Acute kidney injury (AKI) is a common clinical condition, results in patient morbidity and mortality, and incurs considerable health care costs. Sepsis, ischaemia-reperfusion injury (IRI) and drug nephrotoxicity are the leading causes. Mounting evidence suggests that perturbations in circular RNAs (circRNAs) are observed in AKI of various aetiologies, and have pathogenic significance. Aberrant circRNA expressions can cause altered intracellular signalling, exaggerated oxidative stress, increased cellular apoptosis, excess inflammation, and tissue injury in AKI due to sepsis or IRI. While circRNAs are dysregulated in drug-induced AKI, their roles in pathogenesis are less well-characterised. CircRNAs also show potential for clinical application in diagnosis, prognostication, monitoring, and treatment. Prospective observational studies are needed to investigate the role of circRNAs in the clinical management of AKI, with special focus on the safety of therapeutic interventions targeting circRNAs and the avoidance of untoward off-target effects. Acute kidney injury (AKI) is a syndrome of rapid deterioration in kidney function within hours to days. AKI is common and occurs in up to 10–20% of all hospitalised inpatients, and is associated with significant morbidity, mortality, and health care costs ,4. SurviDespite its clinical significance, there is limited progress to date in therapeutic interventions for AKI per se, and management is directed at the underlying causes. Few disease-modifying therapies are available for most causes of AKI, and therapy is largely supportive in nature. Part of the reason may be that AKI is a heterogeneous, broadly defined syndrome with various causes, each with different underlying pathophysiology. The most common causes in developed countries nowadays include sepsis, haemodynamic insults such as hypotension with ischaemia-reperfusion injury (IRI), nephrotoxic drugs, and urinary tract obstruction . MultiplCertain causes of AKI, such as sepsis, remain associated with unacceptably high rates of mortality . There iCircRNAs are distinguished from other linear RNAs by their structure. CircRNAs are typically single-stranded, covalently closed molecules. Typically, pre-mRNA contains exons and introns, followed by a 7-methylguanosine cap and polyadenosine tail added to its 5′ and 3′ ends, respectively. Pre-mRNA then undergoes splicing at canonical splice sites (5′-GU and 3′-AG at introns) to become mature and translatable. CircRNAs are produced by a non-canonical splicing event called back-splicing, in which a downstream 5′ splice donor site is covalently joined to an upstream 3′ splice acceptor site through a 3′5′-phosphodiester bond, resulting in a circular structure .Although circRNAs were first described in viroids and viruses, they have since been found to be ubiquitous among eukaryotes including in the human transcriptome . They arCircRNAs can be assayed using a variety of methods, with RNA-Seq of rRNA-depleted total RNA being the method of choice for discovering new circRNAs as it also allows for the characterisation of their linear counterparts . AdvanceSepsis is the most common cause of AKI in developed countries, and is associated with an exaggerated increase in the risk of mortality, especially in critically ill populations . Septic +/K+ pump, in order to conserve energy [During sepsis, inflammatory mediators such as pathogen-associated molecular patterns (PAMPs) and damage-associated molecular patterns (DAMPs) are released into the circulation. Pattern recognition receptors such as Toll-like receptors (TLRs) initiate signal transduction that eventually results in the release of proinflammatory molecules such as IL-6 and TNFα. When PAMPs and DAMPs are filtered through the glomeruli, similar receptors also take up these signals and result in an increase in oxidative stress, expression of reactive oxygen species (ROS), cellular injury and apoptosis, and mitochondrial injury . Even ine energy .Two key experimental models have been created to study septic AKI, and have proven popular for the study of the epigenetic signature of AKI. Since septic AKI has a complex, multifaceted pathophysiology, these models are necessarily limited in their generalisability to the human syndrome of septic AKI, although they illustrate key features of AKI in sepsis that would require further in vivo studies. The first model of lipopolysaccharide (LPS)-induced inflammation is an in vitro model based on the use of endotoxin expressed on Gram-negative bacteria. Kidney cell lines such as Human Kidney 2 (HK-2) cells derived from human proximal tubular cells, or Normal Rat Kidney Clone 52E (NRK-52E) cells derived from rat kidney epithelial cells, exposed to LPS reliably generate large quantities of proinflammatory cytokines such as IL-1 and TNFα. However, studies have shown that the concentration of cytokines generated by the LPS-induced model is several-fold higher than those typically observed in human sepsis ,70. AddiSeparate studies showed that circ-FANCA (hsa_circ_0040994), circ-BNIP3L (hsa_circ_0002131), circ-HIPK3, hsa_circ_0114427, and hsa_circ_0114428 were each increased in the sera of patients with septic AKI ,34,35,36Candida albicans, where the downregulation of circ-HIPK3 ameliorated the inflammatory response to sepsis, with reduced levels of IL-6 and TNF-α but increased levels of IL-10. This was likely due to the interaction of circ-HIPK3 with miR-124-3p and miR-148b-3p [In murine models, circ-RASGEF1B was upregulated in LPS-treated TCMK-1 cells and contributed to LPS-induced cellular apoptosis and inflammation by binding to and sponging miR-146a-5p. Downstream, the expression of mRNA of the miR-146a-5p target Pdk1 was elevated, in proportion to the increase in circ-RASGEF1B . Like in-148b-3p .Certain circRNAs may be downregulated in septic AKI. For example, both hsa_circ_0068,888 and hsa_circ_0091702 were reduced in the plasma of patients with septic AKI and likewise downregulated in LPS-stimulated HK-2 cells. In vitro studies showed that hsa_circ_0068,888 could sponge miR-21-5p to inhibit the expression of proinflammatory cytokines such as IL-6, TNF-α, and IL-1β, thereby protecting against LPS-induced cell injury via the NF-κB pathway ,40. SimiIRI to any organ is caused by a sudden, significant but temporary impairment in blood flow. In human patients, this can occur secondary to hypoperfusion of any reason; for example, this may occur with haemorrhagic shock due to torrential gastrointestinal bleeding, with hypovolaemia due to severe diarrhoea, or with reduced end-organ perfusion due to heart failure, or in the transplanted kidney . As desc+/Ca2+ antiporter with ATP depletion, in the post-ischaemic cell [Differential hypoxia is commonly observed in IRI. The outer medulla is supplied by the vasa recta, which are relatively oxygen-depleted after supplying the energy-dependent counter-current exchange system in the loop of Henle, and these areas are therefore particularly susceptible to hypoxic/ischaemic insults, even in the absence of global hypoperfusion . Drugs tmic cell . Activatmic cell . The commic cell .Renal IRI can be reliably modelled in animals. Bilateral or unilateral renal IRI murine models are established with the clamping of renal pedicle(s) for desired period(s) of ischaemia. In the unilateral renal IRI model, the contralateral kidney may be removed to reduce variability and to provide control tissue, or kept in situ to provide control tissue in studies looking at renal fibrosis from IRI and progression to CKD. The bilateral model may more closely simulate IRI in humans as hypoperfusion is typically global and bilateral .As described above, certain circRNAs are upregulated in diverse populations with AKI. The exact pathophysiological roles of such circRNA signatures have been discerned by in vitro studies on human and murine cell lines. For example, hsa_circ_0023404 was greatly increased in AKI patients, and was also significantly upregulated in HK-2 cells exposed to hypoxia then reperfusion. Bioinformatic analysis suggests that hsa_circ_0023404 sponges miR-136. Agomirs of miR-136 have been shown to repress the IL-6 receptor mRNA and protein and its downstream proinflammatory effects . In a muThe list of circRNAs that may be differentially expressed in renal IRI is clearly not exhaustive. One study profiled all circRNAs expressed in rat kidneys exposed to IRI compared to the controls, and showed significant differential expression of at least 26 circRNAs, associated with 26 miRNAs and their downstream genes. For example, circ-DNMT3A, circ-PLEKHA7, and circ-ME1 were decreased in rats with ischaemic AKI. Many of these miRNAs and their associated genes are associated with the PI3K/Akt/mTOR pathway, underscoring the importance of this system in modulating the response to renal IRI. Importantly, in the rat model of IRI, pre-treatment with the angiotensin-II receptor blocker losartan attenuated kidney damage, and this was associated with a reversal of the differential circRNA expression profile in the kidneys of untreated controls . In anotThe pathogenesis of AKI resulting from exposure to nephrotoxic drugs depends largely on the nature of the drug in question. Though there is extensive human data regarding the putative pathophysiology of different nephrotoxins, the best characterised animal models studied in vitro include models of nephrotoxicity due to the chemotherapeutic agent cisplatin, the aminoglycoside antibiotic gentamicin, radiocontrast media, and non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac . The finCisplatin is a platinum-based chemotherapeutic agent commonly used for various solid organ tumours in human subjects including cancers of the lung, head and neck, and testes. Cisplatin use is limited by dose-dependent nephrotoxicity, although genetics may also determine individual susceptibility to these toxicities. The mechanisms underlying cisplatin-induced AKI are complex . CisplatIodinated contrast media, used widely for radiological studies in human patients, has been associated with acute impairment of kidney function, particularly in patients with pre-existing CKD. Although the syndrome is common, comparatively little is actually known about the underlying pathophysiology of contrast-associated AKI. Studies suggest that modifications in renal haemodynamics may play a key role. Iodinated contrast media appears to preferentially cause renal medullary vasoconstriction, decreasing oxygen tension in the renal medulla, the part of the nephron most susceptible to hypoxic/ischaemic insults ,84. How Differential expression of circRNAs has been reported for cisplatin-induced AKI. The circRNA hsa_circ_0114427 was upregulated in different AKI models including cisplatin-induced AKI, and likely functions by sponging miR-494 to regulate ATF3 expression, which is associated with the downstream expression of IL-6 . In a muIn a study of a rat model of contrast-associated AKI induced by dehydration and iohexol, 38 circRNA transcripts were differentially expressed, with 16 circRNAs upregulated and 22 circRNAs downregulated, compared with the control rats treated with saline. Several candidate miRNAs were linked with the differentially expressed circRNAs in this study, and pathway analyses showed that these circRNAs were typically associated with DNA replication and steroid hormone biosynthesis as well as chemical carcinogenesis . HoweverObstruction occurring anywhere along the urinary tract can lead to an acute reduction in urine output and glomerular filtration rate. Bladder outlet obstruction or bilateral ureteric obstruction blocks off the urinary outflow of both kidneys, leading to complete renal shutdown, but unilateral ureteric obstruction can also lead to