land use patterns that best explained bacterioplankton community variation. Furthermore, cumulative dendritic distance was the geographic distance parameter that best explained bacterial community variation. Variation partitioning analysis revealed that water chemistry, land use patterns, and geographic distances strongly shaped bacterioplankton communities. In particular, the direct influence of land use was prominent, which alone contributed to the highest proportion of variation (26.2% in wet season communities and 36.5% in dry season communities). These results suggest that the mechanisms of species sorting and mass effects together control bacterioplankton communities, although mass effects exhibited higher contributions to community variation than species sorting. Given the importance of allochthonous bacteria input from various land use activities , these results provide new insights into the environmental factors and determinant mechanisms that shape riverine ecosystem communities.The spatial distribution of bacterioplankton communities in rivers is driven by multiple environmental factors, including local and regional factors. Local environmental condition is associated with effect of river water chemistry (through species sorting); ecological process in region is associated with effects of land use and geography. Here, we investigated variation in bacterioplankton communities  in an anthropogenically disturbed river using high-throughput DNA sequencing of community 16S rRNA genes in order to investigate the importance of water chemistry, land use patterns, and geographic distance. Among environmental factors, sulfate (SO Bacterioplankton compositions reflect environmental changes in riverine ecosystems due to the sensitivity of their responses to environmental conditions . The bioNumerous studies have indicated that bacterioplankton communities are affected by many environmental factors  includinVariation in riverine bacterial communities can be parsed into two determinant mechanisms: species sorting and mass effects. Species sorting emphasizes spatial niche separation, wherein relatively low levels of dispersal allow communities to respond to local conditions, and communities are directly affected by changes in environmental habitats . Mass efThe Yuan River is a tributary of the Ganjiang River, which is the largest tributary of Poyang Lake, China. Yuan River has diverse riparian habitats from upstream to downstream, like forest, mountains, cities, and even a reservoir along streams in the middle reaches. Previous studies have determined that the Yuan River contains abundant organic pollutants . Moreove2. The cities of Pingxiang, Yichun, and Xinyu are located in the Yuan River basin. The climate of the region is influenced by subtropical monsoon patterns, with a wet season between April and September and a dry season from October to March.The Yuan River is located in the lower reaches of the Ganjiang River, which is a major tributary of the Yangtze River and directly feeds Poyang Lake . The len3 of water and generates 9,160 million kwh every year. Mechanical, electrical, textile, chemical, and metal industries  are all prevalent in the Jiangxi Province and are located in Xinyu City. Farmland is mostly present in the downstream areas, and their primary crop is rice. Here, forest (accounting for 52.64%) and farmland (35.10%) were the main land use types  that was calibrated before each measurement. Samples were processed within 4 h of collection and then subdivided for chemical and molecular analyses. Four water samples were collected in separate 100-ml polyethylene bottles at each site: (1) one for dissolved organic carbon (DOC) analysis, (2) one for ammonium (NH4+-N), nitrate (NO3–-N), chloride (Cl–), and sulfate (SO42–) measurements, (3) one for total phosphorus (TP) analysis, and (4) one for heavy metal measurements. Water samples were filtered through a 0.45-μm Durapore membrane filter  for all chemical analyses, except TP. Water samples were then acidified to pH 2 with ultra-purified HNO3 for heavy metal analysis. DOC was measured with a total organic carbon auto-analyzer . NH4+-N and TP were measured using a Smartchem 200 Discrete Analyzer . NO3–-N, Cl–, and SO42– were measured using ion chromatography . The concentrations of manganese (Mn), iron (Fe), zinc (Zn), and lead (Pb) were measured by inductively coupled plasma mass spectrometry .Dissolved oxygen (DO) and pH were measured Digital elevation model (DEM) data (at a 30 m resolution) were used to delineate basin boundaries. Sub-basin classifications at each sampling site ranged from a single sampling site that encompassed the sub-basin area to the inclusion of adjacent upper sample sites to reflect the inputs of allochthonous bacteria due to the fast population growth and replacement rates of bacterial communities.1. Images were then binned into five classes: farmlands, forests, freshwaters, urban areas, and others. ArcGIS v 10.3 was used to delineate basin boundaries and calculate land use proportions.Landsat 8 satellite imagery 2017 was used to generate a land-cover classification at a 30 m resolution. Land use pattern images were obtained from the Geospatial Data CloudFour geographic distance parameters including river length, catchment area, cumulative dendritic distance, and mean dendritic stream length were calculated . River lSamples were pre-filtered through a 5-μm Durapore membrane filter  to remove particulates and algal biomass, followed by filtering through a 0.22-μm Durapore membrane filter  to collect microbial cells. Each water sample was simultaneously filtered through several filters to reduce filtering time. Filters from each sample were mixed and stored at −80°C for subsequent DNA extraction.