The details of two rheumatoid arthritis (RA) patients with systemic sclerosis (SSc) who were administered tocilizumab, an anti-interleukin-6 receptor antibody, are reported, along with a review of the literature.Two RA patients with SSc with inadequate responses to disease-modifying antirheumatic drugs (DMARDs) were given tocilizumab 162 mg every 2 weeks for 18 months. RA disease activity was evaluated by the 28-joint disease activity score with erythrocyte sedimentation rate (DAS28-ESR) and the clinical disease activity index (CDAI). The skin condition of SSc was evaluated by pinching the skin according to the modified Rodnan total skin thickness score (mRSS). Softening of the skin and improvements of arthritis and the patient global assessment were observed during tocilizumab treatment, with reduction of not only RA disease activity, but also of the mRSS.Tocilizumab may be effective in patients with RA and SSc overlap syndrome for which conventional treatment is inadequate. Further research is needed because this report included only two patients. Systemic sclerosis (SSc) is a connective tissue disease that develops sclerotic changes characterized by obliterative and proliferative microvascular involvement, activation of the immune system and increase of extracellular matrix deposition in the skin and various internal organs . SSc preInterleukin 6 (IL-6) is a pleiotropic proinflammatory multifunctional cytokine such as T cell activation, initiation of acute-phase reactants , and stimulation of hematopoietic precursor cell growth, causing maturation of B cells into antibody-producing cells and cell differentiation. IL-6 overexpression and pathogenicity have been demonstrated in SSc as well as rheumatoid arthritis (RA) . TocilizA mini-series of two RA patients with refractory SSc (cases 1 and 2), treated with TCZ (162 mg every 2 weeks), is reported.The patient had joint pain and swelling in 2003. She was diagnosed with RA and treated with disease-modifying antirheumatic drugs (DMARDs). In 2015, the right wrist joint was swollen and tender, and the CRP level increased to 2.83 mg/dl . Although she received treatment for RA with methotrexate (MTX), salazosulfapyridine (SASP), and steroids, her arthritis was poorly controlled. In December 2015, because her arthritis worsened, she visited our hospital. Scleroderma from the fingers to the forearms was also observed at the first visit.Anti-nuclear antibody (ANA) was 1280× (centromere), anti-cyclic citrullinated peptide antibody (ACPA) was 150 U/ml , rheumatoid factor (RF) was 52 IU/ml , and anti-centromere antibody was 17.8 IU/ml ; all of them were elevated, but antibodies against topoisomerase I and U1-RNP were negative. The skin sclerosis developed from her fingers and expanded to her forearms, face, and feet. Chest computed tomography (CT) showed slight interstitial lung disease in the bilateral lower lung areas. The patient met the classification criteria for SSc established by the ACR/EULAR criteria in 2013 . The patBoth the RA and SSc were judged to be active, and it was decided to treat the patient with TCZ, 162 mg every 2 weeks. Administration of steroid (prednisolone 5 mg/day) and DMARDs (MTX 6 mg/week and SASP 1000 mg/day) was continued  for 7 years, which relieved her joint symptoms. However, she abruptly stopped outpatient visits, and was lost to follow-up.In 2010, she was affected by joint pain, swelling and scleroderma of the palms, and visited our hospital again. The skin sclerosis developed from her fingers and expanded to her forearms, face, and feet. The findings of her right forearm skin biopsy were found to be consistent with SSc. She was diagnosed with overlap syndrome involving RA and SSc. She received treatment with cyclosporine, SASP, and steroids for RA and SSc treatment. Though an initial response was seen, the arthritis worsened. In 2016, both wrist joints were swollen and tender, and the CRP level increased to 1.05 mg/dl . Larsen grade 3 was observed on wrist X-rays. A CT study showed patchy infiltrates associated with ground-glass opacities in the bilateral lower lung areas. ANA was 320× (homogeneous), ACPA was 151 U/ml , RF was 229 IU/ml , and anti-topoisomerase I antibody was 88.7 U/ml ; all of them were increased, but antibodies against centromere and U1-RNP were negative. DAS28-ESR and CDAI were high, at 7.14 and 34.6, respectively. Skin sclerosis developed from her fingers to her forearms and face, and the mRSS was 15.Both the RA and SSc were judged to be active, and it was decided to treat the patient with TCZ, 162 mg every 2 weeks. Administration of steroid (7 mg/day) and a DMARD (cyclosporine 150 mg/day) was continued  , TCZ was3.3% , TCThe most common adverse events in the faSScinate study were infections, gastrointestinal disorders, skin or subcutaneous disorders, and musculoskeletal or connective tissue disorders. Treatment was withdrawn for adverse events in 11.6% (5 patients) of patients after 12 months. Although case 2 in the present study had cellulitis of the right foot plantar region, she continued TCZ after the cellulitis resolved.In the present study, two patients with overlapping RA and SSc who were successfully treated with TCZ for polyarthritis as well as skin sclerosis were reported. TCZ administration clearly resulted in improvement of joint disease activity and skin scores in these cases, as well as previously reported cases of RA and SSc overlap patients. TCZ treatment may be useful in patients with RA and SSc overlap syndrome for whom conventional treatment is inadequate. However, as a limitation, the current report included only two cases, and it is therefore difficult to draw any conclusions. Further research is needed.


Introduction Birth-related perineal trauma (BPT) is a common consequence of vaginal births. When poorly managed, BPT can result in increased morbidity and mortality due to infections, haemorrhage, and incontinence. This review aims to collect data on rates of BPT in low- and middle-income countries (LMICs), through a systematic review and meta-analysis. Methods The following databases were searched: Medline, Embase, Latin American and Caribbean Health Sciences Literature (LILACs), and the World Health Organization (WHO) regional databases, from 2004 to 2016. Cross-sectional data on the proportion of vaginal births that resulted in episiotomy, second degree tears or obstetric anal sphincter injuries (OASI) were extracted from studies carried out in LMICs by two independent reviewers. Estimates were meta-analysed using a random effects model; results were presented by type of BPT, parity, and mode of birth. Results Of the 1182 citations reviewed, 74 studies providing data on 334,054 births in 41 countries were included. Five studies reported outcomes of births in the community. In LMICs, the overall rates of BPT were 46% (95% CI 36–55%), 24% (95% CI 17–32%), and 1.4% (95% CI 1.2–1.7%) for episiotomies, second degree tears, and OASI, respectively. Studies were highly heterogeneous with respect to study design and population. The overall reporting quality was inadequate. Discussion Compared to high-income settings, episiotomy rates are high in LMIC medical facilities. There is an urgent need to improve reporting of BPT in LMICs particularly with regards to births taking in community settings.The online version of this article (10.1007/s10995-019-02732-5) contains supplementary material, which is available to authorized users. What is already known on this subject? Birth-related perineal trauma is a common complication of vaginal childbirth. Adequate management reduces morbidity and improves maternal health and wellbeing. Women in LMICs are thought to be at a higher risk of perineal trauma. What this study adds? Women in LMICs are at higher risk for episiotomy, but not for the spontaneous second degree tear and OASI. Better reporting practices and more evidence from the community are needed to provide a more accurate picture of the burden of BPT in LMICs.Maternal health is critical in many countries of the world, and the World Health Organization WHO  estimateEpisiotomy and OASI rates are commonly used as quality indicators of health systems and health care WHO . MisdiagThe high rate of community deliveries by untrained birth attendants UNICEF , the youThis review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Meta-Analysis of Observational Studies in Epidemiology (MOOSE)  reported data on the proportion of vaginal births resulting in perineal trauma ; (2) were conducted in a LMIC as defined by the World Bank ; (3) repEligible studies were identified by a two stage screening process. Firstly, two reviewers independently screened titles and abstracts (MA and LH) and secondly, the full texts of the potentially relevant studies were screened . Data were extracted independently and in duplicate using a predesigned data extraction form . We extracted data regarding the study setting and design, recruitment method, parity, and characteristics of included participants. Any discrepancies during screening or data extraction were resolved through discussion or through the input of a clinical reviewer (SMH) if consensus could not be reached.The quality of included studies was assessed by two reviewers (MA and PS) using a bespoke tool based on Looney’s critical appraisal instrument for systematic reviews of incidence and prevalence studies .  using a random effects model. Random effects was chosen due to expected high clinical and statistical heterogeneity , the remaining 842 articles were screened for eligibility based on their title and abstract. The full text of 240 studies were assessed and of these, 74 studies were included  and upper-middle income (n = 16) countries. Studies varied in their designs with most being cross-sectional (n = 27). There were also cohort studies (n = 20), RCTs (n = 15), and non-randomised interventional studies (n = 6). Several studies provided data on more than one type of BPT. Overall, this review found 118 BPT estimates, of which 46 were episiotomies, 13 s degree trauma, 42 OASI, and 16 were not specified (NS).A summary of characteristics of included studies is provided in Table n = 46) and were set in medical facilities (n = 69). Three studies reported combined results of births in medical facilities and in the community  included women of various parities. Those studies that did not stratify the outcome by parity were classified as having a mixed-parity population. The main characteristics of each of the included studies are provided in Table The majority of the studies reported episiotomy data  of vaginal births in LMICs were facilitated by an episiotomy Fig. . A sub-gA representation of the meta-analysis results by country Fig.  shows thThe overall reported rate of spontaneous second degree tears was 23% (95% CI 16–29%) Fig. .Following a similar trend, OASI occurred more frequently in primiparous women, 3.9% (95% CI 1.7–6%)—than in mixed parity populations, 1.4% (95% CI 1.1–1.6%). The overall reported OASI rate was 1.4% (95% CI 1.2–1.7%)  of the vaginal births in LMICs were facilitated by an episiotomy, while 23% (95% CI 16–29%) resulted in a spontaneous second degree tear and 1.4% (95% CI 1.2–1.7%) in OASI.The use of episiotomy is controversial—while there is no evidence to support the use of routine episiotomy to protect from severe perineal tears Supplementary material 2 (DOCX 17 KB)Supplementary material 3 (DOCX 15 KB)Supplementary material 4 (DOCX 2595 KB)Supplementary material 5 (DOCX 2145 KB)Supplementary material 6 (DOCX 2608 KB)