a reduction in kidney function, even in the contralateral unobstructed kidney, through a number of inflammatory and vasoactive pathways . Typicalper se.In animals, the unilateral ureteric obstruction (UUO) model was first proposed to study the effects of obstructive nephropathy. This typically involves a simple surgery in the target animals whereby the ureter of one kidney is ligated, with subsequent development of hydronephrosis, tubular cell death, inflammation, and the development of renal fibrosis. The unobstructed, contralateral kidney could be studied as a control after the animals involved were sacrificed . AlthougRNA-sequencing showed 63 upregulated and 64 downregulated circRNAs in human patients with ureteropelvic junction obstruction. For illustration, the expression of hsa_circ_0045861 was significantly upregulated, and this was accompanied with a resultant decrease in miR-181d-5p. The increase in hsa_circ_0045861 was simulated in vitro by the treatment of HK-2 cell lines with TGF-β1, suggesting that the circRNA identified is associated with TGF-β1-mediated renal fibrosis . These fper se, especially if they are assayed from the blood. As mentioned previously, like other ncRNAs, circRNAs can be identified in exosomes released into a variety of body fluids. Experimentally, circ-FANCA could be identified from exosomes released from HK-2 cells treated with LPS [CircRNAs are more stable than other ncRNAs such as miRNAs, making them attractive as biomarkers for diagnosis and prognostication. The wide array of differentially expressed circRNAs in both human subjects as well as murine models will have to be validated in prospective trials to ascertain their relationship to important clinical outcomes. As an illustration, as aforementioned, circulating ciRs-126 levels at the start of the first dialysis session showed a logarithmic relationship with short-term mortality in dialysis-requiring AKI patients in the ICU, although this was only a single-centre study with a small study cohort with severe acute kidney injury . Given twith LPS . CircRNAwith LPS .Compelling in vitro data using human kidney cell lines showed that silencing certain upregulated circRNAs or transfection with downregulated circRNAs could both have salutary effects on tissue injury, particularly in septic AKI or IRI. Interestingly, this could be effectuated using non-specific agents such as losartan in the rat model of IRI , or by tAKI is a common clinical condition and important cause of morbidity and mortality. There is an urgent need for better diagnostic, prognostic, and therapeutic tools in different syndromes of AKI. In addition to conventional proteomic and genomic approaches, the characterisation of the epigenetic landscape in AKI has opened the possibility of harnessing ncRNAs for the evaluation and treatment of various diseases. Compared to miRNAs, circRNAs are more stable, and are readily detectable by modern sequencing tools, suggesting that they would be potential candidates for liquid biopsy and other non-invasive diagnostic strategies. Various ncRNAs including circRNAs are differentially expressed in AKI compared to the healthy controls. The characterisation of ncRNA-associated competing endogenous RNA (ceRNA) networks in various models of AKI would help to identify ncRNAs that can be targeted therapeutically to attenuate disease processes. The identification of novel delivery systems for circRNA-based therapeutics would be crucial to translate circRNAs from the bench to the bedside. With a greater understanding of their roles in the pathogenesis and treatment of AKI, circRNAs could eventually become important tools for the diagnosis and treatment of AKI in the years to come.


HIV positive key population (KP) often face health system and social barriers to HIV care. KP include sex workers, men who have sex with men, persons who inject drugs, transgender people, and people in prisons and other closed settings. Community-based ART service delivery (CBART) has the potential to increase access to antiretroviral treatment (ART) and enhance retention in care. This scoping review summarized the evidence on the effect of CBART along the continuum of HIV care among KP in sub-Saharan Africa. We searched Pubmed, Web of Science, Google scholar, and NGO websites for articles published between 2010 and April 2020. We synthesized the involvement of KP community members or lay providers in medical task provision, and outcomes along the continuum of HIV care. Of 3,330 records identified, 66 were eligible for full test screening, out of which 12 were included in the review. CBART for KP was provided through: (a) community drop-in-centres, (b) community drop-in-centres plus mobile team, or (c) community-based health centres. KP were engaged as peer educators and they provided services such as community mobilisation activities for HIV testing and ART, ART adherence counselling, and referral for ART initiation. Across the KP-CBART studies, outcomes in terms of ART uptake, adherence to ART, retention in care and viral suppression were at least as good as those obtained for KP attending facility-based care. KP-CBART was as effective as facility-based care. To achieve the UNAIDS 95–95–95 target in sub-Saharan Africa, national programmes should scale-up KP-CBART to complement facility-based care.The online version contains supplementary material available at 10.1007/s10461-021-03568-3. Key populations (KP) include female sex workers (FSW), men who have sex with men (MSM), transgender people (TG), persons who inject drugs (PWID), and people in prisons and other closed settings . The risIn 2018, KP and their sexual partners accounted for more than fifty percent of all new HIV cases in Sub-Saharan Africa (SSA). In West and Central Africa, KP, their clients and sexual partners accounted for 64% of new infections and for 25% of new HIV infections in East and Southern Africa . Also thCommunity-based approaches to HIV care and treatment have proven to be an effective method of reaching people in the general population, particularly for individuals who are hard to reach . These aA recently published review showed the effect of community-based HIV care along the HIV care continuum among FSW. The HIV care continuum “is a public health model that outlines the steps or stages that people with HIV go through from diagnosis to achieving and maintaining viral suppression . We also summarized the predictors of retention among KP receiving care in KP -CBART models.This is a scoping review of the evidence on the effect of community-based ART service delivery on clinical outcomes along the continuum of HIV care for KP in SSA countries. Outcomes along the continuum of HIV care include HIV testing uptake, diagnosis of an HIV infection, linkage to care, medication adherence, and ART outcomes ]. The framework was developed as recommended by Arksey and O’Malley . This frpresented data on community-based (delivered from a community venue) or community-led  ART delivery programme for KP  in Sub-Saharan Africa, andreported data on one or more ART outcomes.Articles were included in the review if they:Papers published before 2010 were not considered, as community-based approaches to HIV care and ART delivery became popular after this time . Only arWe searched and extracted articles between April 2020 and May 2020 from the Medline database (through Pubmed). Web of Science was searched in September 2021. The grey literature (Google Scholar) and Websites of World Health Organization (WHO), International AIDS Society (IAS) and other international HIV agencies  were also searched. Finally, reference lists of retrieved studies were searched.Two researchers (IO and TD) conducted the literature review. The search string was constructed using the PICO approach Table . Terms wAfter conducting the search, duplicates were identified and removed using Mendeley reference software. Thereafter, titles and abstracts of retrieved studies were screened. Only studies that presented original data on the topic of interest were retrieved. Then the full text of retrieved studies was read and the inclusion criteria were applied.Extracted data were encoded in a data collection tool (Excel sheet), conceived and tested before the start of the review (see the attached Supplementary File 1 for the data extraction template).We collected thematic data on KP-CBART delivery, such as type of CBART model, intervention components, characteristics of lay providers (including KP) and their roles, and capacity building (training) of care providers.We collected quantitative data on the study title, author, publication year, study period, study location, study design, study setting, sample size, participant characteristics , and continuum of HIV care outcomes. Outcomes included uptake of HIV testing, HIV testing positivity among those tested, linkage to HIV care among those tested positive, ART uptake among those linked to care, medication adherence, clinical outcomes among those on ART, including retention , and viral suppression. We also collected data on the definitions used for these outcomes. Finally, data were collected on factors associated with retention or attrition, as reported in the studies. The collected data were summarized in Tables The selection of articles is shown in Fig. The twelve papers described CBART programs for KP in 6 sub-Saharan African countries. The study characteristics are summarized in Table ART services were provided to KP through either a community Drop-in-Centre (DIC), a community DIC with a mobile team, or a community-based health facility Tables  and 3. OA DIC aims at being safe for members of KP to meet, make friends and develop a sense of community . To enhaA DIC with outreach through a mobile team provides, in addition to DIC activities, a mobile health team comprising of clinicians, nurses and peer educators conducting ART outreach to venues of clients’ preference  for HIV testing, ART enrolment and initiation on specific days , 22, 24.Six studies reported using community-based health centre strategy in delivering ART services to either FSW or MSM , 25–28. All the community-based ART programs included in this review engaged KP or lay health workers to provide HIV care and/or ART Table . They weIn all the KP-CBART programmes described in this review, FSW and MSM were involved as peer educators or mobilisers. They actively mobilised their peers and KP communities for HIV testing, linkage to HIV care, ART initiation and viral load testing. Services offered by trained peer educators include venue-based peer education, condom distribution, ART referral with or without assistance (escort services) and clients tracking for ART refill.Members of the KP community, trained as peer educators, supported ART delivery in the community, through DIC, outreach venues (including home-based venues), and community-based health facilities. Eleven studies documented KP roles in antiretroviral therapy delivery, they offered ART referral to HIV positive patients and medication adherence counselling to those on ART , 21–27. In the DIC and mobile health team model in Tanzania, peer educators were reported to have initiated HIV-positive FSW on ART .In the Tanzania study, the KP-CBART delivery programme was designed in line with the national ART guidelines and the national community-based HIV and AIDS services guidelines . TraininMoreover, trained KP offered psychological and social support through their leadership and membership in support groups such as Shikamana support group, Savings and Violence support groups, Adherence Sisters program in Tanzania and Zimbabwe , 18. TheKP were also involved in HIV programme planning, implementation and evaluation. In Tanzania, FSWs were members of