® Soil DNA Kit . The bacterial V4–V5 hypervariable regions of 16S rRNA genes were amplified using the forward primer 338F (5′-ACTCCTACGGGAGGCAGCA-3′) and reverse primer 806R (5′-GGACTACHVGGGTWTCTAAT-3′) . DNA sequencing was conducted on the Illumina MiSeq platform  following standard operating procedures and paired-end 2 × 250 bp sequencing chemistry. The sequencing was conducted at the Shanghai Majorbio Bio-Pharm Technology Co., Ltd., of China. Raw sequence data files were deposited in the NCBI Sequence Read Archive database (Accession number: SRP194014).Total DNA was extracted from the water samples using the E.Z.N.A.TAAT-3′) . PCRs we2 with the following criteria  at the 97% nucleotide similarity level. The phylogenetic affiliation of each sequence was then evaluated using the RDP Classifier v.2.24 and comparison against the Silva database (release 128)5. The 16S rRNA gene taxonomic classifications were identified based on a confidence threshold of 70%  pipelinecriteria : (1) 250d of 70% . Uneven t-test was used to investigate significant differences of water chemistry parameters across seasons. Pearson correlation analysis was used to identify relationships between water chemical parameters and to identify collinearity using the SPSS Statistics software program v.20.0. Hierarchical clustering analysis was conducted using the “hclust” function in the R v.3.6.1 statistical software package. Non-metric multidimensional scaling (NMDS) analysis was used to investigate community compositional differences based on the Bray–Curtis distances of bacterioplankton communities using the “metaMDS” function in the “vegan” package for R. Lastly, an analysis of similarity (ANOSIM) test was used to evaluate significant differences between sample groups based on Bray–Curtis distances.Prior to statistical analysis, all variables were checked for homogeneity and normal distributions using Shapiro–Wilk tests. Water chemistry parameters that were not normally distributed were log-transformed to achieve (or better approach) data normality. Pairwise comparisons of data among sub-classes were conducted using unpaired Wilcoxon rank-sum tests. Analysis of variance (ANOVA) was conducted to test significant differences in water chemistry parameters. A p < 0.05 was considered as the statistical significance threshold). Prior to RDA, variance inflation factors (VIFs) were computed to evaluate multicollinearity of multiple regression models for water chemical parameters. The “vif.cca” function of the “vegan” package for R was used to sequentially exclude water chemical parameters with VIFs > 3. The “bioenv” function in the “vegan” package was then used to identify subsets of environmental factors that best predicted microbial community structural differences. The Bioenv and RDA approaches were together used to identify the environmental factors that most contributed to microbial community variation. Environmental factors were selected from these analyses and then used in variance partitioning analysis (VPA) modeling to assess the individual relative contributions of water chemistry, land use, and geographic distance parameters.Redundancy analysis (RDA) was used to identify relationships in the distribution of phyla in the communities and environmental factors using the CANOCO 4.5 software suite . The sta2, although other factors can be present like multivariate non-linear dependence between sources of variation  in the dry season communities  compared to other sample sites . In the munities . Both ShR value of 0.798 at p < 0.001, indicating statistically significant separation of the two seasonal groups. The distribution of the dominant phyla led to distinct clustering of samples  in the wet season. In contrast, the relative abundances of freshwater bacteria were lower in the dry season upper reach communities compared to the other reaches communities. Non-freshwater bacterial abundances fluctuated among sampling sites and were similar to trends in bacterioplankton community diversity overall (p < 0.05), while proteobacterial abundances were negatively correlated with freshwater bacterial abundances , had spatial and temporal variability along Yuan River  were significantly and positively correlated with each other in the wet season samples. Cl– was significantly and positively correlated with Fe, Zn, and Pb in wet season. DOC, Fe, Zn, and Pb exhibited a significantly higher value in dry season middle and lower reach samples compared to those in the upper reaches; DOC was significantly and positively correlated with NH4+-N; metals were significantly and positively correlated with each other. In addition, Fe concentrations were significantly and negatively correlated with Shannon and Chao1 indices with in the dry season, and the Shannon diversity index was significantly and negatively correlated with Zn concentrations that Mn were significantly and negatively correlated  and SO42– (p = 0.026) concentrations were statistically significant water chemistry parameters that were associated with bacterioplankton community composition (based on 499 Monte Carlo permutations). Freshwater area (p = 0.026) was a land use type that was significantly associated with bacterioplankton community composition (based on 499 Monte Carlo permutations). In addition, Actinobacterial abundances were positively correlated with freshwater area in the wet season, while Bacteroidetes abundances were negatively correlated with freshwater area in the dry season.Redundancy analysis  revealedr = 0.395, p = 0.001 in the wet season; r = 0.356, p = 0.001 in the dry season). A slightly higher association was observed between the bacterial community similarity matrix and geographic distance in the wet season communities compared to those of the dry season.Geographic distances could also be important in structuring bacterioplankton assembly along the Yuan River and were thus evaluated . Cumulat42–, Mn, and Fe (Bioenv correlation = 0.498) in the wet season; DO, DOC, SO42–, Mn, and Fe levels comprised the optimal parameter subset associated with bacterioplankton composition (Bioenv correlation = 0.617) in the dry season. SO42–, Mn, and Fe concentrations also exhibited the highest Spearman correlation with bacterioplankton communities in the wet and dry season. In terms of land use types, the optimal subset of parameters included forest and freshwater area . Catchment area, river length, and cumulative dendritic distance were selected by the Bioenv analysis as the combination that best represented the geographic distance parameters.Bioenv analyses  indicateVariance partitioning analysis indicated that the variations in bacterioplankton communities explained by geographic distance [c + e + f + g] and land use [b + d + e + g] were higher than water chemistry [a + d + f + g] . The varArcobacter (data not shown) that are commonly found in the digestive tracts of vertebrates .The original contributions presented in the study are publicly available. These data can be found in the NCBI Sequence Read Archive database (accession number: WP designed the study. WP, JZ, MD, MN, and GH collected the samples. JZ analyzed the genetic data. JZ, MD, MN, and GH analyzed the geographic data. WP and JZ wrote the manuscript with contributions from all co-authors. All authors approved the final manuscript for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.