Blastocystis is the most commonly found intestinal protist in the world. Accurate detection and differentiation of Blastocystis including its subtypes (arguably species) are essential to understand its epidemiology and role in human health. We compared (i) the sensitivity of conventional PCR (cPCR) and qPCR in a set of 288 DNA samples obtained from stool samples of gut-healthy individuals, and (ii) subtype diversity as detected by next-generation sequencing (NGS) versus Sanger sequencing. Real-time PCR resulted in more positive samples than cPCR, revealing high fecal load of Blastocystis based on the quantification curve in most samples. In subtype detection, NGS was largely in agreement with Sanger sequencing but showed higher sensitivity for mixed subtype colonization within one host. This fact together with use of the combination of qPCR and NGS and obtaining information on the fecal protist load will be beneficial for epidemiological and surveillance studies. Blastocystis sp. is a unicellular eukaryote colonizing the gastrointestinal tract of humans and various other species. Although discovered more than a century ago, its role in human health and disease has not been fully understood. Knowledge gaps remain in its epidemiology and interaction with the host, as well as factors affecting host colonization [Blastocystis may be the most common intestinal human protist in the world, colonizing more than 1 billion people [Blastocystis sp. may reach 100% [rRNA) gene analysis, at least 22 subtypes (ST) exist across mammalian and avian hosts [nization , 9, 26. ach 100% . Based oan hosts . Among tBlastocystis sp., no consensus has been reached on the choice of method(s) for detection and differentiation of the protist  or real-time PCR (qPCR) are often used [Blastocystis and its subtypes [Despite the numerous surveys on otarczak ). Moreovtocystis . Howevertocystis , are lestocystis , 24, 28.ten used , 22, 25.subtypes , 27.The aim of this study was to compare (i) the sensitivity of cPCR and qPCR on a set of DNA samples obtained from stool samples of individuals with no gastrointestinal symptoms, and (ii) subtype diversity detected by cPCR and Sanger sequencing versus NGS.The studies involving human participants were reviewed and approved by Ethics Committee of the Biology Center of the Czech Academy of Sciences (reference number: 1/2017). Written informed consent to participate in this study was provided by the participants or their legal guardian/next of kin. All data were anonymized and processed according to valid laws of the Czech Republic . In case of the rat tissue used for testing of internal inhibition, we used samples from the experiment approved by the Committee on the Ethics of Animal Experiments of the Biology Centre of the Czech Academy of Sciences  and by the Resort Committee of the Czech Academy of Sciences  in strict accordance with Czech legislation , as well as the legislation of the European Union.Blastocystis in a gut-healthy human population in the Czech Republic .In this study, we used 288 DNA samples obtained from fresh stool samples from a cohort created during a previous survey on the prevalence and diversity of rom cPCR . The priBlastocystis subtypes: an informative fragment of SSU rDNA (~450 bp) was amplified, indexed and sequenced on a MiSeq instrument with the Reagent Kit v2, 2 × 250 bp ; this was performed according to the method by Maloney et al. (2019) [Supplementary data 1). These results were compared with the results on subtype diversity described in Lhotská et al. [Blastocystis ST3, which was set in the range of 100 to 105 cells per one qPCR reaction: 100–101 – mild fecal protist load; 102–103 – moderate fecal protist load; 104–105 – high fecal protist load (Supplementary data 2). Blastocystis cell counts from culture were calculated using a Bürker’s chamber and then serially diluted to obtain aliquots containing 100, 101, 102, 103, 104, and 105 cells, which were subsequently subjected to DNA extraction according to Lhotská et al. [Positive samples from qPCR were subjected to amplicon NGS to determine . (2019)  with minSU rDNA ~50 bp wasá et al.  based oná et al. . All negBlastocystis was determined by qPCR and subsequently compared with the results from cPCR obtained in our previous study Lhotská et al. [Blastocystis in stool samples than cPCR  to evaluate the Blastocystis fecal load in positive samples and to extrapolate different colonization intensities from ct values  was found in 13 samples, and 101–102  in 18 samples (n = 12), a very low fecal protist load was found, i.e., 101–102  showed much less intensive amplicon in the electrophoresis. Alternatively, the qPCR protocol might have limited sensitivity for example for ST8, which was not used in the validation panel by Stensvold et al. , who devFigure 1  with a 1Blastocystis in colonized humans based on an established quantification curve. Our results in individuals with healthy intestines  showed a high fecal Blastocystis load in more than half of the samples. This fecal load ranged in values of order from 105 to 106 cells per one qPCR reaction. In the 12 samples scored as positive only by qPCR, low fecal protist load was detected (101–102 cells per sample). A very recent study by Cinek et al. [Blastocystis in feces of asymptomatic children and adolescents. However, more studies on both healthy humans and patients with inflammatory of functional bowel diseases are warranted [Blastocystis loads between healthy and sick individuals could fundamentally contribute to understanding the role of Blastocystis sp. in the human gut ecosystem and could be important for experimental studies testing the effect of Blastocystis sp. on gut inflammation [Blastocystis load might be biased by different copy number of the SSU rRNA gene in individual subtypes and life stages of Blastocystis. This could slightly reduce the accuracy of quantification data. However, such data for Blastocystis and its subtypes are not yet available. Nevertheless, an approximate determination of Blastocystis fecal load can reveal trends between different human cohorts.The advantage of qPCR-based diagnostic approach is the ability to estimate the fecal load of k et al.  quantifiarranted . A compaBlastocystis sp. in humans, the identification of its subtypes plays an important role [Blastocystis subtypes colonize different hosts and apparently differ in geographical distribution, surveys aimed at subtype determination might help reveal transmission pathways and potential sources of specific subtypes in a particular area. To date, most studies used Sanger sequencing for subtype identification [Blastocystis. The remaining seven samples were confirmed by Sanger sequencing from qPCR amplicons (118 bp), however, without information about subtypes.In epidemiological studies on ant role , 16, 21.fication , 8, 18, Blastocystis sp. [Although epidemiological studies usually describe colonization of an individual with only one subtype of stis sp. , 19, 21,stis sp. , 22, 29.stis sp. . Here, tstis sp. ). While stis sp.  revealedBlastocystis. NGS alone cannot achieve qPCR sensitivity, mainly due to the known signal crosstalk between individual samples in a sequencing run . AlthouBlastocystis sp., it is necessary to establish a gold standard method for detection and subtype differentiation. A review of the Blastocystis literature so far suggests that detection and differentiation has not yet been harmonized [Blastocystis sp., and the NGS approach enables accurate assessment of subtype diversity, in particular, mixed subtype colonization. We believe that the combination of these two approaches will be beneficial for future epidemiological surveys and surveillance studies on Blastocystis.To understand the epidemiology of rmonized . The finhttps://www.parasite-journal.org/10.1051/parasite/2022029/olm.The Supplementary materials of this article are available at Supplementary data 1: Detailed description of the next-generation sequencing protocol for Blastocystis.Supplementary data 2: Quantification curve used in qPCR diagnostic protocol for evaluation of the fecal Blastocystis load in human DNA samples . The curve was set in the range of 100 to 105 cells per 1 qPCR reaction based on the Blastocystis ST3 culture.


