Infection caused by Streptococcus pneumoniae, mainly invasive pneumococcal disease (IPD) and pneumococcal pneumonia (PP), are a major public health problem worldwide. This study investigated population-based incidence and risk of PP among Catalonian persons ≥ 50 years-old with and without specific underlying conditions/comorbidities, examining the influence of single and multi-comorbidities in the risk of suffering PP.Population-based cohort study involving 2,059,645 persons ≥ 50 years-old in Catalonia, Spain, who were retrospectively followed between 01/01/2017-31/12/2018. The Catalonian information system for development of research in primary care (SIDIAP) was used to establish baseline characteristics of the cohort (comorbidities/underlying conditions), and PP cases were collected from discharge codes (ICD-10: J13) of the 68 referral Catalonian hospitals.Global incidence rate (IR) was 90.7 PP cases per 100,000 person-years, with a 7.6% (272/3592) case-fatality rate (CFR). Maximum IRs emerged among persons with history of previous IPD or all-cause pneumonia, followed by haematological neoplasia (475.0), HIV-infection (423.7), renal disease (384.9), chronic respiratory disease (314.7), liver disease (232.5), heart disease (221.4), alcoholism (204.8), solid cancer (186.2) and diabetes (159.6). IRs were 42.1, 89.9, 201.1, 350.9, 594.3 and 761.2 in persons with 0, 1, 2, 3, 4 and ≥ 5 comorbidities, respectively. In multivariable analyses, HIV-infection , prior all-cause pneumonia , haematological neoplasia , chronic respiratory disease  and prior IPD  were major predictors for PP.Apart of increasing age and immunocompromising conditions , history of prior IPD/pneumonia, presence of chronic pulmonary/respiratory disease and/or co-existing multi-comorbidity  are major risk factors for PP in adults, with an excess risk near to immunocompromised subjects. Redefining risk categories for PP, including all the above-mentioned conditions into the high-risk category, could be necessary to improve prevention strategies in middle-aged and older adults. Young children, individuals with at-risk or immunocompromising conditions and elderly people support the greatest burden of pneumococcal disease, with higher incidence and mortality in these persons  registered in the electronic primary care medical records of each cohort member at baseline:Chronic pulmonary/respiratory disease: it included chronic bronchitis/emphysema (J41-J44), asthma (J45-J46) and/or other chronic pulmonary diseases .Chronic heart disease: it included congestive heart failure (I50), coronary artery disease  and/or other chronic heart diseases .Diabetes mellitus (E10-E14).Chronic liver disease: it included chronic viral hepatitis (B18), cirrhosis (K74) and/or alcoholic hepatitis (K70)).Alcoholism .Smoking (F17).Anatomic or functional asplenia .Primary immunodeficiency (D80-D84).HIV infection (B20-B24).Chronic renal disease: it included nephrotic syndrome  and severe chronic renal failure (N18-N19 with glomerular filtration rate ≤ 30 ml/min).Cancer: it included solid organ or haematological neoplasia (C00 to C97) diagnosed within previous 5 years.Immunosuppressive therapy: it included long-term immunosuppressive medication and/or radiotherapy in the previous 12 months (coded according to specific SIDIAP codes).


Outpatient parenteral antimicrobial therapy (OPAT) is administering intravenous antibiotics in the outpatient setting. Herein we wish to understand the Atlanta VAMC (AVAMC) home OPAT population, infection details, and risk factors for hospital readmission, adverse drug events (ADEs), and clinical failure.Medical records of AVAMC veterans receiving home OPAT  January 1, 2019 and June 30, 2022 were reviewed. Data collected included: demographic and co-morbidity data, OPAT indication/infection type, microbiological information, presence of surgical debridement, and antimicrobial selection and duration of therapy.Clostridioides difficile infection. Other information include modification of OPAT plan (drug or duration), patient follow-up visit occurrence, re-hospitalization, and clinical resolution of infection. Univariate regression analyses were conducted on a subset of patients with musculoskeletal (MSK) infections .Outcomes included ADEs such as venous access events, laboratory abnormalities, and S. aureas was the predominant bacteria isolated (20%). See included table for full details.A total of 149 veterans were reviewed, with median age 66 years, 92% male, and 44% white race. Median CCI score was 5, and 80/149 (54%) patients had diabetes. The majority of infections were bone infections (30%), followed by diabetic foot osteomyelitis (24%). Methicillin-sensitive In the full cohort, 100/149(68%) had clinical resolution at 6 months and 20/149 (13%) had ADE during therapy. Rehospitalization occurred in 29 (20%) pts. Diabetes was associated with increased risk of failure -- Risk Ratio (RR) 1.68 (95% CI 1.01-2.77). Patients with clinic follow-up had a RR of 0.39 (95% CI: 0.21-0.73) for rehospitalization versus pts without follow-up.For pts with diabetes in the MSK group (N=97), risk of failure was 1.50x higher than those without diabetes (95% CI: 0.67-3.34).The RR for rehospitalization was 0.23 (95% CI: 0.06-0.82) for patients who received follow-up compared to patients who did not receive follow-up.AVAMC OPAT population demographic data, N = 149The AVAMC OPAT cohort is an older group with largely MSK-related infections and MSSA. Few ADEs occurred, and clinical failure remained high.All Authors: No reported disclosures