the Community Advisory Board that offered guidance on KP-programme implementation in the study-region .Across all studies, KP were tested, diagnosed with HIV and linked to HIV care Table . HIV tesThree articles compared a CBART intervention with a control arm for ART initiation among KP. In two studies conducted in the Tanzania and Zimbabwe, CBART was significantly associated with a higher likelihood of ART initiation. For one study the correlation was not significant Table  18]. Ov. Ov18]. The definition of retention among those started on ART varied across programmes and depending on the study, retention in care was assessed at different timepoints Table . RetentiEight papers reported on viral load suppression (VLS) Table . KP who Findings from this scoping review on the effect of KP-CBART on outcomes along the HIV care continuum ranging from HIV testing to viral load suppression and retention in care including ART delivery, showed that outcomes in KP-CBART were at least as good as in facility-based care. Our conclusion is coherent with the conclusion from a recent review on CBART for FSW, even though most of the included studies did not overlap, as different inclusion criteria were used . Our revOur review showed that there are few community-based ART interventions targeting key populations and most were implemented at small scale and in research settings. Three approaches to KP-CBART were described, namely through (a) community drop-in-centres, (b) community drop-in-centres plus outreach through a mobile team or (c) community-based ART centres. What differentiates these models from each other are the locations of service delivery, the roles of care providers in ART delivery, and the package of HIV services offered to KP. From the present review it is not possible to infer which model works best for which population or setting. Already planned research of the existing KP-CBART programmes using realist evaluation will provide more evidence on the contextual factors and types of CBART model that favour good treatment outcomes.CBART models were designed to meet the needs of KP communities, by attempting to reduce or dampen the effect of known socio-cultural and health system barriers to HIV prevention and treatment services . The comKP were trained as peer educators to support HIV service delivery , 21, 24.Another hypothesis that needs further empirical testing in different settings is that the increase in HIV case identification in KP-CBART programmes/through the KP CBART service delivery model is probably due to sensitisation and activities of the outreach workers  in the programme, illustrating the importance of providing a comprehensive package of services . RecruitWhere measured, linkage to HIV care and ART uptake also improved in the KP-CBART programmes compared to the baseline  and was ART uptake in the community-based health centre for MSM in the Nigeria study was remarkably lower (50.1–54.7%%) compared to the other two models , 26. TheThe rates of adherence to medication and retention in care Tables  and 7 inWhere measured, KP receiving ART through the CBART programme, achieved a similar viral suppression rate compared to those in the standard care model , 18. HowThe major difference between CBART organised for PLHIV in the general population and KP-CBART is that the care package was more comprehensive in KP-CBART models, and that the role of lay health workers and peers was not limited to counselling and ART refill. In the trained KP-CBART service delivery model, trained peer educators participated in a wide range of activities, such as ART outreach (mobilising for HIV testing and ART), distribution of condoms, tracking LTFU, referral for ART initiation, and ART initiation. For example, in the Tanzania study, the peer educators and other members of the mobile health team initiated HIV positive FSW on ART. It was not clear for this intervention which type of training peer educators received and how much and what kind of support they received when initiating ART .KP-CBART models can be adapted to lessons learnt from CBART for general population and vice versa. A review of CBART for the general population concluded that clinical outcomes for participants on treatment were at least comparable with facility-based ART and are likely to be cost-effective . KP-CBARWhen compared one-to-one with facility-based care in the RCT, outcomes in KP-CBART were at least as good. Compared to baseline, KP-CBART improved the continuum of HIV care and treatment outcomes across different settings in sub-Saharan Africa  , 22, 24.The summary of strength and limitations of studies included in this review is presented in Table The results from the various studies in sub-Saharan Africa showed the potential of community-based ART delivery to improve engagement in HIV care and ART related outcomes among KP in Africa. Across studies that compared KP-CBART with facility-based care, outcomes in terms of ART uptake, adherence to ART, retention in care and viral suppression were at least as good in KP-CBART as those obtained for KP in facility-based care. Therefore, to fast track the achievement of the UNAIDS 95–95–95 target by 2030 in sub-Saharan Africa, national programmes should promote policies/develop/pilot guidelines on task shifting of medical tasks to members of KP and lay healthcare workers to enrol additional KP in care, providing an alternative model to facility-based care. When community-based ART service delivery for KP would be scaled up to complement facility-based care, future research should focus on long-term benefits of community-based care and explore views, experiences, and preferences of different stakeholders with regards to different community and facility-based models of care, and the mix of differentiated service delivery models in different settings.Supplementary file1 (DOCX 15 kb)Supplementary file2 (DOCX 13 kb)Below is the link to the electronic supplementary material.


Puumala orthohantavirus (PUUV) among forestry workers in northern France, and to explore sociodemographic risk factors. We conducted a random cross-sectional seroprevalence survey among 1777 forestry workers in 2019–2020. The presence of immunoglobulin G against PUUV antigens in serum was assessed using enzyme-linked immunosorbent assay and confirmed using immunofluorescence assay. Poisson regression models were used to explore factors associated with seropositivity. Weighted seroprevalence was 5% (3–6) in northeastern France, 4% (2–6) in north central France, and 1% in two regions located in the center of the country (Auvergne and Limousin). There were no seropositive workers detected in northwestern France. Seropositivity was associated with age, sex, and cumulative seniority in the forestry sector. Seroprevalence was highest in known endemic areas of the northeast and lowest in the northwest. Nevertheless, we found serological evidence of PUUV infection in two regions located in the center of the country, suggesting circulation of the virus in these regions, previously thought to be non-endemic.We aimed to estimate the seroprevalence of  Orthohantavirus genus . They are responsible in Eurasia for mild to severe hemorrhagic fever with renal syndrome (HFRS) [Zoonotic hantaviruses are rodent-borne enveloped viruses with a tri-segmented, negative sense, single-stranded RNA genome, belonging to the e (HFRS) .Puumala orthohantavirus (PUUV) is the hantavirus species most commonly detected in patients in metropolitan France, whereas Seoul orthohantavirus (SEOV) and Tula orthohantavirus (TULV) are detected sporadically. As in some other European countries [ountries ,2, the sountries ,4. Thereountries . The maiountries .Myodes glareolus) for PUUV, the brown rat (Rattus norvegicus) for SEOV, and the common vole  for TULV. There are various hypotheses to explain this heterogeneous geographic distribution of PUUV, including environmental factors , rodent susceptibility (including virus replication and excretion), genetic characteristics of the viruses , and human behaviors (contact with rodents or their excreta) [In contrast to the spatial distribution of HFRS cases, the main natural hosts of these three hantavirus species are present in most regions of metropolitan France. Hantavirus hosts include the bank vole (excreta) ,3,7. PUUexcreta) ,15,16,17Cases may be missed outside the northeastern quarter of metropolitan France because patients are not frequently tested for hantavirus . The occThere is little information on the presence of PUUV in French regions that are considered non-endemic. Given that forestry workers are at higher risk than the rest of the population due to potential exposure to rodents, particularly the bank vole, host of PUUV, and their excreta , conductBorrelia burgdorferi sl. The sample size for our study was therefore determined to answer this research objective. The number of required subjects was calculated for each of the following five geographic areas: northwestern France including Normandie (Haute-Normandie and Basse-Normandie), Bretagne and Pays-de-la-Loire regions; north central France including Hauts-de-France , Île-de-France, and Centre regions; northeastern France including Alsace, Lorraine, Champagne-Ardenne, Bourgogne, and Franche-Comté regions; and Auvergne and Limousin regions, both located in the center of France. Assuming a B. burgdorferi sl seroprevalence of 5% in northwestern and north central France and of 15% in northeastern France [B. burgdorferi sl seroprevalence. A total of 1778 forestry workers were included from May 2019 to March 2020. The number of participants was lower than required due to the COVID-19 pandemic as the lockdown led to the interruption of data collection. We conducted power calculations to estimate the precision of hantavirus seroprevalence estimation using the available sample  of one of the following administrative regions: Normandie (Haute-Normandie and Basse-Normandie), Bretagne, Pays-de-la-Loire, Hauts-de-France , Île-de-France, Centre, Alsace, Lorraine, Champagne-Ardenne, Bourgogne, Franche-Comté, Auvergne, and Limousin.To recruit study participants, we used a stratified random sample. Strata were defined by region , occupational activity , and working status . Within each stratum, simple random sampling was used to select individuals. The number of individuals sampled was proportional to the size of the strata.Individuals were invited for a medical visit by their occupational health physician. After obtaining informed consent, participants were interviewed, and blood samples were collected. The questionnaire administered included sociodemographic information such as age and region of MSA insurance fund affiliation, as well as details on occupational activity including main profession, average weekly exposure to the forest, and cumulative seniority in forestry activities. The questionnaire also included questions on the main departments where forestry activities occurred during the last 12 months, as well as secondary departments or countries. All blood samples were anonymized at the time of collection by giving each a unique number. Blood samples were kept at room temperature (10–30 °C) and centrifuged  within 48 h. Sera were frozen at −20 °C within 2 h after centrifugation. Serum was divided into five aliquots and stored at −30 °C until analyzed.Collected sera were screened for the presence of anti-PUUV immunoglobulin G (IgG) at 1:100 dilution using homemade enzyme-linked immunosorbent assay (ELISA) according to Rossi and colleagues’ method . ELISA-pAll statistical analyses were weighted. The weights used considered the sampling weight and were adjusted for non-response. Non-response was corrected by reweighting using the equal-quantile score method , based