This study was to investigate the correlation between glycated haemoglobin (HbA1c) level, cardiac function, and prognosis in patients with diabetes mellitus combined with myocardial infarction.  Ninety-three patients with type 2 diabetes mellitus combined with acute myocardial infarction who were hospitalized and treated in our hospital from January 2021 to June 2021 were recruited for prospective analysis and equally divided into group A (HbA1c < 6.5%), group B (6.5% ≤ HbA1c ≤ 8.5%), and group C (HbA1c > 8.5%) using the random number table method, with 31 patients in each group. General data of patients were collected on admission and blood glucose and cardiac function indexes were measured; the incidence of myocardial infarction and death during the follow-up period was recorded at 6 months after discharge. P < 0.05). There were statistically significant differences in plasma levels of N-terminal probrain natriuretic peptide (NT-proBNP) and uric acid (UA), left ventricular end diastolic diameter (LVEDD), left ventricular end systolic volume (LVESV), left ventricular ejection fraction (LVEF), and cardiac function classification of the New York Heart Association (NYHA) among the three groups (P < 0.05). By statistical analysis, the HbA1c level was positively correlated with FBG, NT-proBNP, UA, LVEDD, LVESD, and NYHA grades but negatively correlated with LVEF (P < 0.05). The incidence rate of myocardial infarction and mortality was significantly higher in group C than in groups A and B (P < 0.05).  There was a significant difference in blood glucose (FBG) and HbA1c levels at fasting between the three groups ( HbA1c level in patients with diabetes mellitus combined with myocardial infarction is closely related to the degree of cardiac function damage. Glycated haemoglobin levels are associated with the development of cardiac insufficiency in patients with acute myocardial infarction; glycated haemoglobin is also an independent predictor of major adverse cardiovascular events. Reasonable and effective blood glucose control is of great significance to the prognosis of patients. Acute myocardial infarction is a common cardiovascular disease that could be life-threatening and significantly reduce the quality of life of patients. According to some literatures, the amount of people suffering from cardiovascular diseases in China reaches approximately 230 million, and there is epidemiological data indicating that one cardiovascular disease death occurs every 12 seconds in China. Acute heart attacks are common and prevalent in emergency departments, with rapid onset and progression, and could be fatal if not treated promptly and effectively . An addiGlycated haemoglobin (HbA1c) is an essential criterion for evaluating long-term blood glucose control in clinical practice . HbA1c iIn this study, 93 patients with type 2 diabetes mellitus combined with acute myocardial infarction admitted to our hospital from January 2021 to June 2021 were equally enrolled and divided into group A (HbA1c < 6.5%), group B (6.5% ≤ HbA1c ≤ 8.5%), and group C (HbA1c > 8.5%), reflecting the different levels of blood glucose control of the patients. A prospective analysis was conducted on the incidence of recurrent myocardial infarction and death and the correlation between HbA1c level with cardiac function and prognosis. The results are reported as follows.A total of 93 patients with type 2 diabetes mellitus combined with acute myocardial infarction who were hospitalized and treated in our hospital from January 2021 to June 2021 were recruited for prospective analysis and equally divided into group A (HbA1c < 6.5%), group B (6.5% ≤ HbA1c ≤ 8.5%), and group C (HbA1c > 8.5%) using the random number table method, with 31 patients in each group.With a sample size of 31 subjects observed with A, B, and C, the trial will have more than 90% power to detect a difference between A, B, and C in the proportion of subjects with a myocardial infarction and death greater than 10%, given that the probabilities to achieve this myocardial infarction and death are 10% for A and 14% for B.The trial was conducted according to Good Clinical Practice guidelines developed by the International Council for Harmonisation and in compliance with the trial protocol. The protocol was approved by the institutional review boards or independent ethics committees at each site . All patients provided written informed consent per Declaration of Helsinki principles. An independent data monitoring committee monitored safety and efficacy data.Patients aged 18-80 yearsPatients meeting the diagnostic criteria of type 2 diabetes onset time < 12 hPatients with a diagnosis of ST-segment elevation myocardial infarction  and onsePatients who have been on regular hypoglycaemic therapy for more than 6 monthsleads ≥ 2 mm or within 18 hours of onset, with evidence of ongoing ischaemia or haemodynamic instabilityPatients with typical chest pain symptoms lasting more than 30 minutes and ST-segment elevation in two adjacent Patients with serious infectious diseases or autoimmune diseases and traumaPatients with malignant tumorsPatients with diabetic complications, such as diabetic foot and diabetic ketoacidosisPatients with old myocardial infarction or coronary artery caused by various reasons and angiography failurePatients with acute liver and kidney insufficiencyPregnant or lactating womenGeneral information of patients such as age, gender, height, weight, hypertension, hyperlipidemia, history of cardiovascular disease, hypoglycaemic therapy, and infarction site was collected at enrollment. Patients had their venous blood drawn during fasting and centrifuged at 3000 r/min for 20 min; then, the HbA1c level was determined by cationic high-performance liquid chromatography. The kit was purchased from Shanghai Yudole Biotechnology Co., Ltd. Fasting blood-glucose (FBG) levels were determined by enzyme-linked immunosorbent assay. The kit was purchased from Shanghai Jichun Industrial Co., Ltd. (Cat. No. JCSW2609).Fasting venous blood was drawn from patients and centrifuged at 3000 r/min for 20 min to separate the serum, then plasma, and the level of N-terminal probrain natriuretic peptide (NT-proBNP) in the plasma was determined by enzyme-linked immunosorbent assay. The kit was purchased