Open completion gastrectomy (OCG) has been selected to treat remnant gastric cancer (RGC) due to severe adhesions and difficulty recognizing anatomical orientation after primary gastrectomy. In general, elderly individuals’ physiological reserves gradually decrease. Moreover, elderly patients (EPs) often have multiple complicating factors , leading to more postoperative complications after abdominal surgery. Recently, several trials revealed the advantages of laparoscopic surgery for EPs with gastric cancer in early recovery. However, there are limited studies investigating the use of laparoscopic completion gastrectomy (LCG) for RGC in EPs. This study aims to assess the efficacy of LCG in EPs aged ≥ 70 years. We compared the short- and long-term outcomes of LCG with those of OCG.n = 6) and OCG (n = 15) groups. We adopted the G8 geriatric screening tool to comprehensively evaluate the EPs’ physical, mental, and social functions. Patient characteristics, clinicopathological characteristics, surgical outcomes, and survival were retrospectively reviewed and compared between groups.Twenty-one EPs who underwent completion gastrectomy for RGC between 2007 and 2017 were enrolled and classified into two groups according to the surgical approach, namely the LCG (p = 0.002]. The median number of retrieved lymph nodes in the LCG and OCG groups were 7 (range 4–10) versus 3 (range 1–6), respectively. There were no statistically significant differences in postoperative hospitalization, intake of solid food, and Clavien–Dindo grade ≥ II postoperative complications. In patients with a history of gastrectomy for gastric cancer in the LCG group, operative time tended to be longer in patients who underwent D2 lymph node dissection as primary surgery.There was no significant difference in the preoperative modified G8, indicating that the EPs’ backgrounds between the groups were comparable. Of note, blood loss during surgery was significantly reduced in the LCG group [median (range); LCG, 50 ml (20.0–65.0); OCG, 465 ml (264.5–714.0); LCG was comparable to OCG for the treatment of RGC in EPs with significantly reduced blood loss. While LCG should be selected with caution in patients who have undergone D2 lymph node dissection as primary surgery, it could be considered as a surgical procedure in EPs with RGC. In the Japan Clinical Oncology Group (JCOG) 0912 trial, laparoscopic surgery (LS) for treating early-stage gastric cancer was shown to be a feasible procedure in terms of adverse events and short-term clinical outcomes .For remnant gastric cancer (RGC), the surgical resection is indicated in numerous cases  and openElderly peoples require special consideration due to the decline in physical, physiological, and social functions . Thus, aIn the present study, we reviewed RGC patients assigned to either the LCG or the OCG group over a 10-year period. Evaluating short- and long-term outcome, we aim to assess the efficacy of LCG in treating EPs.n = 6) and OCG (n = 15) groups. We adopted the G8 geriatric screening tool to comprehensively evaluate the EPs’ physical, mental, and social functions . There was no significant difference in operative time between the two groups (p = 0.791). Due to the severe adhesion between the abdominal wall and small intestine, the laparoscopic approach was converted to the open approach in one patient from the LCG group who had undergone open gastrectomy with Billroth-I reconstruction for gastric cancer as primary surgery. The median number of retrieved lymph nodes in the LCG group was 7 (range 4–10) versus 3 (range 1–6) in the OCG group (p = 0.171). The LCG and OCG did not differ with respect to the distribution of TNM stages. Furthermore, there were no statistically significant differences in postoperative hospitalization (p = 0.410), intake of solid food (p = 0.867), and the occurrence of C-D grade ≥ II postoperative complications (p = 0.477). Thirty days after surgery, there was no reported perioperative mortality in either group.In terms of surgical outcomes Table , blood lp = 0.683, Fig. In this study, the median follow-up period was 21 months, and the 5-year overall survival rate was 80.0% versus 60.6% in the LCG and OCG groups, respectively ; LCG, 8.0 (7.5–8.5); OCG, 10.5 (8.3–12.8); p = 0.333].In the LCG group, two of the four patients with a history of gastrectomy for gastric cancer underwent D2 lymph node dissection as primary surgery. As shown in Table There was no significant difference in the preoperative modified G8 geriatric screening tool score, indicating that the EPs’ backgrounds in each group were comparable. Blood loss during surgery was significantly reduced in the LCG group. In addition, there was no significant difference in oncological outcomes  and prognosis. Overall, we demonstrated that LCG was shown to be applicable for treating EPs aged ≥ 70 years.A standard surgical treatment for RGC has not been established. In terms of the indication of splenectomy, total gastrectomy without splenectomy was shown to be non-inferior to the one without splenectomy in treating proximal advanced gastric cancer without the lesions on the greater curvature in the JCOG 0110 trial . HoweverOhira recommended endoscopic surveillance after distal gastrectomy and detection RGC at an early stage. Moreover, the minimally invasive approach of endoscopic submucosal dissection and LCG may provide patients with an improved quality of life . CurrentElderly peoples’ physiological reserves gradually decrease. Moreover, elderly peoples’ cases are characterized by multiple complicating factors such as frailty and comorbidities . ConsequThe present study was limited to retrospective assessments. To minimize bias in patient recruitment, we reviewed consecutive EPs who underwent completion gastrectomy at Saiseikai Yokohamashi Tobu Hospital. Another limitation of this study is that the surgical approach was selected based on patient preference and surgeons’ recommendations. However, the retrospective evaluation, using the modified G8 geriatric screening tool score, confirmed no significant differences between the two groups Table , indicatLCG was shown to be comparable to OCG for treating RGC in patients aged ≥ 70 years. Furthermore, blood loss during surgery was significantly reduced in LCG versus OCG. While LCG should be selected with caution in patients who have undergone D2 lymph node dissection as primary surgery, it could be considered as a surgical procedure in EPs with RGC.


Mycobacterium chimaera infections among patients exposed to contaminated heater-cooler devices used during cardiac surgery. Recognition of M. chimaera infection is hampered by its long latency and non-specific symptoms. Standard diagnostic methods using acid-fast bacilli (AFB) culture often require invasive sampling, have low sensitivity, and can take weeks to result. We describe the performance of a plasma-based next-generation sequencing test (plasma NGS) for the diagnosis of M. chimaera infection.There is an ongoing outbreak of M. chimaera infection and underwent testing by plasma NGS between February 2017 and April 2018.We conducted a retrospective study of 10 patients with a history of cardiac surgery who developed invasive M. chimaera in 9 of 10 patients (90%) with invasive disease in a median of 4 days from specimen collection, including all 8 patients with disseminated infection. In 7 of these 9 cases (78%), plasma NGS was the first test to provide microbiologic confirmation of M. chimaera infection. In contrast, AFB cultures required a median of 20 days to turn positive, and the median time for confirmation of M. chimaera was 41 days. Of 24 AFB blood cultures obtained in this cohort, only 4 (17%) were positive. Invasive procedures were performed in 90% of cases, and in 5 patients (50%), mycobacterial growth was achieved only by culture of these deep sites.Plasma NGS detected M. chimaera noninvasively and significantly faster than AFB culture, making it a promising new diagnostic tool.Plasma NGS can accurately detect The online version of this article (10.1186/s12879-019-4001-8) contains supplementary material, which is available to authorized users. Mycobacterium chimaera, a nontuberculous mycobacterium belonging to the Mycobacterium avium complex (MAC), is an opportunistic human pathogen that is ubiquitous in the environment, particularly in water sources [M. chimaera contamination of the LivaNova 3 T  heater-cooler device (HCD) used for thermoregulation during cardiothoracic surgery has been linked to an ongoing global outbreak of serious infections, including in Europe [M. chimaera isolates from infected patients and HCD water samples worldwide has demonstrated sequence similarity, suggesting point source contamination at the time of device manufacturing [ sources . M. chimn Europe –7, Northn Europe , Australn Europe , 12. Durn Europe . Whole gacturing , 15. Theacturing , 17. Whiacturing , 8, 16. M. chimaera infection. Clinical symptoms, including fatigue, fever, sweats, cough, dyspnea and weight loss, are non-specific and indolent, manifesting as long as 6 years after surgery [M. chimaera are typically available only at reference or research laboratories, further delaying confirmation of the causative pathogen [There are several challenges inherent in the diagnosis of  surgery . Standarpathogen –4.M. chimaera infection.Given these challenges, there is an urgent need for innovative diagnostic approaches. Advances in next-generation sequencing (NGS) and bioinformatics have been utilized for the direct detection of pathogen nucleic acid and hold great promise, but invasive procedures are generally necessary to obtain appropriate clinical specimens for testing . The appM. chimaera exposure risk who developed invasive M. chimaera infection and who had testing of cell-free plasma by NGS (plasma NGS) between February 2017 and April 2018. Cases were defined as patients with M. chimaera identified from AFB culture. AFB cultures of blood, urine, sputum, and biopsy samples and identification of isolates to the level of MAC were performed at the hospital’s regional laboratory. Speciation by partial 16S rRNA gene sequencing was performed at the University of Texas at Tyler.This was a retrospective study of patients with a history of cardiac surgery performed at a Southern California hospital with known M. chimaera), DNA viruses, and eukaryotic pathogens including yeasts, mold, and protozoa, and was used for patients 1–6. In May 2017, an M. chimaera plasma NGS test was validated and was used for patients 7–10.Plasma NGS testing was