oWe described population demographic characteristics with absolute and relative frequencies for categorical variables and with mean and standard deviation for continuous variables. We explored factors associated with hantavirus seropositivity by estimating seroprevalence ratios and 95% confidence intervals (CI) using weighted Poisson regression models with robust standard errors. The clustering of observations by geographic area was accounted for using a fixed area effect in all models. The outcome of interest was hantavirus seropositivity, and we used one model per factor of interest (the main exposure variable). Causal diagrams were made between hantavirus seropositivity and each factor of interest using DAGitty  had IgG against PUUV antigens in their serum. We estimated a weighted seroprevalence of 3.3% (95% CI: 2.5–4.3). Seroprevalence varied across age groups, being lowest among individuals aged 18–40 years  and highest among those older than 60 years . Specifically, seroprevalence was four times higher (95% CI: 1.5–10.2) among individuals older than 60 years than among those aged 18–40 years . All worSeroprevalence appeared to be greater among forest technicians and forest rangers  than among woodcutters  or silviculturists , but differences were not statistically significant . SeropreOur primary aim was to estimate the overall and regional seroprevalence of the hantavirus among forestry workers in northern France. In our study, the overall seroprevalence for hantavirus was estimated at 3.3% (95% CI: 2.5–4.3), which aligns with a previous meta-analysis by Riccò and colleagues  that indOur secondary aim was to compare seroprevalence between geographic areas, particularly northeast and other northern areas. As anticipated, the seroprevalence among forestry workers was greatest in known endemic areas of northeastern and north central France, particularly, in the highly endemic regions of Franche-Comté and Hauts-de-France . ChampagWe did not find evidence of the circulation of PUUV in northwestern France , which is considered non-endemic . SpecifiFinally, we also aimed to determine sociodemographic factors associated with the prevalence of anti-PUUV IgG. Age was positively associated with the presence of anti-PUUV IgG similar to the results reported in other studies ,36. ThisB. burgdorferi sl, we did not collect information on the use of preventive measures for hantavirus infections (such as the use of masks while working), and we could not evaluate their relationship with hantavirus seroprevalence.Forestry workers are at higher risk of interacting with rodent hosts than the general population. Thus, our results cannot be generalized to the overall French population. We can also hypothesize that forestry workers are more aware than the general French population of occupational-related infections and their preventive measures. Indeed, there are specific HFRS prevention campaigns targeting forestry workers, as it is part of the list of occupational diseases in France . MoreoveIn our study, we limited selection bias by randomly selecting forestry workers and by adjusting for non-response according to differences in sociodemographic and professional characteristics. Nevertheless, we cannot exclude the possibility of residual selection bias due to differences in hantavirus exposure between participants and non-participants with the same socio-demographic and professional characteristics.In conclusion, the regional seroprevalence of hantavirus antibodies among forestry workers was greatest in the known endemic areas of northeastern and north central France, and lowest in the non-endemic northwestern France. Nevertheless, we found indications of the circulation of hantavirus in the Auvergne and Limousin regions, located in the center of the country, even though they were previously thought to be non-endemic. These results may indicate some risk of local HFRS cases in these regions, and the need to raise awareness among general and hospital practitioners and among at-risk populations. Practitioners in non-endemic areas should still be aware of the possibility of HFRS cases, especially among patients returning from endemic areas. An improved understanding of hantavirus infection rates in reservoir host species and virus transmission to humans is still needed to fully understand the absence of infection in non-endemic areas. Rodents’ ecology is highly variable, not only at the geographical level, but also over time, due to complicated interactions with their environment .Routine surveillance has the disadvantage that cases might be missed in newly endemic areas that are still thought to be non-endemic . The inf


In the Industry 4.0 era, with the continuous integration of industrial field systems and upper-layer facilities, interconnection between industrial wireless sensor networks (IWSNs) and industrial Internet networks is becoming increasingly pivotal. However, when deployed in real industrial scenarios, IWSNs are often connected to legacy control systems, through some wired industrial network protocols via gateways. Complex protocol translation is required in these gateways, and semantic interoperability is lacking between IWSNs and the industrial Internet. To fill this gap, our study focuses on realizing the interconnection and interoperability between an IWSN and the industrial Internet. The Open Platform Communications Unified Architecture (OPC UA) and joint publish/subscribe (pub/sub) communication between the two networks are used to achieve efficient transmission. Taking the Wireless Networks for Industrial Automation Process Automation (WIA-PA), a typical technology in IWSNs, as an example, we develop a communication architecture that adopts OPC UA as a communication bridge to integrate the WIA-PA network into the industrial Internet. A WIA-PA virtualization method for OPC UA pub/sub data sources is designed to solve the data mapping problem between WIA-PA and OPC UA. Then, the WIA-PA/OPC UA joint pub/sub transmission mechanism and the corresponding configuration mechanism are designed. Finally, a laboratory-level verification system is implemented to validate the proposed architecture, and the experimental results demonstrate its promising feasibility and capability. With the rapidly growing demand for wireless data transmission services in the industrial Internet of things (IIoT) ,2, indusAll three IWSN technologies are based on IEEE 802.15.4 and form wireless personal area networks. The gateway of an IWSN is responsible for data collection from wireless devices and for the downward forwarding of commands to wireless devices. In real industrial scenarios, IWSNs are often connected to legacy control systems  and human–machine interface (HMI)), through industrial wired network protocols  via gateways . HoweverAs an open, platform-independent and service-oriented architecture specification, OPC UA supports the secure and reliable exchange of data, in the industrial automation space and other industries, and ensures the seamless flow of information among devices from multiple vendors . OPC UA Most studies on WIA-PA and OPC UA focus on verifying and implementing their respective protocols. Numerous approaches have been proposed to enable connection between WIA-PA networks and the Internet. For instance, the authors in  proposed(1)Taking WIA-PA, a typical wireless technology in IWSNs, as an example, we propose a communication architecture of WIA-PA/OPC UA joint pub/sub. This architecture can combine WIA-PA pub/sub with MQTT broker-based OPC UA pub/sub to realize the integration of the WIA-PA network into the industrial Internet.(2)A WIA-PA virtualization method for OPC UA pub/sub data sources is designed to solve the data mapping problem between WIA-PA devices and OPC UA publisher/subscriber.(3)To ensure the efficient messages exchange between OPC UA publisher/subscriber and WIA-PA networks, we design a WIA-PA/OPC UA joint pub/sub transmission mechanism and the corresponding configuration mechanism.(4)An experimental system is implemented to evaluate the feasibility and capability of the proposed communication scheme. The results show that the proposed scheme performs well in terms of consumed memory, communication success rate, and publishing delay. Furthermore, in this study, the proposed scheme has strong protocol consistency.Although the IWSNs and OPC UA pub/sub modes have been extensively studied in their respective fields of research ,20, the The rest of this paper is organized as follows. WIA-PA is a wireless network protocol for industrial process measurement, monitoring, and control. It is based on IEEE 802.15.4 and is standardized and approved as IEC 62601 by the IEC . Its topAs shown in The WIA-PA application layer includes the user application process (UAP) and the application sublayer (ASL). A UAP consists of one or more user application objects (UAOs). The properties of a UAO include object name, property name, property identifier, property data type, and supported methods. A UAO supports five operation methods for WIA-PA internal data: read, write, publish, report, and report ACK. To specify the access mode between UAOs, WIA-PA uses the virtual communication relationship (VCR), which distinguishes the paths and communication resources used by different UAOs. VCR_ID uniquely identifies each VCR. According to the supported applications, the VCR is divided into three modes: P/S mode (supports preconfiguration and periodic message transmission), R/S mode (supports aperiodic events and trend reporting), and C/S mode (supports WIA-PA aperiodic and dynamic pairwise unicast information transmission for WIA-PA devices).OPC UA is a platform-independent, service-oriented interoperability technology that is standardized by the IEC and consists of 26 specifications and many companion specifications. It has two communication modes: C/S and pub/sub. In C/S, the client and server are deeply coupled. They must establish a direct connection and send requests and responses to each other. Compared with C/S, pub/sub has a flexible communication structure, easy configuration, and support for many-to-many communication.OPC UA pub/sub has three logical roles: publisher, subscriber, and message middleware. The publisher and subscriber are decoupled through the message middleware. They do not require direct information exchange but need to correctly parse and encapsulate message packets as required. Meanwhile, the OPC UA pub/sub specification defines brokerless and broker-based middlewares. With a brokerless middleware, an OPC UA publisher relies on the network infrastructure to deliver messages to one or more receivers. A broker-based middleware needs to use third-party messaging protocols, such as advanced message queuing protocol (AMQP) and MQTT. Compared with AMQP, MQTT is easier to implement and widely used in industrial automation application scenarios. Therefore, this paper uses MQTT as the WIA-PA/OPC UA joint pub/sub broker-based middleware. Eckhardt et al.  evaluateAccording to the analysis results in A broker in the OPC UA publish/subscribe model can decouple the communication between the entities in space, time, and synchronization. The publisher and subscriber do not have to be directly addressable, which makes the network architecture flexible, while there is no need for resource-constrained WIA-PA nodes to maintain address tables for subscribers. In addition, only the events and data that are of interest need to be transmitted to the broker, and the broker supports a one-to-many communication mode, which can reduce the number of messages to be transmitted and further reduce network conflicts and energy consumption. Hence, broker-based OPC UA pub/sub can meet most requirements of WIA-PA