from Wuhan Fein Biotechnology Co., Ltd. (Cat. No. EH0350), and an automatic biochemical analyser  was used to measure serum uric acid (UA) levels. The left ventricular end diastolic diameter (LVEDD), left ventricular end systolic volume (LVESV), and left ventricular ejection fraction (LVEF) were measured by echocardiography. The cardiac cycle was averaged, and the instrument used the cardiovascular ultrasound diagnostic apparatus (iE33 type) produced by Philips. The New York Heart Association (NYHA) was used to evaluate the cardiac function of patients.Grade I: the patient's general activities were basically unrestricted. Grade II: patients were asymptomatic at rest, but physical activity was slightly restricted. Grade III: the patient's physical activity was markedly restricted, and activity less than normal could cause symptoms of palpitations, dyspnea, and angina pectoris. Grade IV: patients had inability to perform any physical activity, and the above symptoms could occur at rest.The patients were followed up monthly by outpatient and telephone for 6 months after discharge, and the occurrence of myocardial infarction and death was recorded during the follow-up period.b is unbiased and normally distributed.If the parameter beta is either a difference of means, a log odds ratio, or a log hazard ratio, then it is reasonable to assume that q test for pairwise comparison. The enumeration data were expressed as [n(%)], the total number of cases was ≥40, the minimum theoretical frequency > 5, and the chi-square uncorrected method was used. Bivariate correlations conforming to a normal distribution were analysed using Pearson analysis, and those not conforming to a normal distribution were analysed using Spearman's rank correlation. P < 0.05 indicated that the difference is statistically significant.SPSS 20.0 software was used for statistical analysis of the data. The measurement data conformed to a normal distribution and were expressed as P > 0.05)  .P < 0.05) (There were significant differences in FBG and HbA1c levels between the three groups of patients ( < 0.05) .P < 0.05)  .P < 0.05)  .P < 0.05)  .Acute myocardial infarction is typically divided into ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction , while SGlucose management is the primary goal of patients with diabetes . Not onlAccording to the latest ESC guidelines, NT-proBNP has been adopted as a marker for evaluation of heart failure and as an essential indicator of cardiac function and prognosis in patients with acute myocardial infarction . UA is aIn this study, the levels of NT-proBNP and UA in blood, cardiac color Doppler ultrasound parameters, and NYHA classification were used to evaluate the cardiac function of three groups of patients. And the composition ratio of NYHA grades III and IV was significantly higher than that of HbA1c < 6.5%, and the LVEF was lower than HbA1c < 6.5%, which consistent with the results of previous research . In addiCertain factors may play a key role in the association between HbA1c levels and poor prognosis. Increased HbA1c levels are associated with certain baseline characteristics that elevate the risk of cardiovascular disease, which explains part of the increase in long-term mortality. Additionally, there is a robust association between overt diabetes and adverse cardiovascular outcomes, and it is conceivable that part of the association between poor long-term glycaemic control and outcomes has the same complex mechanisms as the association between overt diabetes and cardiovascular outcomes. Indeed, it is well established that the risk of developing coronary artery disease is not limited to diabetics but exists in other states of impaired fasting glucose, impaired glucose tolerance, and insulin resistance. Reasonable and effective blood glucose control is an important means of reducing cardiovascular complications in patients. In terms of prognosis, the incidence of remyocardial infarction and mortality of patients in group C was significantly higher than those in the groups A and B, further indicating the prognostic importance of glycaemic control on patients' prognosis.As the proportion of people with chronic poor glycaemic control and consequent cardiovascular disease is likely to increase in the next decade, more appropriate treatment should be recommended for this population. According to the European guidelines for the management of diabetes, prediabetes, and cardiovascular disease, it is recommended that people at high risk of type 2 diabetes should undergo lifestyle modifications. If necessary, medication should be administered to reduce their risk of developing overt hyperglycaemia and type 2 diabetes and, in particular, to prevent or slow down the onset of cardiovascular disease. While this approach has yet to be proven for slowing the course of diabetes, in patients with diabetes or mildly abnormal blood glucose levels, the overall increased risk of cardiovascular disease cannot be explained by abnormalities in blood glucose or HbA1c alone. However, considering that lowering HbA1c levels may have an improved prognosis, it is still possible to encourage our patients to make lifestyle modifications or take medication to prevent or slow down the onset of cardiovascular disease. There are still some limitations to our study. Firstly, this study was conducted in a single centre and is subject to a large margin of error and chance due to the small sample size, limited follow-up time, and small number of cases followed up to the clinical endpoint. Furthermore, as glycated haemoglobin levels were only measured once during hospitalization, it was not feasible to assess the change in HbA1c levels after active treatment and its correlation with clinical events.To sum up, the HbA1c levels in diabetic patients combined with myocardial infarction are closely related to the degree of cardiac impairment, and reasonable and effective glycaemic control is of great significance to the prognosis of patients. Considering the possible role of lowering HbA1c levels in improving the prognosis of STEMI, patients with elevated HbA1c should be advised to make lifestyle modifications or take medication to prevent or slow down adverse cardiovascular events. This requires the consideration of clinicians.