performed at Karius, Inc. , a reference laboratory with Clinical Laboratory Improvement Amendments certification and College of American Pathologists accreditation. A broad plasma NGS was validated to detect over 1000 microorganisms, including bacteria  or in plasma preparation tubes (PPT) via a peripheral blood draw. Samples in K2EDTA tubes were centrifuged at 1600 rcf for 10 min within 72 h of collection, and separated plasma was aliquoted into a sterile polypropylene tube. Samples in PPTs were centrifuged at 1100 rcf for 10 min within 6 h of collection to separate the plasma. Processed specimens were then shipped at ambient temperature to Karius, Inc.For plasma NGS, whole blood (minimum of 4 mL) was collected in BD Vacutainer™ KThe plasma sample was centrifuged at 16,000 rcf for 10 min at room temperature and spiked with a known concentration of synthetic DNA molecules for quality control purposes. Cell-free DNA was extracted from 0.5 mL plasma using a magnetic bead-based method , typically yielding 0.1 ng to 10 ng to be used for sequencing. DNA libraries for sequencing were constructed using a modified Ovation® Ultralow System V2 library preparation kit . Negative controls (buffer only instead of plasma) and positive controls  were processed alongside patient samples in every batch. Samples were multiplexed and sequenced on the Illumina NextSeq® 500 .M. chimaera, see Additional file Primary sequencing output files were processed using bcl2fastq v2.17.1.14) to generate the demultiplexed sequencing reads files. Reads were filtered based on sequencing quality and trimmed based on partial or full adapter sequence. The bowtie2 (version 2.2.4) method was used to align the high-quality reads against human and synthetic-molecules references. Sequencing reads that aligned to the human or synthetic molecule references were removed from further analysis. Remaining reads were aligned against Karius’ proprietary microorganism reference database using NCBI-blast (version 2.2.30). Only taxa present at statistically significant levels above background were reported. The entire process from DNA extraction through analysis is typically completed within 28 h. For full analysis details and evaluation of the bioinformatics analysis pipeline for the detection of 7.1.14 toA 54-year old male, who had undergone aortic valve and root replacement 17 months prior, was admitted with a 2-month history of fatigue, night sweats, and weight loss. Laboratory studies revealed pancytopenia, but transesophageal echocardiogram (TEE) showed no vegetations. AFB blood cultures and plasma NGS were drawn upon admission, and the patient was empirically treated with azithromycin, rifabutin, ethambutol, and amikacin.M. chimaera 6 days later. The patient improved clinically and was discharged on oral therapy. One of three AFB blood cultures turned positive after 43 days. The isolate was identified as MAC 4 days later but speciation to M. chimaera required an additional 15 days, a total of 62 days from specimen collection.Plasma NGS detected M. chimaera was again detected. The patient underwent aortic valve and root revision. Valve tissue was 4+ AFB smear positive and AFB culture was positive after 5 days, with identification as MAC one day later and no further speciation.Five months later, the patient developed progressive renal failure and was readmitted with severe aortic insufficiency and rocking of the prosthetic valve seen on TEE. Repeat plasma NGS was sent, and in 2 days, M. chimaera disease, all confirmed by standard AFB culture, who had undergone testing by plasma NGS were identified , growth of mycobacteria was achieved only by culture of these deep sites. In the remaining patients, blood, sputum, and/or urine for AFB culture was diagnostic. Of note, a total of 24 AFB blood cultures were obtained in this cohort, and only 4 (17%) were positive.M. chimaera required a median of 19 additional days (range: 8–57 days). From specimen collection for AFB culture, the median total time required for confirmation of M. chimaera was 41 days (range: 23–92 days) ; identification of MAC took a median of 3 additional days (range: 0–9 days), and further speciation to M. chimaera in 90% of these patients with invasive disease in a median of 4 days from specimen collection (range: 2–6 days), including all 8 patients (100%) with disseminated disease and 1 of 2 patients (50%) with localized disease. In 7 of these 9 cases (78%), plasma NGS was the first test to provide microbiologic confirmation of M. chimaera infection (Table Plasma NGS detected patients 00% with M. chimaera while two (in patients 3 and 4) detected EBV and one (in patient 6) detected 5 microorganisms  in addition to M. chimaera. Of note, EBV PCR of the blood drawn from patient 3 was positive at 600 copies/mL.Of the 6 positive broad plasma NGS tests performed in this cohort, three (50%) detected only M. chimaera, providing microbiologic confirmation of this fastidious organism noninvasively and over 1 month faster than standard AFB culture. Cases included in this series were typical of other patients with invasive M. chimaera reported in the literature with regard to the type of exposure, presence of prosthetic material, long incubation period, nonspecific presenting symptoms, disease manifestations, and mortality [M. chimaera. The median overall time from AFB culture collection to confirmation of M. chimaera was 41 days. In contrast, plasma NGS detected this pathogen in a median of 4 days, and in 78% of cases, this provided the first microbiologic confirmation. In four cases, plasma NGS detected M. chimaera weeks to months after initiation of antimycobacterial therapy, demonstrating that the pathogen cfDNA signal may persist even in the face of antibiotic pretreatment.To our knowledge, this is the first report describing the successful application of a plasma-based NGS test for the direct detection of ortality –12. As iM. chimaera infection has the potential to improve patient outcomes, this benefit was difficult to demonstrate in this small study. The mortality rate for our overall cohort was 60%, and this rate was similar even in the subset for whom plasma NGS was the first to provide microbiologic confirmation (7 patients) as well as the subset in whom M. chimaera was detected by plasma NGS prior to the start of antimycobacterial therapy (5 patients). Among the 4 patients who survived their infection, all underwent redo cardiac surgery, suggesting that removal of the infected prosthesis may be crucial. In 3 of these patients, plasma NGS was the first to provide microbiologic confirmation of M. chimaera infection. Thus, timely diagnosis could potentially improve mortality by informing early surgical intervention.Although early diagnosis of The application of NGS for the detection of cfDNA in plasma has been successfully employed for noninvasive diagnosis in other areas of medicine. Prenatal detection of fetal chromosomal defects can be accomplished by the sequencing of fetal cfDNA in maternal circulation, obviating the need for amniocentesis . Organ rCapnocytophaga canimorsus, in an asplenic patient presenting with culture-negative sepsis [Aspergillus, Rhizomucor, and Scedosporium species, can be detected by NGS applied to a cell-free plasma sample, potentially providing a more rapid diagnosis and obviating the need for invasive biopsies.In contrast to these applications, which focus on human cfDNA, the plasma NGS test described in this report targets microbial cfDNA in the plasma for pathogen detection. This approach has previously been used to rapidly detect another fastidious bacterium, e sepsis . In addie sepsis . SimilarM. chimaera plasma NGS was validated and made available. Finally, this particular study was limited by its small sample size. To truly define test performance characteristics such as sensitivity, specificity, and positive and negative predictive values, larger studies are needed [Despite the promise of NGS technology, some limitations remain . The kine needed . NeverthM. chimaera infection, and the high case fatality rate, there is an urgent need for sensitive and noninvasive tests to detect this pathogen in a clinically actionable time frame. This plasma NGS test rapidly and noninvasively detected M. chimaera in 90% of patients with deep-seated infection and is a promising new diagnostic tool for clinicians.Considering the widespread exposure to contaminated HCDs, the challenges with recognition and diagnosis of Additional file 1:Supplementary Methods Appendix. This document describes the analytical components of the plasma next-generation sequencing methods in greater detail. (DOCX 603 kb)


Canine Kobuvirus (CaKoV) has been detected both in healthy and diarrheic dogs and in asymptomatic wild carnivores. In this study, we conducted a survey of CaKoV at small animal hospitals in Bangkok and vicinity of Thailand during September 2016 to September 2018.n = 55) and dogs with gastroenteritis symptoms (n = 252). Of 307 swab samples tested by using one-step RT-PCR specific to 3D gene, we found CaKoV positivity at 17.59% (54/307). CaKoVs could be detected in both sick (19.44%) and healthy (9.09%) animals. In relation to age group, CaKoV could be frequently detected in younger dogs (25.45%). Our result showed no seasonal pattern of CaKoV infection in domestic dogs. In this study, we characterized CaKoVs by whole genome sequencing (n = 4) or 3D and VP1 gene sequencing (n = 8). Genetic and phylogenetic analyses showed that whole genomes of Thai CaKoVs were closely related to Chinese CaKoVs with highest 99.5% amino acid identity suggesting possible origin of CaKoVs in Thailand.Three hundred and seven rectal swab samples were collected from healthy dogs  contains supplementary material, which is available to authorized users. KoV belongs to the family Piconaviridae, genus Kobuvirus, which consists of four species Aichivirus A, B, C and D [Kobuvirus (KoV) is a single-strand positive-sense RNA virus C and D –3. KoV h C and D . The Kob C and D , 11. CaK C and D , 12–15.  