networks, industrial Internet remote applications, and cross-network communication between field networks.In summary, OPC UA pub/sub is deployed in the WIA-PA scheme in this paper as follows. MQTT broker-based OPC UA pub/sub is the broker transport protocol, and JSON and UADP are the message encoding formats. Furthermore, the coupling of OPC UA and the WIA-PA network is realized through the WIA-PA gateway.In an IWSN, the computing resources and energy of sensor devices are relatively limited, whereas those of the gateway are generally greater. Therefore, the use of a WIA-PA gateway as the coupling point between WIA-PA and OPC UA can maximize its abundant computing resources and energy. The system architecture of the WIA-PA/OPC UA joint pub/sub is illustrated in The system architecture includes an OPC UA pub/sub communication unit and a WIA-PA/OPC UA joint pub/sub unit. The former realizes MQTT broker-based OPC UA pub/sub. The latter virtualizes the OPC UA pub/sub data source through a virtualization mechanism. In this way, the device binding and data resource mapping of the OPC UA publisher/subscriber are realized. Meanwhile, through the WIA-PA/OPC UA joint pub/sub transmission configuration mechanism, the WIA-PA network device can communicate with the OPC UA publisher/subscriber. As shown in WIA-PA and OPC UA have different pub/sub mechanisms and cannot be directly combined. Thus, a virtualization mechanism must be designed for the OPC UA pub/sub data source in the WIA-PA application layer. This mechanism is the basis of WIA-PA/OPC UA joint pub/sub communication. The method is to map the OPC UA pub/sub data source to the UAO of the WIA-PA application layer, such that the WIA-PA field devices obtain the data source of the OPC UA publisher/subscriber through the WIA-PA protocol. This method is divided into three steps: device interconnection, resource discovery, and OPC UA pub/sub data source mapping.The device interconnection process is divided into two phases: WIA-PA gateway-based device interconnection and WIA-PA device address binding. In the former phase, the WIA-PA gateway performs resource discovery and communication transmission and realizes the connection between the OPC UA publisher/subscriber and the WIA-PA network. In the latter phase, the OPC UA publisher/subscriber and its corresponding broker middleware are virtualized as a virtual device in the WIA-PA application layer, which has a WIA-PA logical address and names the OPC UA pub/sub virtual device, as shown in The resource discovery process, which is shown in After resource discovery, the discovered OPC UA pub/sub data source should undergo resource mapping. This process entails mapping the OPC UA publisher/subscriber information model to a pub/sub configuration UAO, which is in the WIA-PA gateway. Each OPC UA pub/sub configuration UAO corresponds to a publisher/subscriber. Therefore, through the WIA-PA protocol, the WIA-PA field devices can directly address the desired OPC UA data source.The OPC UA publisher/subscriber information model is completely mapped to the UAO, and the payload becomes overly complex when WIA-PA devices communicate with the OPC UA servers. Therefore, in the design of the resource-mapping mechanism in this paper, the OPC UA pub/sub configuration information model is partially discarded to facilitate the data transmission of the WIA-PA field devices; only the necessary information models of these devices  are retained.Based on the simplified OPC UA pub/sub information model, we construct the communication parameters of the OPC UA pub/sub configuration UAO, which are divided into the public section, publisher section, and subscriber section.The public section contains the name, state, transport protocol, and connection address of the pub/sub connection, which are required by all publishers and subscribers.The publisher section includes the ID information of the publisher, writer group, and dataset writer; the data item and metadata of the published dataset; and the encoding format for message mapping.The subscriber section describes the publisher information subscribed by the OPC UA subscribers. To facilitate WIA-PA device communication, we add SubscriberID to identify the subscriber devices and DataSetReaderID to identify the dataset readers.The parameters of the OPC UA pub/sub configuration UAO are classified as static and dynamic. The static configuration parameters are the various identification information of the OPC UA publishers and subscribers, such as PublisherID and SubscriberID, which are only used within the OPC UA applications and have little relationship with the WIA-PA field devices. We choose static parameters maintained by the WIA-PA gateway. The dynamic configuration parameters mainly are the connection protocol, connection address, topic, pub/sub time interval, and OPC UA message format, which are needed by the field devices to pub/sub data to the OPC UA server and are configured by the field devices before transmission. In this way, the protocol complexity of combining WIA-PA with OPC UA is effectively reduced, and the WIA-PA field devices can execute a pub/sub transmission without fully understanding the parameters of the entire OPC UA pub/sub.OPC UA pub/sub configuration UAO in the gateway. After discovering and mapping the OPC UA publisher/subscriber resources, the WIA-PA gateway establishes the pub/sub configuration mirror within it, namely the OPC UA pub/sub configuration UAO.OPC UA pub/sub message UAO in the gateway. It is responsible for parsing and forwarding the data sent by the WIA-PA field device. Each OPC UA pub/sub message UAO corresponds to an OPC UA pub/sub configuration UAO.Pub/sub configuration UAO in the field device. In the WIA-PA/OPC UA joint pub/sub configuration process, through the pub/sub configuration UAO, the field device registers the pub/sub operation parameters with the OPC UA pub/sub configuration UAO in the gateway and obtains the address of the OPC UA pub/sub message UAO in the gateway. The OPC UA pub/sub configuration UAO in the gateway and the pub/sub configuration UAO in the field device jointly realize the WIA-PA/OPC UA joint pub/sub configuration process.Pub/sub message UAO in the field device. It publishes the data collected by the WIA-PA field device to the OPC UA pub/sub message UAO in the gateway or receives the data from the OPC UA pub/sub message UAO in the gateway. The OPC UA pub/sub message UAO in the gateway and the pub/sub message UAO in the field device jointly realize the WIA-PA/OPC UA joint pub/sub execution process.The functions of the different UAOs in The WIA-PA/OPC UA joint pub/sub configuration process can be divided into two parts: the pub/sub registration phase and the VCR establishment phase. Its time sequence flowchart is shown in In the pub/sub registration phase, the pub/sub configuration UAO in the WIA-PA field device uses the “write” method to write the dynamic configuration parameters to the pub/sub configuration UAO in the gateway, including the broker address and protocol, topic, time interval, and message format (UADP or JSON), and finally enables the publication or subscription.In the VCR establishment phase, the WIA-PA network manager allocates VCRs for the pub/sub message UAO in the WIA-PA field device and pub/sub message UAO in the gateway and configures the parameters, such as the UAO identifier and communication cycle.The pub/sub transmission process between the WIA-PA field device and OPC UA publisher/subscriber entirely relies on the WIA-PA and OPC UA pub/sub modes, as shown in In the publication of the data of the WIA-PA field device to the MQTT broker middleware, the WIA-PA gateway parses the received WIA-PA application layer protocol data and transmits them to the OPC UA publisher through the network cable. Next, the OPC UA publisher parses and enters the received data into the information space of the OPC UA publisher and then sends them to the MQTT broker middleware.In the subscription process of the data from the MQTT broker middleware by the WIA-PA field device, after receiving the data subscribed from the MQTT broker middleware, the OPC UA subscriber enters the data into its information space and forwards them to the WIA-PA gateway through the network cable. The WIA-PA gateway encapsulates the received data into WIA-PA protocol data and sends them to the WIA-PA field device.On the basis of the system architecture  and softIn the verification system, embedded devices with STM32L152 (16KB SRAM and 128KB Flash) microcontroller run the WIA-PA wireless node protocol stack. An embedded device with RT5350 SoC (32MB SDRAM and 8MB NAND Flash) runs the WIA-PA gateway program. The WIA-PA nodes and the WIA-PA gateway form a star topology with the time slotted channel hopping function and the retransmission function (maximum number of retransmissions is three) enabled. The OPC UA publisher, subscriber, and MQTT broker run on a computer running Ubuntu 16.04 (Linux 4.4.0). The WIA-PA gateway connects to the computer through the network cable. The OPC UA publisher and subscriber are implemented using the open62541 SDK . The MosThis section describes system testing, which is divided into functional testing and performance testing. Functional testing includes WIA-PA/OPC UA joint publishing testing and subscription testing. Performance testing includes the memory occupied, the communication success rate, and the publishing delay.In WIA-PA/OPC UA joint publishing, the WIA-PA field device publishes data to the MQTT broker. In WIA-PA/OPC UA joint subscription, the WIA-PA field device subscribes to data from the MQTT broker. The WIA-PA/OPC UA joint publishing process and subscription process are detailed below.WIA-PA/OPC UA joint publishing processThe WIA-PA field device sends data to the OPC UA pub/sub virtual device in the WIA-PA gateway. Then, the OPC UA pub/sub virtual device parses the received data and forwards them to the OPC UA publisher through the network cable. The OPC UA publisher stores the received data, which are the data to be published, in its address space. The dataset writer adds properties to the data to be published and encapsulates them into the publishing dataset. The dataset writer group adds a publisher ID to the publishing dataset and encapsulates it into a message packet. Finally, the writer group encapsulates multiple message packets into a published message packet and then sends this packet to the MQTT broker. The dataset writer, dataset writer group, and writer group are logical concepts in the OPC UA publisher.WIA-PA/OPC UA joint subscription processThe OPC UA subscriber obtains the publisher-related communication parameters from the WIA-PA field device, such as Publisher ID, DataSetWriterID, and DataSetWriterGroupID, and then connects to the MQTT broker, according to the topic of the subscription message. After the OPC UA subscriber receives the subscribed data, it forwards them to the OPC UA pub/sub virtual device in the gateway through the network cable. Finally, the OPC UA pub/sub virtual device encapsulates the data into WIA-PA protocol data and sends them to the WIA-PA field device.We built a laboratory-level experimental system to validate the WIA-PA/OPC UA joint pub/sub process. The experimental result shows that the proposed system can realize the WIA-PA/OPC UA joint pub/sub, supporting both the UADP and JSON message encoding formats and enabling the WIA-PA network to connect to the industrial Internet through OPC UA pub/sub.Memory occupancy testingMemory occupancy testing involves the sizes of the read-only memory (ROM) and random-access memory (RAM) consumed by the OPC UA publisher/subscriber application. The test results are shown in Communication success rate testingThe communication