Background and Aims: Due to increasing knowledge of the “gut–liver axis”, there has been growing interest regarding the use of fecal microbiota transplant in the management of chronic liver disease. There are limited data available and current guidelines are mostly based on expert opinions. We aim to perform the first systematic review investigating safety and efficacy of fecal microbiota transplant particularly among high-risk decompensated cirrhosis patient populations. Methods: Literature search was performed using variations of the keywords “fecal microbiota transplant” and “cirrhosis” on PubMed/Medline from inception to 3 October 2021. The resulting 116 articles were independently screened by two authors. In total, 5 qualifying studies, including 2 randomized control trials and 3 retrospective case series, were found to meet established eligibility criteria and have adequate quality of evidence to be included in this review. Results: Of the total 58 qualifying patients, there were 2 deaths post fecal microbiota transplant, 1 of which could not rule out being related (1.7%). Among the remaining 56 participants, 8 serious adverse events were reported, of which 2 could not rule out being related (3.6%). The success rate of fecal microbiota transplantation in treating recurrent Clostridioides difficile infection among patients with decompensated cirrhosis was 77.8%. The success rate when used as investigational treatment for hepatic encephalopathy was 86.7%, with multiple studies reporting clinically significant improvement in encephalopathy testing scores. Conclusions: We found a marginally higher rate of deaths and serious adverse events from fecal microbiota transplant in our patient population compared with the average immunocompetent population, where it was previously found to have 0 deaths and SAE rate of 2.83%. The efficacy when used for recurrent C.difficile infection was 77.8% and 87% in the decompensated cirrhotic and general populations, respectively. Studies on efficacy in novel treatment of hepatic encephalopathy have been promising. This study concludes that fecal microbiota transplant use in decompensated cirrhosis patients should be used with caution and preferably be limited to research purposes until better data are available. Fecal microbiota transplantation (FMT) is a novel and growing field with expanding therapeutic potential. Limitations to widespread FMT use despite promising outcomes is likely due to the lack of large, well-designed studies; one such example is the use of FMT in cirrhotic patients. In recent years, the therapeutic role of FMT in the cirrhotic population has become more prominently discussed, as new research hypothesizes that underlying intestinal dysbiosis may play a fundamental role in worsening clinical status in such patients ,2,3,4,5.Clostridioides difficile infection (CDI) and decompensated chronic liver disease” with very low grade of evidence and weak strength of recommendation [Yet, before further large studies can be undertaken it is imperative to determine the safety of FMT in this patient population, specifically in decompensated cirrhotics who have the highest associated risk and mortality . There iendation . In otheendation . Recentlendation . Howeverendation . Hence, We performed a comprehensive literature search using variations of the keywords “fecal microbiota transplant” and “cirrhosis” including MeSH terms to identify original studies published in PubMed/Medline from inception through 3 October 2021. The systematic review was performed on studies published prior to 3 October 2021. Results were limited to human studies published in English. There was a total of 116 studies for review. See Inclusion criteria: (1) FMT for various indications; (2) decompensated cirrhosis defined as stage 4 fibrosis with Child–Turcotte–Pugh (CTP) C, or a major complication including variceal hemorrhage, large ascites, spontaneous bacterial peritonitis (SBP), hepatic encephalopathy (HE), hepatocellular carcinoma, hepatorenal syndrome, and hepatopulmonary syndrome; (3) reporting of patient data and outcomes after first fecal infusion; (4) adult patients (≥18 years old) of any sex; (5) minimum follow-up of 1 month; and (6) at least moderate quality of evidence.Exclusion criteria: (1) individual case reports which reflect unique cases and significant bias; (2) studies available only as abstracts; (3) studies without patient data; (4) non-English studies; (5) animal studies; and (6) patients younger than 18 years of age.An initial 116 articles were retrieved from PubMed. Two authors (A.S.H. and K.M.T.) independently reviewed these titles and abstracts, after which 13 articles were deemed relevant with patient data. Full texts were then reviewed, after which 5 remaining studies fulfilled complete eligibility criteria. In cases of disagreement, a third reviewer (J.M.H.) arbitrated the final decision for inclusion. Study selection process by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement is detailed in The primary endpoint was safety of FMT in decompensated cirrhosis patients in terms of death and serious adverse events (SAE) occurring within 30 days after FMT. SAEs were defined as death or any event requiring hospitalization. Adverse events were further determined to be more likely or unlikely to be related to FMT. Thirty days was chosen as the latest time an adverse event could still be reasonably attributed to the original fecal transplantation .The secondary endpoint was the efficacy of FMT. When used for CDI, FMT success was defined as the absence of symptoms (≥3 loose bowel movements in ≤24 h) with positive CDI confirmatory stool testing within 8 weeks of treatment . When usWe then referred to and compared our outcomes with those from previously published articles that studied the efficacy and safety profiles of FMT in various populations such as general population, immunocompetent cohort, immunocompromised patients, and cirrhotic patients.Revised Cochrane risk-of-bias tool (RoB 2) was used to evaluate the methodological quality of randomized controlled trials (RCT). RoB 2 is a revised version of the original Cochrane risk-of-bias tool that has been widely used in systematic reviews . The toohttps://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools) (accessed on 14 March 2022). A set of question items with Yes/No answers were used, with a “Yes” counting as a score of 1 and a “No” as a score of 0. In the tool used for case series, there were a total of 9 questions. A score of 7–9 corresponds to good quality, while scores of 4–6 and 1–3 indicate moderate and poor quality, respectively [For case series, observational and cohort studies, appraisal of quality and risk of bias was performed by a series of quality assessment tools developed by US National Heart Lung and Blood Institute (NHLBI) of National Institutes of Health (NIH) (ectively . On the ectively . Howeverectively . In the n = 1), enema (n = 10), colonoscopy (n = 13), and capsule (n = 10). Cheng et al. described the methods of FMT administration as capsule (n = 3), colonoscopy (n = 59), and percutaneous endoscopic gastrostomy (PEG) tube (n = 1) but did not differentiate between cirrhotic and decompensated cirrhotic patients.Escherichia coli bacteremia 3 days post FMT without any other documented causes, which is likely to be related to FMT. One patient developed SBP in week 4, which was considered to still be possibly related to initial FMT. The remaining reported 4 SAEs were deemed unlikely to be related to FMT, including SBP at week 8, bleeding portal hypertensive gastropathy at day 23, hospitalization for HE at day 56, acute renal failure at day 85, and chest pain at day 1115 post FMT.p = 0.03) and