C and D , in foxe C and D  and in f C and D  and wolv C and D . Several C and D . To dateDuring September 2016 to September 2018, the center of excellence for emerging and re-emerging infectious diseases in animals (CUEIDAs), Chulalongkorn University conducted a survey of canine Kobuvirus in domestic dogs at small animal hospitals in 5 provinces of Thailand. The survey was conducted under the Chulalongkorn University’s animal use and care protocol # 1731074. The result of this study provided the first detection and genetic characterization of CaKoV isolated from domestic dogs in Thailand.n = 6), CaKoV/Canine parvovirus (n = 20) and CaKoV/Canine Coronavirus (n = 2). In this study, 12 CaKoVs were selected and characterized by whole genome sequencing (n = 4) or 3D and VP1 gene sequencing (n = 8). The viruses were selected to represent epidemiological and demographic data such as age, date of isolation and breed. In this study, nucleotide sequences of the CaKoV were submitted to the GenBank database under the accession numbers MK201776 - MK201795 . We tested 307 rectal swab samples for CaKoV by using one-step RT-PCR specific to 3D gene. Based on a two-year survey, we found CaKoV positivity at 17.59% (54/307). CaKoVs could be detected in both sick (19.44% (49/252)) and healthy (9.09% (5/55)) animals. Our result showed no seasonal pattern of CaKoV infection in dogs  was also observed in Thai CaKoVs as well as reference viruses  is an emerging pathogen in Thailand. To the best of our knowledge, the CaKoV was described in Asia in retrospective study in Korea in 2011 and have been reported in Japan, China and Australia, respectively , 17, 21.In this study, the genome size of 4 Thai CaKoVs is 7,530 bp with one ORF encoding 2,444 amino acids of a putative polyprotein, which comparable to previous reports. Genome organization of CaKoV includes leader protein (L), structural proteins , non-structural proteins . Phylogenetic analyses showed that the Thai CaKoVs were closely related to each other and clustered with Aichivirus A. It is noted that Thai CaKoVs were closely related to Chinese CaKoVs sub-cluster but in separated sub-cluster from the viruses from the US, UK, Brazil and Tanzania  was observed both in Thai CaKoVs and reference viruses. Previous studies indicated that proline rich region may associate with enteric receptor binding of the viruses [Genetic analyses of Thai CaKoVs showed that whole genome of 4 Thai CaKoVs posed highest nucleotide similarity to Chinese CaKoVs including SMCD-59 and CH-1. This observation supported phylogenetic analysis that Thai CaKoVs were closely related to Chinese CaKoVs sub-cluster but in separated sub-cluster from the viruses from the US, UK, Brazil and Tanzania. Of all viral genes, the VP1 gene was the most diverse gene among Thai CaKoVs and other reference CaKoVs. Similar observation was also reported in previous study that VP1 protein is the most variable capsid protein . It is n viruses , 24. It  viruses , 20. How viruses .In conclusion, this study is the first to report of canine Kobuvirus in dogs in Thailand. CaKoVs were mostly detected in clinical dogs of young age. However, the viruses could be detected from both healthy and sicked dogs. Genetic and phylogenetic analyses showed that whole genomes of Thai CaKoVs were closely related to Chinese CaKoVs in 2015 (SMCD-59) with high nucleotide similarity suggesting a possible origin of CaKoVs in Thailand. CaKoV is considered as an emerging viral pathogen in the domestic dogs. Since CaKoVs have never been reported in the country and SEA region, the detection and characterization of CaKoV from different parts of the regions should be extended for better understanding the epidemiology and evolution of CaKoVs. Our result raises the concerns to vet practitioners that diarrhea in dogs due to canine Kobuvirus infection should not be ignored.n = 55) and dogs with gastroenteritis symptoms (n = 252) including vomiting, watery diarrhea, hemorrhagic diarrhea and dehydration. The swab samples were collected from dogs of young age (< 1 year) (n = 165), adult (1–5 years) (n = 98) and older (> 5 years) (n = 44). The animal demographic data including age, sex, breed, and vaccination history were also recorded. The ethics was conducted under the Chulalongkorn University’s animal use and care protocol # 1731074. The consent to participate of the owners of the animals used in this study was obtained in writing.Sample collection was conducted in domestic dogs at small animal hospitals in Bangkok and vicinity of Thailand During September 2016 to September 2018. 307 rectal swab samples were collected from healthy dogs (n = 307), Canine Rotavirus (n = 307) and Canine Coronavirus (n = 30) [All 307 samples were subjected to canine Kobuvirus identification by one step RT-PCR using primers specific to 3D gene of CaKoV . First, (n = 30) –27.In this study, four CaKoV positive samples  were selected for whole genome sequencing and additional eight CaKoV positive samples were selected for 3D and VP1 gene sequencing. The CaKoVs were selected based on epidemiological and demographic data such as age, date of isolation, breed, and vaccination history. For sequencing, nucleotide sequences of each gene of the viruses were amplified by new primer sets designed by using Primer 3 plus program . List ofThe phylogenetic and genetic analyses were performed by comparing nucleotide sequences of Thai CaKoVs with those of Kobuvirus available from the GenBank database. The reference nucleotide sequences of CaKoVs were retrived based on their different geographic locations, host species and date of isolation. Phylogenetic analysis of CaKoV was performed by using MEGA v.6.0   with neiAdditional file 1:Table S1. Oligonucleotide primers used for CaKoV whole genome sequencing. (DOCX 35 kb)Additional file 2:Table S2. Association of age of CaKoVs detection in this study. (DOCX 34 kb)


Recent advances in genomic technologies have facilitated genome-wide investigation of human genetic variations. However, most efforts have focused on the major populations, yet trio genomes of indigenous populations from Southeast Asia have been under-investigated.− 8 – 1.33 × 10− 8, 1.0 × 10− 9 – 2.9 × 10− 9, and ~ 0.001 per site per generation for SNVs, indels, and CNVs, respectively. The trio-genomes also allowed for haplotype phasing with high accuracy, which serves as references to the future genomic studies of OA and NB populations. In addition, high-frequency inherited CNVs specific to OA or NB were identified. One example is a 50-kb duplication in DEFA1B detected only in the Negrito trios, implying plausible effects on host defense against the exposure of diverse microbial in tropical rainforest environment of these hunter-gatherers. The CNVs shared between OA and NB groups were much fewer than those specific to each group. Nevertheless, we identified a 142-kb duplication in AMY1A in all the 15 samples, and this gene is associated with the high-starch diet. Moreover, novel insertions shared with archaic hominids were identified in our samples.We analyzed the whole-genome deep sequencing data (~ 30×) of five native trios from Peninsular Malaysia and North Borneo, and characterized the genomic variants, including single nucleotide variants (SNVs), small insertions and deletions (indels) and copy number variants (CNVs). We discovered approximately 6.9 million SNVs, 1.2 million indels, and 9000 CNVs in the 15 samples, of which 2.7% SNVs, 2.3% indels and 22% CNVs were novel, implying the insufficient coverage of population diversity in existing databases. We identified a higher proportion of novel variants in the Orang Asli (OA) samples, i.e., the indigenous people from Peninsular Malaysia, than that of the North Bornean (NB) samples, likely due to more complex demographic history and long-time isolation of the OA groups. We used the pedigree information to identify de novo variants and estimated the autosomal mutation rates to be 0.81 × 10Our study presents a full catalogue of the genome variants of the native Malaysian populations, which is a complement of the genome diversity in Southeast Asians. It implies specific population history of the native inhabitants, and demonstrated the necessity of more genome sequencing efforts on the multi-ethnic native groups of Malaysia and Southeast Asia. Informed written consent was obtained from the volunteers aged 18 years and above. Their family history, pedigree, and self-reported ethnicity were recorded via an interview using local dialect. These five trios were from five native groups (one for each). Three of them were from Peninsular Malaysia, including Bateq (BTQ), Mendriq (MDQ) (both are the Negrito tribes) and the Semai (SMI) (Senoi) groups. They are collectively known as Orang Asli (OA). The other two were from North Borneo (abbreviated as NB population), including Dusun (DSN) and Murut (MRT) populations. The information of the trios is listed in Additional file /6], the Briefly, the pair-end reads in fastQ files were mapped to human reference genome GRCh37 with BWA 0.7.5a , and werA variant in the offspring was defined as a de novo one if it presents in neither parent but in the offspring of a trio. In detail, it should meet the following criteria: i) the locus did not fall in the regions with poor mappability, low complexity or with enriched aberrant SNPs  ; ii) theWe defined autosomal CNVs in this study as deleted or duplicated DNA segments larger than 100 bp to distinguish it from the indels (< 100 bp). CNVs were identified using CNVnator  and ERDShttp://dgv.tcag.ca/dgv/app/home, GRCh37 [A novel CNV was defined if it had < 50% overlap with a CNV region reported in the Database for Genome Variants (DGV) . We defs with an actual de novo mutation, the callability Ck(s) is defined by the probability of calling s as a de novo mutation in the family k. The de novo mutation rate of a family k isWe calculated de novo mutation rate for SNVs and indels in each trio based on a callability-based method in which the probability of each site that can be called as a de novo mutation is considered in denominator rather than simple counts of sites . For a sFor CNVs, the de novo mutation rate was calculated as the number of de novo CNVs divided by the total CNVs in the offspring and averaged across trios.http://cdna.eva.mpg.de/neandertal/altai/) [We used PopIns  with def/altai/) , 35. Thep value < 0.05 were considered as thresholds of significance.Annotation of the variants  were performed using SnpEff version 4.3 T , which pParent-trio haplotype phasing was carried out using SHAPEIT for the five trios . SHAPEITAdditional file 1: Figure S1. Data quality of the de novo variants. Table S1 Sample information. Table S2. Summary information of genomic regions with top 1% of SNV density over the genome. Table S3. Summary information of genomic regions with top 1% of indel density over the genome. Table S5. Functional annotation of SNVs in each native population and global populations. Table S6. Functional annotation of indels in each native population and global populations. Table S7. Functional annotation of SNVs and indels in each native Malaysian genome. Table S9. Genomic regions identified as novel SNV hotspots. Table S10. Genomic regions identified as novel indel hotspots. Table S11. List of the de novo SNVs identified in each offspring. Table S12. List of the de novo indels identified in each offspring. Table S13. Summary of CNVs identified in each trio. Table S14. De novo CNVs identified in the 5 off-springs. Table S16. Inheritance of selected genes that are known to either lie on the segmental duplication regions, or carry CNVs.Additional file 2: Table S4. Functional enrichment of genes underlying the mutation hotspots, loss-of-function variants, de novo variants, copy number variants and novel insertions.Additional file 3: Table S8. Distribution of FS indels and the candidate genes affected.Additional file 4: Table S15. CNVs sharing across the native Malaysian trios.Additional file 5: Table S17. Inherited novel insertions in the 5 native Malaysian trios.