success rate of WIA-PA/OPC UA joint pub/sub in different pub/sub periods  is tested. The number of data packets sent by the WIA-PA field device or the MQTT broker is set to 10,000 in each period. In the joint publishing process, the success rate of publishing communication is the ratio of the number of messages received by the MQTT broker to the number of messages sent by the WIA-PA field device. Similarly, in the joint subscription process, the success rate of subscription communication is the ratio of the number of messages received by the WIA-PA field device to the number of messages sent by the MQTT broker. The test results are shown in Publishing delay testingThe joint publishing delay is defined as the time interval from when a message is received from the gateway’s wireless interface, after the gateway has processed the message and sent it to the OPC UA subscriber, to when the OPC UA subscriber receives this message. In cases with different numbers of field devices, we measure the publishing delay of the experimental system. The number of field devices is set to 1, 5, 10, 50, and 100. In each case, we count 100 sets of data and calculate the average. The results are shown in This paper addresses the problem of achieving interconnection and interoperability between IWSNs and the industrial Internet. Taking WIA-PA, a typical wireless technology in IWSNs, as an example, we propose an architecture of WIA-PA/OPC UA joint pub/sub. On the basis of the WIA-PA standard and OPC UA specification, we designed an OPC UA publisher/subscriber data source virtualization mechanism, the WIA-PA/OPC UA joint pub/sub transmission mechanism, and the corresponding configuration mechanism in the WIA-PA gateway. These mechanisms allow WIA-PA field devices and the OPC UA publisher/subscriber to communicate with each other. The WIA-PA gateway, which plays an important role in linking WIA-PA and OPC UA, was designed to ensure good coupling between WIA-PA and OPC UA and reliable data transmission. After simplifying the OPC UA pub/sub information model, we constructed UAOs for the OPC UA publisher/subscriber, which are used for parameter configuration and data transmission, according to the UAO design method provided by the WIA-PA standard. In addition, a laboratory-level WIA-PA/OPC UA joint pub/sub verification system was assembled to validate the proposed architecture. The experimental results of system execution showed that the proposed system architecture is feasible and performs well in terms of consumed memory, communication success rate, and publishing delay. It can meet most communication requirements of IWSNs.In this study, the system architecture has strong protocol consistency; it does not modify the protocols of WIA-PA and OPC UA. This study serves as a valuable reference for connecting other industrial wireless technologies to the industrial Internet through OPC UA and can inspire more researchers to further advance this field. Future outlooks related to the proposed system architecture include the combination of the aggregation and disaggregation functions of WIA-PA to realize WIA-PA aggregation data transmission. We will add TSN technology to improve the real-time performance and reliability of the system, and we will also test the whole system in a real industrial scenario.


Based on our study, high-risk clinical trials with continuous outcomes reported more favorable intervention effects than did low-risk trials in general.Many experimental and clinical trials have investigated the dental application of probiotics, although the evidence concerning the effects of probiotic supplements is conflicting. We aimed to examine whether sponsorship in trials about dental applications of probiotics is associated with biased estimates of treatment effects. Overall, 13 meta-analyses involving 48 randomized controlled trials  with continuous outcomes were included. Effect sizes were calculated from differences in means of first reported continuous outcomes, divided by the pooled standard deviation. For each meta-analysis, the difference in standardized mean differences between high-risk and low-risk trials was estimated by random effects meta-regression. Differences in standardized mean differences (DSMDs) were then calculated via meta-analyses in a random effects meta-analysis model. A combined DSMD of greater than zero indicated that high-risk trials showed more significant treatment effects than low-risk trials. The results show that trials with a high risk of sponsorship bias showed more significant intervention effects than did low-risk trials (combined DSMD, 0.06; 95% confidence interval, 0.3 to 0.9;  Probiotics, in 2002, were defined by the Food and Agriculture Organization of the United Nations and the WHO as “live microorganisms that, when administered in adequate amounts, confer a health benefit on the host” .In recent decades, the benefits of probiotics on general health have been extensively investigated, increasing the consumption of probiotics for the promotion of health and well-being all over the world . StudiesDue to their potential ability for microbiota modification and host regulation, probiotics are also widely studied in dentistry, including periodontal disease ,16, dentPharmaceutical companies might fund studies with weaker comparators.Industry may have conducted low-quality research.Higher doses of the drug may be administered to subjects.Manufacturers tend to prevent the publication of studies unfavorable to their products.Sponsored research is more likely to appear in symposiums and use publication platforms with a lack of peer review.Evidence suggests that industry sponsorship of research is associated with favorable efficacy results . PossiblAll the above biases adherent to sponsorship are termed as sponsorship bias and might account, in part, for the conflicting results of dental probiotics trials.In the dental field, up to now, only few publications have evaluated the effect of sponsorship on intervention outcomes ,24,25. TExistence of both trials sponsored by industry and trials by non-industrial institutions;At least one qualitative continuous outcome related to oral health;At least three trials included in the meta-analysis.We sought meta-analyses investigating probiotics’ application for oral disease treatment or maintenance. The inclusion criteria were as follows:Inaccessible trials included;Studies other than randomized control trials included.Exclusion criteria were:Systematic searches were conducted in 3 databases , while unpublished papers were searched in OpenGrey. The search strategy for meta-analyses can be found in the We retrieved each trial publication in eligible meta-analysis studies. For included trials, we extracted the following information : author To identify factors affected by or correlated with sponsorship status, we assessed each included trial’s risk of bias according to the Consolidated Standards of Reporting Trials (CONSORT) statement . In accoTrials reporting that they did not receive sponsorship or only received support from universities or other academic institutions were judged as low-risk.Trials reporting that they received sponsorship from industry and academic institutions and declaring the sponsor was not involved in the trial conduct, data management/analysis, or co-authorship were judged as low-risk.Trials reporting that they received sponsorship from industry and academic institutions without declaring the sponsor was not involved in the trial conduct, data management/analysis, or co-authorship were judged as high-risk.Trials reporting that they received sponsorship from the industry and declaring that the sponsor was not involved in the trial conduct, data management/analysis, or co-authorship were judged as low-risk.Trials reporting that they received sponsorship from the industry without declaring that the sponsor was not involved in the trial conduct, data management/analysis, or co-authorship were considered high-risk.The criteria are listed as follows:For the whole process of data extraction, two investigators (Q.H. and G.P.) extracted data independently. Any disagreements were resolved after discussion with a third investigator (A.A.).Treatment effects were expressed as standardized mean difference  model; difference in mean outcomes between groups divided by a pooled standard deviation within groups) for the first reported continuous outcomes in each meta-analysis . Due to I2 statistic, Cochran’s Q χ2 test, and the between-meta-analyses variance τ2 were used to assess heterogeneity across differences in standardized mean differences.The meta-epidemiological analysis relied on previously described methodology . To evalTo account for the difference in estimated effects between high-risk and low-risk trials, the domains of the reporting study  were assessed using Chi-square tests. Furthermore, we compared the publication bias of high-risk and low-risk trials using the regression-based Egger test  with a vp < 0.05.All statistical analyses were performed using Stata software version 17.0 . Statistical significance was considered at a two-sided The initial search identified 285 citations, of which 83 were removed due to duplication, while 15 meta-analyses fulfilled the inclusion criteria after reviewing the title, abstract, and full text. However, two meta-analyses were excluded since they included inaccessible trial publications. The final study database contained 13 meta-analyses ,42,43,44® (Sweden), six obtained products from Sunstar® (Switzerland), and the rest of the trials obtained probiotics from other companies. Lactobacillus and Bifidobacterium were the two most common genera used.Among those 48 trials, most  adopted probiotic products from BioGaiap < 0.01; I2 = 0%; between-meta-analysis variance τ2 = 0.00).Overall, 23 trials with and 25 trials without sponsorship risk were collected from the included 13 meta-analyses. In the meta-regression, the direction of effects was standardized so that DSMD > 0 indicates a larger intervention effect estimate in trials with sponsorship bias versus without sponsorship bias. On average, treatment effects in trials with a high risk of sponsorship bias were more significant than those in low-risk trials . In addition, a higher proportion (65.7%) of trials at low risk performed blinding of outcome assessment, while a lower proportion (52.2%) of high-risk trials performed blinding of outcome assessment (p = 0.02). Though we did not observe significant statistical differences for items such allocation concealment, blinding of outcome assessment, and selective reporting, the proportion of low-risk studies reporting a better quality was higher than that of high-risk studies.The Cochrane Collaboration’s tool for assessing the risk of bias in randomized trials (RoB) is the most commonly used RCT quality evaluation tool. Considering previous publications which raised the hypothesis that poor quality might account for the conflicting results of clinical trials , we compp > 0.05) in both groups, which was confirmed by the funnel plot analysis . Overall, our results regarding the application of probiotics in dentistry displayed a significant difference in the effect size between trials with and without sponsorship bias, as seen in studies of pharmaceuticals , devicesThis study revealed that the effect size estimates of industry-sponsored trials were 0.6 times greater than those of trials without industrial sponsorships, indicating a sponsorship bias. Therefore, we suggest that the design, analysis, interpretation, and reporting of clinical trials investigating probiotics should follow the Consolidated Standards of Reporting Trials (CONSORT) to ensure study quality in trials of probiotics within dentistry.