PHES improvement  at 5 months compared to patients receiving standard of care (SOC), with PHES score improvement [p = 0.02) [rovement . In Baja = 0.02) . In Meht = 0.02) .In our study, we found that the overall rate of death possibly attributable to FMT was 1.72% (1/58) with the rate of other SAEs attributable to FMT as 3.57% (2/56). In contrast, the systematic review on cirrhotic patients by Tun et al. demonstrated that overall death rate was 1.57% (2/127), and the number of SAEs and AEs were 9.45% (12/127) and 19.68% (25/127), respectively . There wp < 0.001) [In terms of efficacy data for CDI, we found that the rate of success for first time FMT treatment in the decompensated cirrhotic patient population was 77.8% 21/27), which is lower than previously reported data such as a randomized control trial by Cammarto et al. where efficacy was 90% . Of note/27, whicFMT also appears to be effective in HE. Our review demonstrates that an improvement in cognitive tests  or reduced recurrence of HE was seen across all the studies compared to SOC. Furthermore, the effect of FMT was maintained over the course of the year. Similar findings were reported in the previous systematic review on cirrhotic patients . A similThe primary weakness of this study is due to the lack of published literature with direct patient data on FMT use in cirrhosis patients. Due to the limited number as well as the fact that efficacy was often reported but was not the primary endpoint in these studies, a true meta-analysis was unable to be performed. Two of our strongest studies included were by the same research group, and although two separate selection processes of patients were used and made up most of the data for use of FMT in treating HE. Due to the nature of this systematic review, we were unable to control for confounding factors or variables both in the patient qualities and in the procedural protocols . Additionally, AEs and SAEs were reported by the original authors as related or unrelated to FMT based on DSMB guidelines (Data and Safety Monitoring Board). Since we were not able to obtain the original data of the studies, it is possible that the number of adverse events attributable to FMT may be inaccurate. Lastly, after an initial search on multiple databases and exclusion of articles that did not meet the inclusion criteria, it was noted that the results were largely identical. Therefore, only PubMed/Medline was used to retrieve qualifying articles for further review as it is the largest and most robust database, which may not have extracted smaller studies and may have introduced publication bias.Based on available literature, we found that there may be a marginally higher rate of death and SAE from FMT in decompensated cirrhosis compared with the average immunocompetent population. When used for CDI, the efficacy of one-time infusion was also found to be less effective. New data does appear to support a therapeutic advantage of FMT compared with SOC in hepatic encephalopathy. We conclude that although FMT is likely to be a valuable tool in the future management of cirrhosis patients, its use in decompensated cirrhosis patients should be used with caution and preferably limited to research purposes until better safety and efficacy data is available. Although this study was confined by paucity of published data and inability to perform a true meta-analysis, it does highlight the need for more robust randomized controlled studies regarding FMT in this specific patient population in the future.


Highly digestible and high-quality proteins are especially needed in weaned pigs to alleviate weaning stress in piglets. Fishmeal (FM) and soybean protein (SPC) are two commonly used protein supplements in the diets of weaned pigs, but the high prices of those two kinds of ingredients have prompted a search for an alternative cost-effective protein source. After the removal of anti-nutritional factors, degossypolized cottonseed protein (DCP) shows potential as an alternative to FM and SPC. In this study, the effects on weaned piglets of replacing FM and SPC with DCP in diets were evaluated. The results showed that replacing FM with DCP weakens the small intestinal morphology and decreases nutrient digestibility, but improves the community structures of cecum microbiota that relieve these negative effects without impairing the growth performance of weaned piglets.The inclusion of high-quality proteins is commonly used in swine production, especially in weaned pigs. Our research investigated the effects of replacing fishmeal (FM) and soybean protein concentrate (SPC) with degossypolized cottonseed protein (DCP) on the growth performance, nutrient digestibility, intestinal morphology, cecum microbiota and fermentation in weaned pigs. A total of 90 pigs were used in a 4-week trial. Pigs were randomly assigned to three dietary treatments , including a basal diet group (CON) with a 6% SPC and 6% FM; two experimental diets group (SPCr and FMr) were formulated by replacing SPC or FM with 6% DCP, respectively. There were no differences in growth performance and diarrhea rate among three treatments except for the ADFI during day 14 to day 28. Using the DCP to replace FM would weaken the jejunum morphology and decrease the nutrient digestibility of pigs during day 0 to day 14. However, replacing FM with DCP can improve the community structure of cecum microbiota, and may relieve these negative effects. In conclusion, DCP can be used as a cost-effective alternative protein supplement. In the weaning period, piglets undergo a transition from a highly digestible liquid milk to a solid diet including complex protein . Under tCotton is cultivated in large quantities in China, with a production of 6.42 million tons in 2021 . This kiHowever, limited information is available on the effects on pigs’ intestinal morphology, cecum microbiota and fermentation of replacing SPC and FM with DCP. Therefore, the objective of this study is to evaluate the effects on weaned pigs’ growth performance, nutrient digestibility, intestinal morphology, cecum microbiota and fermentation of replacing SPC and FM with DCP.All procedures used in this experiment were approved by the China Agricultural University Institutional Animal Care and Use Committee . All animal trials were conducted in the China Agricultural University Animal Experimental Base . In this study, the DCP was kindly provided by Sino-leader Biotech Co., Ltd. . The chemical compositions of DCP, FM and SPC were analyzed and are presented in A total of 90 healthy 28 day aged crossbred pigs [Duroc × (Landrace × Large White)] with an initial BW of 8.06 ± 0.26 kg were used in this study. They were both from 10 sows  in the same batch and the lactation period lasted 21 days. After 7 days of weaning adaption period, they were assigned to 3 dietary treatments in a completely randomized design. Each treatment diet was fed to 5 replicated pens with 6 pigs (3 barrows and 3 gilts) per pen. The control group (CON) were fed the diet that included 6% FM and 6% SPC supplement, and the 2 experimental groups were fed diets formulated by replacing all the FM (FMr) and SPC (SPCr) with DCP, respectively . We envi2 and ammonium in the air, ventilation intensity, humidity and temperature. The average indoor temperature was controlled at 24–26 °C, while relative humidity was maintained at 60–70%. To prevent disease, the experimental house was cleaned every day and a health-assessment procedure was conducted by a veterinarian every week. After 12 h of starvation, the individual weight of each piglet and the remaining feed weight of each pen were weighed on day 0, 14 and 28, and then to calculate the average daily gain (ADG), average daily