Accurate and early diagnosis of residual tumors or intrahepatic recurrences after TACE is critically needed for determining the success of treatments and for guiding subsequent therapeutic planning. This meta-analysis was performed to assess the efficacy of diffusion weighted imaging (DWI) with the quantitative apparent diffusion coefficient (ADC) value in diagnosing residual or recurrent hepatocellular carcinoma after transarterial chemoembolization (TACE).A comprehensive literature search of PubMed, Embase, Web of Science, Scopus and the Cochrane Library database, from inception to July 2019, was conducted to select original studies on diagnosing residual or recurrent HCCs after TACE using DWI sequence with its ADC value. Two researchers independently chose study, extracted data, conducted meta-analysis, and evaluated methodological quality according to Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool.P < 0.01).Twelve studies comprising 624 patients and 712 tumors were finally included. The pooled sensitivity, specificity and AUC value of DWI in diagnosing residual or recurrent HCCs after TACE were 85% (95%CI: 74–92%), 83% (95%CI: 75–88%) and 0.90 (95%CI: 0.87–0.92), respectively. Residual or recurrent HCCs have significantly lower ADC value than necrotic tumors (MD = -0.48, 95%CI: − 0.69~ − 0.27, This study demonstrated that DWI performed better in diagnosing residual or recurrent HCCs after TACE, and ADC value may serve as alternatives for further evaluation of residual or recurrent leisions in HCC patients after TACE. Hepatocellular carcinoma (HCC) is one of the most malignant tumors, with serious threats to human life and health, and it is estimated to be the fourth major factor of cancer death in the worldwide population . HoweverAs a first-line and curative therapy, transarterial chemoembolization (TACE) operates by injecting chemotherapeutic drugs at the HCC site while impeding blood supply to the tumor. In previous studies, TACE has been proven to be an efficient bridge therapy for patients waiting for liver transplantation and can improve survival prognosis in patients with inoperable HCC , 5. HoweBy detecting water diffusion indirectly, diffusion weighted imaging (DWI) provides information regarding tissue cellularity and cell membrane integrity, and its quantitative value of the apparent diffusion coefficient (ADC) is highly associated with tumor cellularity , 8, indiAccording to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines , a compr(1) DWI and the calculated ADC values were used as diagnostic indices for detecting residual or recurrent HCCs after TACE. (2) Pathology and/or digital subtraction angiography (DSA) and/or follow-up clinical results served as the reference standard . (3) The(1) Surgical resection and any other therapies besides TACE were applied to treat HCC. (2) The two-by-two table of DWI alone could not be acquired when DWI was used in conjunction with other MRI images; these studies were also excluded. (3) Review articles, case reports, animal studies, and editorial comments were excluded. (4) Conferences abstracts were also excluded, as their conclusions might not be up to date.Two researchers (ZL and HFL) independently extracted the study data and evaluated the methodological quality using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool , and anyP-value less than 0.05 indicated the threshold effect. A chi-squared test was performed to measure the heterogeneity degree of the enrolled studies, and the degree was considered low for I-squared (I2) = 25 to 49%, moderate for I2 = 50 to 74%, and high for I2 > 75%.Data synthesis and statistical analysis were performed using STATA  and Review Manager software . To present the study characteristics of DWI in diagnosing residual or recurrent HCCs after TACE suitably, data synthesis was performed by the METANDI module and hierarchical logistic regression modeling in STATA software. The Spearman correlation coefficient was calculated to test the threshold, and a P-value < 0.05 was representative of publication bias.The pooled sensitivity (SEN), specificity (SPE), positive likelihood ratio (PLR) and negative likelihood ratio (NLR) with their 95% confidence intervals (CIs) were computed from the two-by-two table data. Then, the receiver operator characteristics (ROC) curve and area under the ROC curve (AUC) were computed to evaluate the value of DWI in diagnosing residual or recurrent HCCs after TACE, and the value was considered good for AUC values > 0.9 and medium for AUC values from 0.7 to 0.9. Moreover, the ADC values of the residual or recurrent HCC group and the necrotic lesion group were compared and pooled as the mean difference (MD) with a random-effects model to incorporate expected heterogeneity. Additionally, possible factors, including study design type (retrospective or prospective), b value (< 800 or ≥ 800) and threshold method , that may lead to heterogeneity were analyzed through subgroup analysis. Moreover, the reliability and stability of this study were evaluated through sensitivity analysis. Last, Deeks’ funnel plot with the linear regression of log odds ratios on the inverse root of effective sample sizes was performed to test for publication bias: a Figure The methodological assessment results of the included studies are shown in Table P = 0.662 > 0.05), indicating that there was no obvious threshold effect of DWI in diagnosing residual or recurrent HCCs after TACE. The chi-squared value of the pooled SEN was 27.47 (P = 0.02 < 0.05), and the I2 value was 49.03%, demonstrating low heterogeneity for SEN. SPE had a chi-squared value of 56.58 (P < 0.01), and the I2 value was 75.38%, representing high heterogeneity.The Spearman correlation coefficient was 0.141 , SPE =83% (95% CI: 75–88%), PLR =5.12 (95% CI: 3.27–7.38), NLR =0.18 (95% CI: 0.09–0.34), and AUC =0.90 (95% CI: 0.87–0.92). Forest plots and ROC curves for the 12 studies are shown in Figs. –92%, SPEP < 0.01), which is shown in Fig. Among the included studies, 8 studies compared the ADC value between residual or recurrent HCCs and necrotic tumors. Our pooled analysis demonstrated that residual or recurrent HCCs had significantly lower ADC values than necrotic tumors .For the use of DWI in the detection of residual or recurrent HCCs after TACE, the reliability and stability of this meta-analysis were assessed by removing one study with unclear field strength and the use of the b value. The resulting SEN was 87% (95% CI 78–93%), SPE was 83% (95% CI 74–89%) and AUC was 0.91 (95% CI 0.88–0.93), indicating that the effect values were still within the 95% CI of the original results, thus showing that the results were reliable and stable. Deeks’ funnel plot is presented in Fig. Because of the potential severe complications and relatively high cost, pathology and digital subtraction angiography are not recommended as routine follow-up examinations for diagnosing residual or recurrent HCCs after TACE . HoweverAfter the TACE procedure, the HCC tumor cells undergo necrosis and apoptosis, with increased cell membrane permeability and enlarged cell gaps, leading to more water molecule movement on DWI and an increased ADC value. For residual or recurrent HCCs, the tortuosity of the extracellular space and the higher density of hydrophobic cellular membranes will increase cell density and restrict the apparent diffusion of water protons, thus presenting a high signal on DWI and a lower ADC value , 29; theIn this study, 12 studies comprising 624 patients and 712 tumors detected on DWI were included. The SEN, SPE, and AUC values of DWI in diagnosing residual or recurrent HCCs after TACE were 85% (95% CI: 74–92%), 83% (95% CI: 75–88%), and 0.90 (95% CI: 0.87–0.92), respectively, indicating a high value of DWI in diagnosing residual or recurrent HCCs after TACE. Additionally, the PLR for DWI was 5.12 (95% CI: 3.27–7.38), revealing moderate accuracy in diagnosing residual or recurrent HCCs after TACE. The NLR value for DWI was 0.18 (95% CI: 0.09–0.34), and a negative DWI result may be used as a moderate justification to rule out residual or recurrent HCCs after TACE. Moreover, this pooled analysis also indicated that the ADC value of necrotic tumors was significantly higher than that of residual or recurrent HCCs, confirming previous findings and revealing that the ADC value can be used as an efficient imaging method to differentiate the properties of lesions after TACE.In this meta-analysis, the opposite results of false-negative (1-SEN) and false-positive (1-SPE) rates were 15 and 17%, respectively, for DWI in diagnosing residual or recurrent HCCs after TACE, and some of the following possible factors could contribute to the relatively high number of false-negative and false-positive results. 1) Adjacent hepatic inflammation could restrict water diffusion, resulting in sustained hyperintensity on DWI, thereby producing a false-positive DWI diagnosis of the lesion after TACE , 31. 2) 2. This meta-analysis demonstrated that DWI performed better for the diagnosis of residual or recurrent HCCs after TACE with lower b values than with higher b values, revealing that the b value of DWI was one of the factors affecting diagnostic efficacy. 2) Heterogeneity might be induced by the different threshold methods used. There is a trend towards a higher diagnostic value of ADC measurement compared to visual diagnosis. Visual diagnosis is easily affected by the T2 shine-through effect and may account for this result [Significant sources of heterogeneity concerning the use of DWI in the diagnosis of residual or recurrent HCCs after TACE and the evaluation of this meta-analysis demonstrated 4 potential factors that may account for this result: 1) Freiman et al.  reporteds result . 3) Thers result , becauseThere were some deficiencies in this study that should be noted. First, although a combination of electronic and manual searches was performed, only 12 studies comprising 624 patients on DWI were involved. The small number of included studies might have a negative impact on the diagnostic accuracy; therefore, further high-quality studies on a larger scale may be required. Second, the exclusion of studies other than those published in English, review articles and conference abstracts may contribute to potential publication bias. Third, field strength was found to affect the efficacy of DWI in diagnosing residual or recurrent HCCs after TACE. However, because of the limitations of the included studies, the accuracy of DWI in diagnosing residual or recurrent HCCs after TACE from the perspective of field strength was not been explored.In conclusion, our study suggested that DWI performs well in diagnosing residual or recurrent HCCs after TACE, and the ADC value may serve as an alternative marker in the further evaluation of HCC patients after TACE.