Accurately estimating respiratory rate (RR) has become essential for patients and the elderly. Hence, we propose a novel method that uses exact Gaussian process regression (EGPR)-assisted hybrid feature extraction and feature fusion based on photoplethysmography and electrocardiogram signals to improve the reliability of accurate RR and uncertainty estimations. First, we obtain the power spectral features and use the multi-phase feature model to compensate for insufficient input data. Then, we combine four different feature sets and choose features with high weights using a robust neighbor component analysis. The proposed EGPR algorithm provides a confidence interval representing the uncertainty. Therefore, the proposed EGPR algorithm, including hybrid feature extraction and weighted feature fusion, is an excellent model with improved reliability for accurate RR estimation. Furthermore, the proposed EGPR methodology is likely the only one currently available that provides highly stable variation and confidence intervals. The proposed EGPR-MF, 0.993 breath per minute (bpm), and EGPR-feature fusion, 1.064 (bpm), show the lowest mean absolute error compared to the other models. Further, continuous signal measurement methods using PPG and electrocardiogram (ECG) sensors have been developed to estimate RR [An increased respiratory rate (RR) over long periods indicates abnormal cardiorespiratory functions. Therefore, it is essential to estimate RR for cardiopulmonary health. The normal RR for adults at rest is 12–20 beats per minute (bpm) . Althougonomical . Today, imate RR ,8,9,10. imate RR . PPG is Machine learning (ML) is also widely used to estimate response values in the biomedical field. Lee et al.  proposedFurthermore, the training dataset is used to predict the parameters of this Gaussian distribution. Because GPR is robust to noisy data and naturally regularizes, it resists overfitting and produces uncertainty estimates . The GPRThe proposed EGPR algorithm with hybrid feature extraction and weighted feature fusion is an excellent model for accurate RR and uncertainty estimations.As far as we know, this is the first study of the EGPR-based feature fusion model that expresses uncertainty in RR estimation by estimating confidence intervals (CIs).The proposed EGPR model shows to be powerful in practice for quickly estimating the RR in hospitals and healthcare centers, featuring better prediction performance and lower estimated mean absolute errors, and standard deviations, CIs.Here, we propose a novel methodology to estimate RR with high confidence using EGPR-assisted hybrid feature extraction and feature fusion based on PPG and ECG  signals. However, our limited data can lead to overfitting when using ML techniques . In geneThe study of this paper is composed as follows. In We use the dataset Beth Israel Deaconess Medical Center (BIDMC) randomly drawn from the MIMIC-II dataset . The BIDPPG signals are commonly used for estimating several bio-signals, such as the RR, HR, and blood pressure. Resampled wave signals are extracted using signal preprocessing techniques. In Step 1, the PPG signals are collected, as mentioned in In Step 5, we resample irregular PPG signals at 5 Hz using linear interpolation . In StepWe used the wavelet transform to extract features and AR coefficients  using thn; here, the mean function is denoted as n and RR estimation is closely related to converting to bpm by multiplying the respiratory rate by 4 for more than 15 s . For thiThe power spectral denotes a fast Fourier transform of the correlation coefficient and provides information regarding the correlation structure of the wave signal . The corIn this paper, we propose a feature fusion (FF) model using hybrid feature extraction, such as PPG-based PS features, PPG-based MF features, ECG-based PS features, and ECG-based MF features, to improve RR estimation reliability as shown in n denote the number of observations. Regression was used to randomly select a reference point kth feature. Hence, the probability As mentioned, we acquired a set of fuse features, resulting in higher-order features. However, we cannot guarantee that all features will provide helpful information to estimate RR. Also, fuse feature vectors can be overlapped. These overlapping feature vectors unnecessarily increase the complexity of the ML algorithm. As a result, overlapping feature vectors may not give satisfactory performance. Therefore, reducing the feature space size is essential while retaining only relevant features. In this study, we choose weighted feature vectors among high-dimensional features using robust neighbor component analysis (RNCA) . A diagoint γ(x) .(2)Dw=∑ce point . Here, wHere, we can use the regularization parameter lgorithm  as shownThe performance of the RNCA is highly dependent on the regularization parameter Algorithm 1: RNCAProcedure: Input   c . In pracThe expected value of  for the cIt is commonly used to train EGPR by finding local maxima for hyper-parameters First, we computes Using known hyper-parameters, probabilistic estimations for the Bayesian EGPR model need the probability density function f as follows:To obtain the joint density probability in the numerator, as shown in (16), it is necessary to use the mapping functions Here, the EGPR model assumes that each target Given The goal is to obtain an estimate Commonly used metrics to evaluate estimation accuracy are the mean absolute error (MAE). The MAE is the mean value of the sum of the absolute differences between the actual and estimated values. This study uses the MAE as a loss function, as given by ®2022  [The first thing to do was to extract resampled wave signals from dual signals. This process filtered out very high and low frequencies. Fifty-three long-resampled wave signals were used to design the proposed EGPR algorithm with hybrid feature extraction and weighted feature fusion process. These signals were randomly split into 80% for the training dataset and 20% for the testing dataset. Although mentioned in the previous section, we used the PPG signals 400 s to reconstruct the wave signal (12 × 32 windows) and get it back. We can then obtain 12 × 256 (=3072) data points from the long resampled wave signal (400 s) of the BIDMC data set. Finally, we acquired 12 × 53 (=636) samples with 256 dimensions of the feature, where 53 represents the number of patients. We calculated the reference RR from oral and nasal pressure signals based on the custom breath detection algorithm . The parMA, USA)  based onMA, USA)  using thWe acquired the mean absolute error (MAE) and standard deviation (SD) results using hybrid feature extraction such as PPG-based PS features, PPG-based MF features, ECG-based PS features, and ECG-based MF features. Each hybrid feature set was used to input machine learning algorithms such as SVR, LSTM, GBA, and the EGPR models. Therefore, we obtain 16 different MAE and SD results as shown in Next, we display the MAE results obtained using the dual signals based hybrid feature extraction and arithmetic fusion (AF) and hybrid feature extraction and feature fusion (FF) as in We display the MAE and SD results acquired for PPG-based SVR-MF, PPG-based SVR-PS, PPG-based LSTM-MF, and PPG-based LSTM-PS concerning the reference RR values as illustrated in As illustrated in We used ANOVA  experimep-value of 5.55 p-value, 5.55p-value of 1.82The null hypothesis of ANOVA is that there is no difference in the mean. The alternative hypothesis is that the means are not the same. Therefore, we used multiple comparisons to determine different and average group results. One-way ANOVA denotes an easy example of a linear model, given that p-value of 0.037 is less than the significance value (0.05) in the 6th column of p-value of 6.25p-value of 3.45p-value of 3.85Using the PPG signals, we also compare the MAEs of all methodologies based on ANOVA experiments as shown in Notably, this is the first study that combines EGPR with hybrid feature extraction and weighted feature fusion methodology to estimate RR and uncertainty from ECG and PPG signals. As shown in Furthermore, we noticed that using the dual signals (ECG and PPG), the proposed EGPR-MF model showed the lowest MAE results compared to the other models, such as SVR-MF, LSTM-MF, and GBA-MF. The EGPR-PS model also exhibited low MAE, 1.5 and 1.6 (bpm), and a very stable standard deviation (SD). We confirmed that the EGPR-AF model exhibited lower MAE than other methods showing simple mean results using PPG-based PS features, PPG-based MF features, ECG-based PS features, and ECG-based MF feature extraction models. In addition, we found that the proposed feature fusion (FF) model showed lower MAE results than the arithmetic fusion (AF) method while increasing the reliability of RR estimation. These results indicate that the proposed models are optimized to enable an exact balance between data fit and smoothness.In addition, it shows that the proposed models are excellent algorithms because they are resistant to overfitting and provide well-corrected prediction errors based on small samples. Finally, we confirm that the fusion feature extraction process performed good respiration rate estimation. We predict confidence intervals (CIs) using ECG-based EGPR-MF, ECG-based EGPR-PS, PPG-based EGPR-MF, PPG-based EGPR-PS, and EGPR-based function methods to express uncertainty in RR estimation for the first time in the world. Although we experimented with dual signals obtained from the BIDMC datasets , this stIn conclusion, we proposed a novel technique that uses PPG and ECG signals based on EGPR-assisted hybrid feature extraction and feature fusion to improve the reliability of accurate RR estimations. The EGPR, a non-parametric approach, provided a significantly better RR estimation accuracy and uncertainty estimation than parametric models such as SVM and GBA. First, we obtained the input data dimension using the power spectral (PS) features based on an autocorrelation function and then segmented the signal to increase the input data. We then used the multi-phases (MF) feature extraction model based on the AR method, MWL, wavelet packet, and MODWT to compensate for insufficient input data. Therefore, we acquired hybrid feature extraction such as PPG-based PS features, PPG-based MF features, ECG-based PS features, and ECG-based MF features. Then, we fused four different feature sets and chose features with high weights using a robust neighbor component analysis (RNCA). In addition, the proposed EGPR algorithm provides a confidence interval (CI) representing the uncertainty . Therefore, the proposed EGPR algorithm, including hybrid feature extraction and weighted feature fusion, is an excellent model with improved reliability for accurate RR estimation. In the future, we plan to increase the number of ECG and PPG records to improve our RR estimates, which vary widely across age groups and genders. Finally, the proposed model can be used to design a framework for improving telemedicine monitoring and optimizing clinical decision support frames.