feed intake (ADFI) and the ratio of feed to gain (F:G). The incidence of diarrhea was calculated according to the following formula: diarrhea rate (%) = [(number of pigs with diarrhea × diarrhea days)/] × 100  × 100 . The higBefore the experiment, 2 kg samples of DCP, FM and SPC were collected. During the experiment period, approximately 2 kg of representative feed samples were collected weekly. From day 12 to 14 and day 26 to 28, the rectal palpation was used every day to make sure approximately 100 g of fresh feces were collected from at least 3 medium BW pigs in a pen. All the fecal samples were frozen at −20 °C immediately after collection until analysis every day. Finally, the feces collected in the 3 days were pooled by pen and dried at 65 °C for 72 h. Before analysis, all these dried feces and feed samples were ground to pass through a 1 mm sieve.On day 29, a total of 9 pigs with median BW in three groups (3 pigs each treatment) were humanely killed by exsanguination after electric shock. Segments of the mid-jejunum and mid-ileum were collected and rinsed with 0.9% saline, and then stored in 10% buffered formalin. The digesta collected from the cecum were frozen in liquid nitrogen and stored at −80 °C until further analysis.diet × nutrientfeces)/(Crfeces × nutrientdiet), nutrient digestibility was determined.The dry matter (DM), crude protein (CP), ether extract (EE) and free gossypol of the ingredients , diets and fecal samples were measured by following the methods of the Association of Official Agricultural Chemists . The groSamples from the mid-jejunum and mid-ileum segments were embedded in paraffin and cut into 5-μm serial sections, and five non-successive sections from each tissue sample were selected and stained with hematoxylin-eosin for identification . Six welhttp://rdp.cme.msu.edu/) [Until analysis, total genomic DNA was extracted from cecum digesta using a QIAamp DNA Stool Mini Kit  according to the manufacturer’s instructions. The final DNA concentration and purification were determined by NanoDrop 2000 UV-vis spectrophotometer , and DNA quality was checked by 1% agarose gel electrophoresis. The bacteria 16S ribosomal RNA genes in the region of V3-V4 were amplified using polymerase chain reaction (PCR) with primers 338F (5′-ACTCCTACGGGAGGCAGCAG-3′) and 806R (5′-GGACTACHVGGGTWTCTAAT-3′). After extracting from a 2% agarose gel, the resulting PCR products were further purified using the AxyPrep DNA Gel Extraction Kit  and then quantified using QuantiFluor™-ST  according to the manufacturer’s protocol. Purified amplicons were pooled in equimolar and paired-end sequenced on an Illumina MiSeq platform  according to standard protocols by Majorbio Bio-Pharm Technology Co., Ltd. . Raw fastq files were quality-filtered by Trimmomatic and merged by FLASH. In addition, operational taxonomic units (OTUs) were defined as a similarity threshold of 0.97 using UPARSE. The taxonomy of each 16S rRNA gene sequence was analyzed by the RDP Classifier algorithm (su.edu/)  against g for 5 min. Then, the collected supernatants were diluted (1:50) using ultrapure water and finally filtered into an injection vial through a 0.22 mm membrane. Each sample was detected using a high-performance ion chromatography system . The contents of VFAs and BCFAs were expressed as μmol/g of cecum digesta.The content of VFAs  and BCFAs  in the digesta were analyzed for evaluating the fermentation among three groups, based on the methods of He et al. . The cecp < 0.05 and tendency was defined as 0.05 ≤ p < 0.10.Data for growth performance, diarrhea rate and digestibility of nutrients were analyzed with replicate as the experimental unit while intestinal morphology and fermentation were analyzed with pigs as the experimental unit. The data were subjected to ANOVA using the GLM procedure of SAS . Statistical differences among treatments were separated by Student–Newman–Keul’s multiple range tests. Data for the bacterial community were analyzed with the three cecum samples per treatment. According to the guidance of R software, standardized OTUs reads were applied to analyze bacterial diversity by principal component analysis (PCA). In addition, the Kruskal–Wallis method was conducted to analyze the populations of the bacterial community in cecum samples of pigs at the phylum and family level. The abundance of bacteria at the phylum and family levels were shown as bar plots. Significant differences were defined at As shown in p < 0.01). Meanwhile, pigs fed the FMr diet showed a tendency for lower diarrhea frequency in phase 1 (d 1-d 14) (p = 0.06).As presented in p < 0.01). In phase 2, there was no difference in the ATTD of nutrients among the three groups, and only ATTD of CP presented a decreased tendency in FMr compared with SPCr groups (p = 0.06).As shown in p = 0.08). Meanwhile, the crypt depth of jejunum in the FMr group increased compared with the CON and SPCr groups (p < 0.01) but the ratio of villus height to crypt depth of jejunum in the FMr group was lower than it in the CON group (p = 0.03). No differences in the three indicators were founded in the ileum.The intestinal morphology was given in The Venn analysis identified 311, 297 and 375 operational taxonomic unit (OTUs) from cecum samples in the CON, FMr and SPCr groups, respectively, and showed 7, 12 and 70 unique OUTs in the three groups A. The Shp < 0.05, At the phylum level, Firmicutes, Bacteroidetes and Proteobacteria were the dominant bacteria, which accounted for more than 90% A and no p = 0.02). The FMr showed the greatest propionate and butyrate while the CON group contained the lowest butyrate in cecum digesta (p < 0.01). No differences were detected in total VFAs, isobutyrate, valerate and isovalerate in cecum digesta.As shown in The noticeable differences between the three ingredients  lie in the fiber, EE, Lys, Met, Arg and free gossypol. Differing from fish meal, which is an animal protein source, SPC and DCP are plant-based protein ingredients that contain more plant cell walls and plant fibers, resulting in more ADF and NDF. However, SPC involves a stricter peeling process, which leads to a lower fiber concentration of SPC compared with DCP . The higIn this experiment, replacing FM and SPC with DCP does not affect the growth performance of weaned pigs except for the ADFI in phase 2. The negative effect of a 6% replacement of DCP on ADFI can be attributed to the lower palatability compared with FM and SPC, which are always considered high-palatability ingredients . SurprisThe intestinal morphology is a common marker to estimate the digestion and absorption capacity and the health of the intestine . In thisThe gut microbiota offers many benefits to the host through a range of physiological functions such as strengthening gut integrity or shaping the intestinal epithelium . The α-dAs with the previous report , FirmicuIn vitro, it has been proven that the dietary fiber of plants allows the selective proliferation of Lactobacillus strains . As LactAs mentioned before, the plant-origin ingredients usually contain more polyphenols, which can increase beneficial bacteria but reduce pathogenic bacteria . Among tThe cecum is the major site of microbial fermentation of undigested carbohydrates in pigs due to a great richness of bacteria and enough retention time of digesta . VolatilA diet supplemented with 60 g/kg of DCP to replace FM and SPC weakens the intestinal morphology and decreases the nutrient digestibility, but improves the community structures of cecum microbiota, and may relieve these negative effects without impairing the growth performance of weaned piglets. Degossypolized cottonseed protein can be used as a cost-effective protein to replace FM and SPC.