NOS1 contribute to CP susceptibility in a Han Chinese population.Cerebral palsy (CP) is the leading cause of motor disability in children; however, its pathogenesis is unknown in most cases. Growing evidence suggests that Nitric oxide synthase 1 (NOS1) is involved in neural development and neurologic diseases. The purpose of this study was to determine whether genetic variants of NOS1 gene  were selected, and the MassARRAY typing technique was applied for genotyping. Data analysis was conducted using SHEsis online software, and multiple test corrections were performed using SNPSpD online software.A case-control study involving 652 CP patients and 636 healthy controls was conducted. Six SNPs in the p = 0.004, 0.012, and 0.002, respectively). The T allele of NOS1 SNP rs3782219 was negatively associated with spastic quadriplegia . There were no differences in allele or genotype frequencies between CP subgroups and controls for the other genetic polymorphisms.There were no significant differences in genotype and allele frequencies between patients and controls for the SNPs except rs6490121, which deviated from Hardy-Weinberg equilibrium and was excluded from further analyses. Subgroup analysis revealed differences in genotype frequencies between the CP with neonatal encephalopathy group (CP + NE) and control group for rs10774909, rs3741475, and rs2682826  contains supplementary material, which is available to authorized users. Cerebral palsy (CP), the most common cause of motor disability in childhood, is a group of permanent movement and posture disorders attributed to non-progressive abnormalities in the immature brain. Patients with CP often exhibit secondary musculoskeletal problems, epilepsy, and disturbances of sensation, perception, cognition, communication, and behavior . EpidemiV/VII, lymphotoxin-alpha, tumor necrosis factor, IL-6, and IL-8, to determine whether they contribute to the causal pathway of CP [CP is a complex disease. It is highly heterogeneous with regard to phenotype and etiology, and the different subtypes of CP might result from different causal pathways. Some cases may be caused by a single mutation in a single gene, but many may be caused by complex interactions of multiple genetic loci and environmental factors. However, the causes of CP are unknown in most individuals. An increasing association studies have explored the interactions between the susceptibility to CP and SNPs of candidate genes, including those involved in the inflammatory system and the coagulation cascade such as coagulation factor II/ay of CP –14.NOS1 gene is the major isoform and is widely expressed throughout the brain, accounting for approximately 90% of NO in the CNS [NOS1 variants are associated with disorders such as Alzheimer’s disease [Nitric oxide (NO) acts as a pleiotropic gaseous messenger molecule, and it is dynamically controlled during normal development and brain injuries. NO is synthesized from L-arginine by nitric oxide synthase enzymes (NOSs), of which there are three isozyme forms: neuronal NOS , inducible NOS (iNOS), and endothelial NOS (eNOS) . The NOS the CNS . NO prod the CNS , 18, and the CNS . NO appe the CNS . During  the CNS . Recent  disease , schizop disease , and Par disease . The assNOS1 knockout mice were less vulnerable to HI-induced histopathological brain damage than their wild-type counterparts [NOS1 gene and CP. Therefore, we performed a comprehensive association study on polymorphisms of the NOS1 gene and the risk of different subtypes of CP.Genetic and pharmacological studies have also provided valuable insights into the pathophysiology of NOS1. In a neonatal animal model of hypoxia-ischemia (HI), terparts . Selectiterparts . These rThis was a case-control study based on a Chinese Han population. The study cohort included 652 CP patients and 636 healthy participants who were recruited from the centers for CP rehabilitation and Child Healthcare Departments in the Third Affiliated Hospital of Zhengzhou University, Zhengzhou Children’s Hospital and the First Affiliated Hospital of Henan Traditional Chinese Medical College. The CP group consisted of 198 female (30.4%) and 454 male (69.6%) patients ranging in age from 8 to 116 months. The control group was selected from healthy individuals who came to the facility for routine examinations and did not have neurologic conditions or predefined medical conditions; this group was comprised of 214 female (33.2%) and 422 male (66.8%) individuals ranging in age from 8 to 106 months. The diagnosis of CP was made by child neurologists, based on either a clinical examination or medical records and followed the guidelines proposed by the “Surveillance of CP in Europe” network . WrittenThe database of medical records contains information on the subtypes of CP, such as spastic; CP risk factors, such as preterm and birth asphyxia; symptoms concomitant with CP, such as mental retardation (MR); neonatal complications, such as periventricular leukomalacia (PVL) and hypoxic-ischemic encephalopathy (HIE); maternal factors, such as premature rupture of membrane (PROM); and neonatal encephalopathy (NE) Table . The evaNOS1 gene with minor allele frequencies in the Chinese Han population greater than 0.1 were selected from the dbSNP database (www.ncbi.nlm.nih.gov/SNP) and the phase II genotyping data of the HapMap project (http://www.1000genomes.org/). rs2293052 (exon 13) and rs3741475 (exon 22) were synonymous mutation, rs2682826 is located in 3’UTR, while the other three SNPs are located in intron: rs3782219 (intron 1), rs6490121 (intron 10), 10,774,909 (intron 20). Exception for rs10774909, the rest 5 SNPs were reported in published literature online, which were associated with disorders, such as Schizophrenia, Alzheimer’s disease, Parkinson’s disease.Altogether, six SNPs  of the http://www.sequenom.com), and the sequences are available upon request. After the amplification of polymorphism-spanning fragments by multiplex polymerase chain reaction (PCR), the selected SNPs were genotyped using the MassARRAY system  following the manufacturer’s directions (http://www.sequenom.com). SpectroTYPER software  was used to automatically perform genotype calling with a set of digital filters optimized for the mass spectra of oligonucleotides. The individual who analyzed the genotype results was blinded to the clinical data.Genomic DNA was extracted from whole blood of CP patients and controls, using the AxyPrep Blood Genomic DNA Miniprep Kit  according to a standard protocol. Probes and primers were designed using the SEQUENOM online tools . Linkage disequilibrium was measured using standardized D’, and the discrepancies in allele and genotype frequencies at single loci between patients and controls were compared using a Monte Carlo simulation strategy. The number of observations for each haplotype were compared by χ2 tests. All reported p values are two-tailed, and statistical significance was set at p < 0.05. The relative risk was approximated by the estimate of odds ratio (OR), and for each OR, a 95% confidence interval (CI) was computed. All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS version 19.0) and GraphPad Prism 6.0 software package . For all comparisons, multiple testing for each individual SNP was corrected using the SNPSpD program , which is based on the linkage disequilibrium. Multiple testing for each haplotype was corrected by the Bonferroni correction. Statistical efficacy was evaluated with G.power 3.1 software.Hardy-Weinberg equilibrium testing was performed to analyze the allele and genotype frequencies, using the SHEsis online software platform (p = 0.0338), did not deviate from Hardy-Weinberg equilibrium (p > 0.05) among the control population (Table p = 0.046) were different between all CP patients and the controls, but the differences disappeared after SNPSpD correction  when an effect size index of 0.1 was used. The genotypic distribution of the selected SNPs, except for rs6490121  (D’ > 0.9)  (Table p = 0.013), rs3741475 (p = 0.043), and rs2682826 (p = 0.042) also showed differences between spastic tetraplegia (n = 238) and controls, but the differences disappeared after SNPSpD correction. The haplotype analysis for rs10774909, rs3741475, and rs2682826 revealed a global P-value of 0.034 (Table p = 0.025), but the differences disappeared after Bonferroni correction (p = 0.075). There were significant differences in genotype between CP patients with NE (n = 261) and controls at rs10774909, rs3741475, and rs2682826   located in the 3’-UTR of exon 29 of the  of mRNA –45. Some of mRNA , 47. Whi of mRNA . The genThe etiology and pathogenesis of CP are complex. Regarding the genetic mechanism, CP may exhibit different genetic patterns, and the disease is polygenic in most CP cases. Although genome-wide association studies (GWASs) have been successful in identifying many cerebral disorder-associated loci, no GWAS on CP has been performed, and most of the CP-related genes have not been identified. Because of the complicated genetic architecture of CP, multiple genes might be involved in the etiology of CP, and the effect size of each individual risk allele is likely to be small. Moreover, the factors underlying inter-individual variations in the susceptibility to CP may also include demographic, clinical, and environmental variables. Our results need to be validated or replicated in other, larger population samples.NOS1 gene polymorphisms and CP at the total level, but NOS1 was associated with spastic tetraplegia and CP + NE, suggesting that NOS1 may play a more important role in the pathogenesis of severe forms of CP. However, we only assessed five SNPs of the NOS1 gene, and it is necessary to explore more NOS1 gene variants. It is important to note that a comprehensive evaluation of the NOS1 gene and CP requires a large sample for which sample independence can be validated and functional evidence is available. Furthermore, functional studies on the impact of these polymorphisms on gene expression in CP populations might help to define new therapeutic perspectives for CP.There was no significant association between Additional file 1:Table S1. Linkage disequilibrium among the five SNPs. The standardized D’ values are shown above the diagonal, and the r2 values are shown below the diagonal. (DOCX 12 kb)