To evaluate the prognostic impact of the lowest level of tumor location for upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy (RNU).Data were collected from patients with UTUC treated with RNU (01/2005- 06/2020) at a single center in Taiwan. Patients were stratified by the lowest level of tumor location into three groups: renal pelvis only (RPO), above upper ureter (AUU), and below upper ureter (BUU). We compared characteristics between groups and examined the association of the lowest level of tumor involvement with intravesical recurrence (IVR), systemic metastasis (SM), and cancer-specific mortality (CSM).in situ, and variant histology were significantly different across different tumor locations. BUU had worse five-year intravesical recurrence (IVR), systemic metastasis (SM) and cancer-specific mortality (CSM) . In multivariable models, the lowest level of tumor involvement was an independent predictor of IVR (AUU hazard ratio (HR) = 1.52, p = 0.007; BUU HR = 1.75, p < 0.001), but only BUU was an independent predictor of SM  and CSM .Overall, 1239 patients  were enrolled. Concurrent bladder cancer, multifocality, tumor architecture, lymphovascular invasion, carcinoma The lowest level of tumor involvement in UTUC, especially BUU, was associated with a higher risk of IVR, SM and CSM. Assessment of the lowest level of tumor involvement after RNU may help identify patients who require more intensive follow-up. Upper urinary tract urothelial carcinoma (UTUC) is a cancer of the renal pelvis and ureter lining. The incidence and biological characteristics of UTUC differ according to ethnicity and geographic region . The incThe incidence and disease pattern of UTUC in Asia differs from those in Western countries. UTUC is much more common in Asian populations, and accounts for more than 10% of all UCs in Asia , 5. FurtRadical nephroureterectomy (RNU) with bladder cuff excision is the standard treatment for patients with localized UTUC , 6. For In the 2010s, studies on patients with UTUC followed by RNU, renal pelvis tumors (RPT), and ureteral tumors (UT) did not find any significant difference in disease recurrence and mortality after adjustment for other pathologic covariates , 12. In This study included patients with clinically localized UTUC who underwent RNU at our institution between January 2005 and June 2020, and excluded patients who underwent nephron-sparing surgery and those with non-urothelial carcinoma histology. Finally, 1239 patients with available clinical and pathological data were included in the analysis. All patients underwent preoperative cystoscopy or computed tomography (CT) to determine the presence of concurrent bladder tumor or distant metastasis. Demographic data, such as age, sex, smoking history, concurrent bladder cancer (BCa), adjuvant therapy, disease recurrence outcome, and death, were obtained using chart review. Patients were separated into three different groups according to the lowest level of tumor location . This retrospective study was approved by the Institutional Review Board of our hospital (IRB number: 202201112B0).in situ (CIS) were assessed by a uropathologist on each representative slide.The diagnosis of UC was confirmed by histological analysis, and variant histology was also included in this study. Genitourinary pathologists reviewed all slides according to strictly identical criteria and were blinded to the clinical outcomes. Tumor grading was performed according to the 2004 and 2016 World Health Organization classifications . Tumors Our institutional follow-up protocol included postoperative fiber cystoscopy every three months, and renal ultrasonography every six months to assess the contralateral urinary tract. These procedures were performed during the first two years, every six months during the third year, and then annually thereafter. Abdominal CT was performed either annually or depending on the patient’s condition to assess lymph node status and local or regional recurrence of the tumor. Bone scanning, chest CT, and magnetic resonance imaging (MRI) were performed when clinically indicated. The use of postoperative bladder instillation was empirically decided by the individual urologist. Intravesical recurrence (IVR) was defined as post-nephroureterectomy urinary bladder tumor recurrence. Systemic metastasis (SM) was defined as a local recurrence or distant metastasis. Local recurrence was defined as locoregional recurrence in the ipsilateral surgical field outside the urinary tract, and distant metastasis was defined as disease recurrence outside the urinary tract and out of the locoregional surgical field. Disease in the urinary bladder or contralateral upper urinary tract was not considered indicative of SM. CSM was defined as a local recurrence or distant metastasis at the time of death.SPSS software (v.21) was used for statistical analyses. Chi-square or two-sample t-tests were used to analyze the distribution of between the two groups, and for intergroup comparisons. The Kaplan–Meier method with log-rank test was used to compare event-free survival between the groups. Multivariate Cox regression analysis was used to identify independent prognostic factors for oncologic outcomes. Statistical significance was set at p < 0.05, as shown in Of 1239 patients, tumor(s) located in the renal pelvis only (RPO), above upper ureter (AUU), and below upper ureter (BUU) were presented in 542 (43.7%), 260 (21%), and 437 (35.3%) patients, respectively Figure 1In our study, 342 (27.6%) patients experienced IVR. Kaplan–Meier analysis, stratified by the lowest level of tumor involvement, showed that BUU was associated with a significantly lower five-year bladder recurrence-free survival than were RPO and AUU Figure 2During the follow-up period, distant metastases were observed in 289 (23.3%) patients. Kaplan–Meier analysis, stratified by the lowest level of tumor involvement, showed that BUU was associated with significantly lower five-year metastasis-free survival than was RPO Figure 3Lastly, cancer-specific death from UTUC occurred in 89 (16.4%), 46 (17.7%) and 96 (22%) patients in the RPO, AUU, and BUU groups, respectively. Kaplan–Meier analysis of cancer-specific survival between the three lowest levels of tumor involvement revealed no statistical difference Figure 4According to the latest EAU Guidelines, age, sex, smoking, a history of BCa, tumor stage, tumor grade, LVI, CIS, and variant histology are reported as significant prognostic factors for the development of UTUC. In addition to these well-established factors, tumor location has also been identified as a risk factor for poorer oncological outcomes . SeveralIn this study, we found that the lowest level of tumor involvement significantly correlated with higher IVR. Audenet et al. reported that upper tract cancer and subsequent BCa are clonally related . We specWe observed that the SM and CSM rates of RPO and AUU were similar, whereas that of BUU was significantly higher. The difference in the SM and CSM rate between BUU and the other two groups (RPO and AUU) might result from the different anatomic structures surrounding the tumors. Waseda et al. suggested that the thin adventitia comprised of abundant blood plexus and lymphatic vessels, can advance tumor invasion . HoweverA limitation of this study is that it was a retrospective cohort study in a single institution with physicians and patients related protocol deviated bias on surgical technique or density of follow-up duration. However, most patients were managed and followed according to the institutional protocol in this study. In addition, real-world patients with advanced disease may receive adjuvant chemotherapy without the same cycles because of patient preferences and tolerance of side effects. However, we included a relatively large cohort with an adequate follow-up duration, and carefully examined the prognostic impact by considering the established prognostic factors.Our results indicate that a detailed classification of ureteral tumor location provides more prognostic information for physicians to set a more intensive follow-up and adjuvant therapy protocol. Further multi-institutional validation regarding the level of tumor involvement in patients with UTUC should be performed based on this finding, since it might improve precision clinical care.The lowest level of tumor involvement in UTUC, especially BUU, is an independent predictor of IVR, SM and CSM. Assessment of the lowest level of tumor involvement after RNU may help identify patients with a high risk of cancer recurrence who require more intensive follow-up or early administration of intravesical instillation and adjuvant therapy.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Chang Gung Medical Foundation Institutional Review Board. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.Conception and design, Y-CH and H-LL; acquisition of data, Y-CH, H-JW, M-TS, Y-CC, Ye-TC, Yu-TC, C-HK, H-YL, Y-LC, P-HC and H-LL; analysis and interpretation of data, Y-CH and H-LL; drafting of the manuscript, Y-CH and H-LL; critical revision of the manuscript for important intellectual content, Y-CH and H-LL; statistical analysis, H-YL, Y-LC and H-LL; obtaining funding, H-LL; administrative, technical, or material support, Y-CH and H-LL; supervision, H-LL. All authors contributed to the article and approved the submitted version.This study was supported by grants from Chang Gung Memorial Hospital Research Project Grant CMRPG8K1091, CMRPG8K1092 and Ministry of Science and Technology, Taiwan (MOST-110-2314-B-182A-050-MY3).We thank Chun-Chien Hsu, Weng-Chou Yang, Wei-Ching Lee for their efforts about perioperative care and monitoring of their UTUC patients contributed in this cohort. We thank Hsin-Yi Chien, Chih-Yun Lin and the Biostatistics Center, Kaohsiung Chang Gung Memorial Hospital.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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