Elsberg syndrome (ES) is a neuroinflammatory disease that causes acute or subacute lumbosacral radiculitis, with or without myelitis which accounts for approximately 5–10% of cauda equina syndrome and myelitis. We herein present a case of a middle-aged female who recently returned from the Dominican Republic and presented to the emergency room with complaints of a 10-day history of progressive lower extremity sensory changes and weakness preceded by transient bilateral arm pain and neck and head pressure. Based on clinical, radiographic, and serological testing the patient was diagnosed with HSV2 lumbosacral radiculitis (ES). After 21 days of Acyclovir, 5 days of high dose IV methylprednisolone, and one month of inpatient rehab, our patient was discharged home walking with a cane. As ES is poorly defined and rarely reported, it can be unrecognized in patients with acute cauda equina syndrome (CES). Appropriate testing for viral infection in a timely manner facilitates reaching a definitive diagnosis and prompt initiation of treatment, which is essential for resolution of symptoms. Elsberg syndrome (ES) is a neuroinflammatory disease that causes acute or subacute lumbosacral radiculitis, with or without myelitis Below we present a unique case of HSV2 lumbosacral radiculitis (Elsberg Syndrome) diagnosed at a large New York City Hospital Center.Our patient was a 51-year-old female with a past medical history significant for fibromyalgia, right-sided sciatica, right lower extremity deep venous thrombosis, asthma, nephrolithiasis, vertigo, and oral and genital herpes infection who recently returned from Dominican Republic. She presented to the emergency room with complaints of a 10-day history of progressive lower extremity sensory changes and weakness preceded by transient bilateral arm pain and neck and head pressure. Furthermore, she reported being unable to completely void for one day in duration. She described the weakness to be worse in the right leg compared to the left leg, describing it as “leg heaviness” which resulted in a fall at home a day prior to presentation. While she was sitting in the bathroom, she tried to stand but her knees 'buckled' and she fell backward, hitting her head on the floor (denied any loss of consciousness). Her family carried her to the Emergency Department as she was unable to bear weight.Vital signs on presentation were within normal limits. Physical exam was most notable for reduced power of knee flexors and knee extensors (3/5), dysesthesia to touch and pinprick from mid-thigh distally in stocking distribution bilaterally, absent knee reflexes bilaterally, positive Babinski bilaterally, and no clonus. Given her weakness and urinary hesitancy, a magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar spine was done to assess for spinal cord pathology and a bladder scan was done to rule out urinary retention. Neurology evaluated the patient for acute progressive lower extremity neuropathic pain and weakness. A lumbar puncture was performed to rule out atypical Guillain Barre syndrome or multiple sclerosis.Complete blood count showed a white blood cell count of 5.1 × 103 cells/mL, hemoglobin of 11.9 g/dL, platelet count of 371 × 103 cells/mL, and eosinophils elevated to 5.7%. The basic metabolic panel was within normal limits. Vitamin B12 level came back low at 290 pg/mL, homocysteine of 11.2, ESR 30.9 and CRP 5.9. Other labs including creatine phosphokinase, aldolase, methylmalonic acid, Lyme titers, copper level, vitamin B12, SSA/SSB (Sjogren Antibodies), were unremarkable. The CSF PCR cytology showed pleocytosis with a WBC count of 360 (100% lymphocytes), although no albumin cytologic dissociation was seen, and protein of 182 mg/dL. CSF PCR was positive for HSV-2. Infectious disease (ID) was consulted and reviewed the MRI spine with radiology, which demonstrated a very faint enhancement of the L4–5 nerve roots. An MRI brain came back within normal limits. An initial electromyography (EMG) study done during the first week of her admission was unremarkable. A repeat MRI of the whole spine 7 days later showed linear enhancement in the dorsal aspect of the thecal sac from L2 to L4 which may represent an abnormal enhancement of a nerve root in the cauda equina. A repeat EMG was indicative of bilateral L3/L4 radiculopathies. At this point, based on clinical, radiographic, and serological testing the patient was diagnosed with HSV2 lumbosacral radiculitis (Elsberg Syndrome) .Fig. 1ReThe patient was started on Acyclovir IV 10 mg/kg q8hr for 21 days along with adequate IV fluid hydration, 5 days of high dose methylprednisolone 1 g IV daily, and B12 supplementation 1000 mcg daily. She needed an aggressive pain control regimen which included Tylenol, Flexeril, lidocaine patch, duloxetine, Percocet, and Dilaudid. 10 days after the first LP was performed a second lumbar puncture was done and came back positive for HSV-2 but with no significant improvement of the CSF fluid analysis. 14 days later, a third LP was remarkable for improved WBC count (360 down to 80) and protein level (182 down to 73).After being an inpatient for three weeks, the patient was discharged to acute inpatient rehabilitation to improve mobility and to maximize safety and functional independence. She remained in rehab for intensive physical and occupational therapy for one month before being discharged home. Her overall duration of symptoms may have also contributed to her symptom improvement. Although she made great progress while being in the acute rehabilitation unit, she was discharged from rehab with a walking cane as a main mode of ambulation.Elsberg syndrome is a rare cause of infectious lumbosacral radiculitis with a wide variety of clinical presentations and diagnostic criteria. A proposed diagnostic criteria of Elsberg syndrome includes clinical signs and symptoms of caudal equina syndrome, such as urinary/ bowel retention, hesitancy, or incontinence, and MRI or electrophysiologic evidence of cauda equina involvement. Other features that may be suggestive of Elsberg syndrome include preceding genital herpes infection, herpes virus infection in the CSF, clinical or radiographic evidence of myelitis in the conus, acute/subacute onset, and CSF pleocytosis Antiviral treatment may affect symptom duration, but there is no evidence it helps with neurologic improvement in herpetic radiculomyelitis. Our patient was started on IV Acyclovir for a total duration of 21 days and received 5 days of high dose corticosteroids. Steroids were initiated to reduce inflammation, and after receiving three days of steroids, the patient began to see improvement in her symptoms. Being cognizant of Elsberg syndrome while treating patients with signs and symptoms of lumbosacral radiculitis is crucial as initiating IV acyclovir for 10–14 days along with corticosteroids is regarded as a treatment of choice due to the possibility of shortening symptoms duration and improving overall morbidity Consent was obtained from patient.Nothing to declare.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Omar Belfaqeeh: Writing – original draft. Alexandria Markley: Writing – original draft. Mudita Patel: Writing – review & editing. Brian Markoff: Writing – review & editing, Supervision. Georgina Osorio: Writing – review & editing, Supervision.Nothing to declare.