We investigated this outbreak to describe the magnitude and associated risk factors due to the malaria outbreak in Tanquae Abergelle district, Tigray, Ethiopia, in 2017.P value = 0.001], sleeping outside a home [OR = 5.06 CI (1.75–14.61) P-value = 0.003] and having unscreened window [OR = 14.89 CI (1.87–118.25) P-value = 0.011] were associated with illness in multivariate analysis.Case fatality rate of this study was zero. Among the 62 cases and 124 controls, the presence of mosquito breeding sites [OR = 6.56 CI (2.09–20.58)  In 2017, globally malaria caused an estimated number of 219 million cases in 87 countries, and 435,000 deaths , the presence of mosquito breeding site around home [AOR = 6.56 (CI 2.09–20.58) P-value of 0.001], and having unscreened window [AOR = 14.89 (CI 1.87–118.25) P-value of 0.011] were associated with malaria.In our observation, there were multiple stagnant waters which could be potential mosquito breeding sites. There were also visible larvas in the stagnant waters especially in the Gerea kebelle of Tanquae Abergelle.In the district, there were multiple mosquito breeding sites identified which might be a source of the outbreak. Moreover, indoor residual spraying of houses in affected kebeles with deltamethrin was not performed timely. Spraying in some rural kebelles had started after the outbreak had begun but didn’t involve the district town Yechella.According to this case–control study, malaria was prevalent in females than males, an identified risk factor for malaria was the presence of mosquito breeding sites around home or vicinity, sleeping outside the home and having an unscreened window.This study shows that malaria was more prevalent in females than in males. It was different from the finding of studies done in Oromia, and Gedio zone of Ethiopia , 9. ThisOur study finding of sleeping outside the home was significantly associated with malaria. This was consistent with studies done in west Begal, India, and Swaziland , 11. ThiIn our study, the finding of the presence of a mosquito breeding site around home or vicinity was significantly associated with malaria. This was in agreement with studies done in the Laelay Adeyabo, and Gedeo zone of Ethiopia, Tanzania, and Zimbabwe , 12–14. The finding of having an unscreened window as a risk for malaria was in agreement with a study done in Equatorial Guinea .In Tanquae Abergelle district 15–44 years of age group and females were more affected by malaria. Malaria transmission had an increasing trend. There was a significant association of malaria with the presence of mosquito breeding sites around home or vicinity, sleeping outside a home and having an unscreened window. We would like to recommend the district health office to mobilize residents to avoid potential places of mosquito breeding site and to conduct regular indoor residual spray.The selected disease-free controls might be in the incubation period for developing malaria.Additional file 1: Table S1. Bi-variate analysis related to malaria outbreak in Tanquae Abergelle district, Tigray, Ethiopia, 2017.


Background: Folate deficiency may increase the risk of peripheral neuropathy but there is a paucity of data from large prospective studies examining this association. Methods: Longitudinal analysis of electronic health records in The Health Improvement Network (THIN), a U.K. primary care database including 594,338 patients aged 18–70 years with a folate measurement and without a history of peripheral neuropathy. Results: After a mean follow-up of 3.71 (standard deviation (SD) = 3.14) years, 1949 patients were diagnosed with peripheral neuropathy and 20,679 patients died. In those <40 years, compared to patients with folate ≥13.6 nmol/L, those with folate <6.8 (deficient) and 6.8–13.5 nmol/L (insufficient) had a hazard ratio (HR) for peripheral neuropathy of 1.83  = 1.16–2.91) and 1.48 (95% CI = 1.04–2.08), respectively. There was no significant association between folate and peripheral neuropathy among those aged 41–70 years. Compared to patients with folate ≥ 13.6 nmol/L, folate <6.8 nmol/L was associated with a greater risk of death among all ages. Conclusion: Folate deficiency and insufficiency was associated with a greater risk of peripheral neuropathy among younger patients. This investigation should be replicated in other large datasets and it may be important to monitor peripheral neuropathy incidence after the introduction of mandatory folic acid fortification of flour in the U.K. Peripheral neuropathy is a term given to indicate a disorder of the peripheral nervous system. It can involve sensory and/or motor fibres, and is relatively common, with an estimated prevalence of 8% in adults older than 55 years . The mosFolate is a water-soluble B vitamin, and in the U.K., good dietary sources are green vegetables, such as broccoli, citrus fruit and foods voluntarily fortified with folic acid, including some breakfast cereals . DeficieIn this study we aimed to assess the relationship between folate deficiency and the risk of peripheral neuropathy of an otherwise undetermined aetiology in a large U.K. population younger than 70 years. A secondary objective was to assess the association between serum folate and all-cause mortality.This was a retrospective cohort found in The Health Improvement Network (THIN) primary care database, which contains health records for more than 11 million patients from over 600 general practices (GPs) in the U.K. The distribution of age, sex, prevalence of major medical conditions and mortality rates in the THIN cohort is generalizable to the U.K. population . The datn = 138,903), had a value of serum concentrations of folate that was above 68.2 nmol/L or not recorded , or a missing BMI (n = 2387) or were older than 70 years  leaving 594,338 patients available for this analysis  and acceptable computer usage (ACU) standards measures of quality assurance for THIN data ,12. Adulanalysis .Folate deficiency was defined as serum folate <6.8 nmol/L, folate insufficiency was defined as serum folate 6.8 to <13.6 and folate sufficiency was defined as serum folate ≥13.6 nmol/L based on World Health Organization (WHO) guidance [Peripheral neuropathy was the primary outcome and was defined using Read codes that included peripheral neuropathy or polyneuropathy but excluded cause-specific peripheral neuropathy, such as diabetes and alcoholism. The secondary outcome for this analysis was death from any cause. 2); vitamin B12 deficiency [Person-years of follow-up were calculated from one year after the date of measurement of serum folate concentrations up to whichever came first: diagnosis of peripheral neuropathy, exit from the THIN database (transferred practice or died), the last date practice data was collected or December 31 2017. Cox proportional hazard regression was used to calculate the hazard ratios (HRs) and 95% confidence intervals (CI) of peripheral neuropathy and mortality by categories of serum folate concentrations. As there was a statistically significant folate by age interaction, analyses were conducted separately for the following age categories: <40, 40–55, 56–70 years. All analyses were adjusted for sex; age; fifths of socioeconomic group (based on the Townsend deprivation score), smoking ; BMI  years, there were 1949 patients diagnosed with peripheral neuropathy (947 women and 1002 men) and 20,679 patients died . The incidence of peripheral neuropathy was higher in men (0.49%) than in women (0.24%).p-trend = 0.35) and aged 56–70 years (p-trend = 0.31). After adjusting for age, sex and other confounding variables, there was an inverse relation between serum folate concentrations and peripheral neuropathy among those <40 years of age. The adjusted hazard ratios with baseline folate >13.6 nmol/L set as a reference within each age group are shown in The inverse association between serum folate concentrations and the risk of mortality was evident across the three age groups where HR in the lowest folate category compared with the highest folate category was 1.55 (95% CI = 1.26–1.90) in those aged 18–40 years, 1.66 (95% CI = 1.51–1.83) in those aged 41–55 years and 1.48 (95% CI = 1.40–1.57) in those aged 56–70 years.p-trend = 0.05). Censoring of an additional two years of follow-up made little difference to the association of serum folate and hazards of mortality.All analyses were repeated after censoring an additional two years from the index data and the results are shown in 12 and folate concentrations as measured using Pearson’s correlation was r = 0.24. There was no overall association between serum vitamin B12 concentrations and the risk of peripheral neuropathy. The correlation between vitamin BFor the patients 40 years and younger, circulating folate concentrations were inversely associated with the risk of developing peripheral neuropathy in a dose-dependent manner. There was also a significant inverse association between serum folate and mortality across all age groups. Only a few observational studies have examined the relationship between serum folate and the risk of peripheral neuropathy; results from one small cross-sectional study showed that in patients with Parkinson’s disease there was an inverse association between serum folate and the risk of peripheral neuropathy that was independent of age . The res12 deficiency because of the role that vitamin B12 has as a co-enzyme in the conversion of homocysteine to methionine, a precursor to S-adenosyl methionine (SAM), which is important for myelination of nerve cells [12 deficiency [Peripheral neuropathy is much more common among patients with vitamin Bve cells . As nervficiency . Neverthficiency , togethe6 and/or vitamin B12) was not significantly different from the control group [The inverse association between serum folate and risk of all-cause mortality has also been reported in one other large cohort study conducted in the USA where flour has been mandatorily fortified with folic acid since 2002 . Despiteol group . This isol group . While tol group . This study has some limitations. From the patients’ records, we were not able to determine the method used to measure serum folate concentrations, which is important as methods, such as folate binding assays, produce systematically lower folate results than the microbiological assay or the gold standard liquid chromatography coupled to tandem mass spectrometry . HoweverIn conclusion, our results suggest that folate deficiency is a risk factor for neuropathy in patients younger than 40 years. Importantly, the risk of peripheral neuropathy increased as serum folate decreased, and even insufficient serum folate of 6.8 to 13.5 nmol/L appeared to be important. These associations warrant further investigation in other large electronic health datasets. Moreover, future surveillance of peripheral neuropathy in the U.K. after the introduction of folic acid fortification of flour may help to understand whether improving serum folate concentrations in the population also leads to a change in the incidence of peripheral neuropathy across the different age groups.