BackgroundSocial media has been more widely used by urology residency programs since the COVID-19 pandemic. There are no studies on the relationship between Doximity residency ranking and social media usage in urology.ObjectivesIn this study, we aim to investigate the relationship between social media usage and the academic prestige of urology residency programs.MethodsResidency reputation data was acquired from the Doximity Residency Navigator website. Twitter and Instagram activity in 2019 and 2021 was analyzed by collecting data on the total number of posts and followers. Data on residency virtual recruitment was obtained from Twitter and UroResidency website.ResultsBy the end of 2021, 122/139 (87.8%) urology residency programs had a Twitter account and 61/139 (43.9%) had an Instagram account. A significant linear regression was found between Doximity ranking and the number of Twitter followers (p<0.001), Twitter posts (p=0.005), and Instagram followers (p=0.026). Virtual recruitment events were held by 107/139 (77%) programs in 2021. There was a significant linear regression between Doximity rankings and the number of virtual events (p<0.006).ConclusionsSocial media use by urology residency programs has increased since the COVID-19 pandemic. A program’s higher Doximity ranking was correlated with the presence of Twitter and Instagram accounts as well as the number of Twitter followers, Twitter posts, and Instagram followers. There was a significant relationship between Doximity rankings and the number of hosted virtual events. Programs should consider increasing social media visibility to potentially improve their Doximity rankings. Social media use has become more prevalent and important in the field of academic urology. In 2014, the American Urological Association (AUA) reported that 71% of its members used some form of social media . InstagrThere have been a few studies analyzing the use of social media with the AUA Match outcomes ,6, but tWith travel restrictions and away rotation limitations due to COVID-19 making it more challenging for prospective residents to explore residency programs , programA comprehensive list of urology residency programs in the United States was acquired and ranked 1 to 145 based on the Doximity Residency Navigator, with 1 being the highest ranked . ProgramTwo independent reviewers used the Google search engine with the search term “name of institution + urology residency” + “social media account”  urology residency Twitter) to determine the presence of a social media account. Reviewers also used the Association of American Medical Colleges’ Electronic Residency Application Service and official urology departmental websites to identify social media accounts ,15. All If a program had multiple accounts identified within the same social media platform, the account with more followers was used in the statistical analysis. Finally, for the 2021-2022 application cycle, the presence and number of virtual residency recruitment events  were collected using Twitter and UroResidency, a urology residency application advisement website, and analyzed against Doximity ranking.Since the variable of interest in social media usage was the COVID-19 pandemic, the years 2019 and 2021 were chosen as the proxy for “before the pandemic” and “after the pandemic,” respectively. The year 2021, rather than 2020, was chosen for comparison because COVID-19 was not declared a pandemic until March 11, 2020, and the first stay-at-home order in the United States was not ordered until March 19, 2020 ,17.The Shapiro-Wilk test was run to assess for normality of all study distributions, and the appropriate statistical analyses were then performed. Significance was set at p<0.05. All statistical analyses were performed on Statistical Package for the Social Sciences (SPSS) version 28.0 . This study was deemed Exempt Category 4 by the Institutional Review Board (IRB).Social media among urology residency programsA total of 145 urology programs were available on the Doximity Urology Residency Navigator, of which 139 programs were included. Six programs were excluded from the analysis; five were military programs, and one was not recruiting for the 2021-2022 cycle. Overall, 122 (87.8%) programs had Twitter accounts and 61 (43.9%) had Instagram accounts by the end of 2021, an increase from 88 (63.3%) and 12 (8.6%) in 2019, respectively  but normally distributed for Instagram (p=0.456). Both Twitter and Instagram posts were not normally distributed in 2021 . Of the programs that owned Twitter accounts in 2019 versus 2021, the median (interquartile range (IQR)) number of Tweets made by each program was 27 (44) versus 23 (51), respectively  had a median Doximity ranking of 67, whereas programs without Twitter (n=17) had a median Doximity ranking of 133 (Table 22 had a Urology residency programs with Instagram n=61) had a median Doximity ranking of 66, whereas programs without Instagram (n=78) had a median Doximity ranking of 84  urology programs hosted virtual residency recruitment events. For the programs that hosted virtual events, the median  number of hosted events was 2 . A significant linear regression relationship was found between a program’s Doximity ranking and the number of virtual events (p<0.006)  of urology residency programs hosted virtual recruitment events during the 2021-2022 AUA Match cycle, compared to 75% of orthopedic surgery , 59% of 7% of uroThe main limitation of our study is the relative paucity of metrics to rank urology residency programs. Our study relied on the Doximity reputation rankings, which are based on three components: satisfaction data via current resident and alumni surveys, reputation data via board-certified physician surveys, and objective data via research output and a “proprietary Doximity database” . While iA final comment is that our study does not imply that social media is the only factor in rankings. With urology’s highly competitive environment in both education and practice, many variables determine academic prestige, and social media may be one of many. The goal of this study is primarily to voice our recommendations by providing additional data for urology programs to make informed decisions on their own social media activity.More research is needed to investigate the relationship between social media usage by urology residency programs and their academic prestige. A future direction of interest would be to analyze the content of Twitter and Instagram posts, particularly how many of these posts were used for residency recruitment specifically. Although Tweet categories  have been examined in prior studies, it was not done so in relation to a program’s ranking . AnalyziThe use of social media by both urology residency programs and applicants has been largely increasing as a result of the COVID-19 pandemic requiring residency recruitment and interviews to become primarily virtual. There was a significant relationship between a program’s Doximity ranking and the presence of Twitter or Instagram, as well as the number of Twitter followers, Twitter posts, Instagram followers, and virtual recruitment events. Although Twitter appears to be more widely utilized and a better indicator than Instagram regarding academic prestige on Doximity, both platforms have been used by the majority of urology residency programs.