Among a cohort of postmenopausal breast cancer survivors, we aimed to compare the risk of dementia associated with aromatase inhibitor (AI) therapy versus tamoxifen.Using UK primary care electronic health records, we identified 14,214 postmenopausal breast cancer survivors (aged ≥ 54 years) with a first AI or tamoxifen prescription between January 2002 and December 2015 and no previous dementia diagnosis. Women were followed-up to identify incident cases of dementia. Cox regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) to quantify the association between AI exposure (vs. tamoxifen) and dementia, adjusted for confounders.A total of 368 incident dementia cases was identified over 57,102 person-years of follow-up. The crude incidence rate of dementia was 7.46 per 1000 person-years (95% CI 6.43–8.65) among women starting endocrine treatment on an AI, and 6.32 per 1000 person-years (95% CI 5.34–7.47) among women starting on tamoxifen. After accounting for age differences and assessing other potential confounders, there was no evidence of a difference in dementia risk between exposure groups . There was no evidence of effect modification by age.There was no evidence for a difference in dementia risk between AI and tamoxifen users among postmenopausal breast cancer survivors.Our findings suggest that there is no reason for concern about a difference in dementia risk with AI vs. tamoxifen, which is relevant to postmenopausal breast cancer patients recommended these treatments.The online version of this article (10.1007/s11764-019-00782-w) contains supplementary material, which is available to authorized users. Adjuvant endocrine therapy remains the mainstay of treatment for postmenopausal women with oestrogen-receptor positive breast cancer. Aromatase inhibitors (AIs)—anastrozole, exemestane, and letrozole—have become the preferred treatment in this patient population , 2, beinOver recent decades, there has been much interest in whether adjuvant endocrine therapy is adversely associated with cognitive functioning in breast cancer survivors—a commonly reported side effect in these patients . SubstanAs the majority of women with oestrogen-receptor positive breast cancer will actually receive treatment with either an AI or tamoxifen, an important question is whether there is a different effect on cognition function between these two treatments. Owing to their different mechanisms of action, circulating oestradiol levels are substantially lower following treatment with AIs than with tamoxifen , and couWe used data from the Clinical Practice Research Datalink General Practice Online Data (CPRD GOLD) primary care database of anonymised electronic health records (EHRs), which covers approximately 7% of the UK population, and to which 674 general practices across the UK have contributed patient data , 18. TheIdentification of the study population is depicted in the Fig. In the UK, the recommended duration of use for AIs during the period of this study was 5 years or 3 years as part of a sequential regimen following 2-year tamoxifen treatment . EndocriThe primary outcome of interest was any type of incident dementia, defined as a first record of a prescription for a dementia-specific medication , alcohol consumption , diabetes (type I or II), hypertension, cardiovascular disease (CVD), cerebrovascular disease, hyperlipidaemia, depression, use of hormone replacement therapy (HRT), and time since the index date . For lifestyle variables, we used the most recently recorded status/value before the index date.Variables evaluated as potential confounders included age at the start of endocrine therapy (< 75 years and ≥ 75 years), practice level index of multiple deprivation (IMD)—a measure of socioeconomic deprivation (five quartiles with 1 being the least deprived and 5 being the most deprived) , smokingBaseline variables were described according to initial endocrine therapy prescribed, using frequency counts and percentages for categorical variables and means with standard deviation (SD) for continuous variables. Mantel-Haenszel stratification was used to calculate the crude incidence rate ratio with 95% confidence interval (95% CI) for incident dementia comparing use of AIs with tamoxifen (reference group) as first endocrine therapy. Cox regression  was used with AI exposure as a time-updated variable to quantify the association between use of AIs (vs. tamoxifen) and incident dementia, adjusted for confounders. Hazard ratios (HRs) with 95% CIs were calculated for any type of dementia as the primary outcome, and for Alzheimer’s disease and vascular dementia as secondary outcomes . The main comparison of interest was between person-time on an AI as first endocrine therapy (prior to any switch) and person-time on tamoxifen as first endocrine therapy (prior to any switch). In the Cox regression modelling, each potential confounder was added to the attained-age adjusted model one at a time, i.e. a series of 2-variable models, with a change in the HR of 10% or more compared with the age-only model deemed to provide evidence of confounding by the added variable. For variables with missing data , potential confounding for each was explored using a complete case approach (excluding patients with missing data on that particular variable). A sensitivity analyses was performed, restricting to dementia cases identified on the basis of a Read code (i.e. those with only a dementia medication prescription during follow-up were deemed non-cases). Potential effect modification by age and previous use of HRT was investigated. Stata 14  was used for all analyses.n = 8018), with less than a quarter  receiving an AI as part of a sequential regimen following initial tamoxifen therapy. Median follow-up was 2.5 years among women starting treatment on an AI and 4.8 years among women starting on tamoxifen; maximum follow-up times in the two groups were 12.9 years and 13.0 years respectively. Overall, 1222 patients (8.6%) had missing data on at least one lifestyle variable.We identified 14,214 postmenopausal women with a first prescription for an AI or tamoxifen following a first breast cancer diagnosis. Among these, 8018 (56.4%) women started endocrine treatment with an AI and 6196 (43.6%) started with tamoxifen. Baseline characteristics of the study population are presented in Table n = 127; median age 79.4, IQR 73.5–85.5) and vascular dementia for a quarter . There was one case of dementia with Lewy bodies (0.3%), seven cases of mixed dementia (1.9%), and 143 cases had unknown dementia subtype . The crude incidence rate of dementia was 7.46 per 1000 AI exposed person-years (95% CI 6.43–8.65) among women on an AI as their first endocrine treatment, and 6.32 per 1000 tamoxifen exposed person-years (95% CI 5.34–7.47) among women on tamoxifen as their first endocrine treatment. In unadjusted analyses, no association was seen between AI use (vs tamoxifen) and dementia incidence . Age-adjusted HRs for the association between AI exposure and other explanatory variables with incident dementia are shown in Table A total of 368 incident cases of dementia  were identified during 57,102 person-years of follow-up. Alzheimer’s disease accounted for over a third of cases  or previous HRT use (p = 0.661) (Table There was no evidence that the risk of dementia with AI therapy (vs. tamoxifen) was modified by age at start of therapy (1) Table . TestingIn this large population-based cohort study with up to 13 years’ follow-up, we found no evidence that postmenopausal breast cancer survivors receiving treatment with an AI had a higher risk of incident dementia compared with those on tamoxifen. This finding was also seen for both Alzheimer’s disease and vascular dementia.We are unaware of other studies that have directly compared the effect of AIs and tamoxifen on the risk of dementia among postmenopausal breast cancer patients in any setting. Our findings are, however, in line with those from a meta-analysis of six small cross-sectional studies by Underwood et al., who found no differences between AIs and tamoxifen among cognitive performance in breast cancer patients . It shouStrengths of our study include the large sample from a validated data source representative of the UK demographic, and which has a high PPV for recorded dementia diagnoses , 21 and Further evaluation of the cognitive safety of adjuvant endocrine breast cancer therapy in other large population-based cohorts is needed to corroborate our findings, including exploration of possible age-related and treatment duration effects, as well as potential effects of previous tamoxifen treatment. It is also important to note that our findings do not rule out the possibility that both AIs and tamoxifen are detrimental in terms of dementia risk compared with no endocrine therapy. Tamoxifen has oestrogen antagonist properties in some tissue (e.g. breast) and agonist properties in others (e.g. bone) but its action in the brain is unknown and it could potentially have an independent causal association with dementia risk. Among cognition RCT sub-studies and the few large observational studies on this topic, findings have been mixed, and comparisons are limited by heterogeneity in the study population, the exposure and comparison groups, and the specific cognitive outcome(s) evaluated –10, 12.Dementia is a common disease, with an estimated prevalence of 7% among the general population aged over 65 years ; therefoESM 1(DOCX 78 kb)ESM 2(DOCX 86 kb)ESM 3(DOCX 77 kb)ESM 4(DOCX 80 kb)