GRT-R910 , a self-amplifying mRNA (samRNA) vaccine expressing the spike protein plus T-cell epitopes of SARS-CoV-2 (D614G variant), was tested in a phase 1 study as a booster in healthy adults.This phase 1 open-label, dose escalation study enrolled healthy adults who previously received an approved mRNA COVID-19 vaccine series. Groups of 10 adults aged 18-60 years were boosted with GRT-R910 at 3 or 6 mcg. Adults > 60 years were boosted with GRT-R910 at 3, 6, or 10 mcg. All participants > 60 years in the 6 and 10 mcg dose groups received prior mRNA COVID-19 boosters; none in other groups had prior boosts. Study boosts occurred at least 112 days after completion of primary series/boost of authorized mRNA COVID-19 vaccine or prior SARS-CoV-2 infection. Solicited local and systemic reactogenicity events were collected for 7 days, unsolicited adverse events for 28 days, and serious adverse events (SAEs) for 366 days post-vaccination. Humoral  are being assessed at multiple time points over 1 year after study vaccination. Participants who self-reported SARS-CohV-2 infection or receipt of non-study COVID-19 booster during the study were censored in the immunogenicity analyses.No severe local reactogenicity events were observed. Overall, out of 48 enrolled across all groups, 8 reported at least 1 severe systemic reactogenicity event (figure 1). Most severe systemic reactogenicity events were transient, with most graded severe for 1 day or less. No SAEs have been reported. Neutralizing antibody responses remain durable up to 1 year after 3 and 6 mcg boosts in adults 18-60 years (figure 2) and up to 6 months after 3, 6, and 10 mcg boosts in adults > 60 years .GMT= geometric mean titer; Boxes and horizontal bars denote interquartile range (IQR) and median AUC, respectively. Whisker endpoints are equal to the maximum and minimum values below or above the median +/- 1.5 x IQR. All participants in the 3 μg GRT-R910, 18-60 yo and 6 μg GRT-R910, 18-60 yo groups received a mRNA two dose primary COVID-19 vaccination series prior to enrollment. None were previously SARS-CoV-2 infected.GMT= geometric mean titer; Boxes and horizontal bars denote interquartile range (IQR) and median AUC, respectively. Whisker endpoints are equal to the maximum and minimum values below or above the median +/- 1.5 x IQR. All participants in the 3 μg GRT-R910, > 60 yo group received a mRNA two dose primary COVID-19 vaccination series prior to enrollment. All participants in the 6 μg GRT-R910, > 60 yo and 10 μg GRT-R910, > 60 yo groups received a mRNA two dose primary COVID-19 vaccination series plus a mRNA booster vaccine prior to enrollment. Two participants each in the 6 μg GRT-R910, > 60 yo and 10 μg GRT-R910, > 60 yo groups had a previous COVID-19 infection at enrollment (green dots). D1, D15, D29 testing for Groups 9 and 10 are planned against BA.4/5.While transient systemic reactogenicity with GRT-R910 as a booster was observed, no safety signals were identified. Preliminary immunogenicity data demonstrate durable neutralizing antibody responses for 6-12 months in both younger and older age groups. Forthcoming T cell response data will aid in assessing the immunogenicity of this novel vaccine.Nadine Rouphael, MD, Icon, EMMES, Sanofi, Seqirus, Moderna: Advisor/Consultant Anna Wald, MD, MPH, Aicuris: Advisor/Consultant|Bayer: Advisor/Consultant|Curevo: Participation on Data Safety Monitoring Board|GSK: Grant/Research Support|Sanofi: Grant/Research Support|UpToDate: Royalties or licenses Pedro Garbes, MD, Gritstone bio, Inc.: Employee|Gritstone bio, Inc.: Employee|Gritstone bio, Inc.: Stocks/Bonds|Gritstone bio, Inc.: Stocks/Bonds Karin Jooss, PhD, Gritstone bio: employee|Gritstone bio: Stocks/Bonds Andrew Allen, MD, PhD, Gritstone bio: Board Member|Gritstone bio: Ownership Interest|Gritstone bio: Stocks/Bonds Amanda Eaton, MBA, Moderna: Grant/Research Support David M. Koelle, MD, Curevo Vaccines: Board Member|MaxHealth LLC: Board Member|Sanofi Pasteur: Grant/Research Support Daniel F. Hoft, MD, PhD, Moderna: Advisor/Consultant|Poolbeg: Advisor/Consultant


Coccidioidomycosis is an endemic mycosis in the southwestern United States. While most infections are mild or asymptomatic, severe cases are associated with high morbidity and mortality. We aimed to evaluate the clinical outcomes of patients admitted to the intensive care unit (ICU) with proven culture-positive coccidioidomycosis.Coccidioides spp. culture within a multi-healthcare system between 10/01/2017 – 07/01/2022. Clinical information was collected by chart review.After institutional review board approval, we retrospectively included ICU patients with positive Coccidioides spp. culture, 145 patients required ICU stay. The median age was 51 (32-62), with 100 (68.9%) male, 56 (38.6%) White non-Hispanics, and 25 (17.2%) Blacks. Fifty-seven (39.3%) received azole antifungals before hospitalization. Seventy-two (49.7%) had another fungal, bacterial, or viral infection during their hospitalization, and 41 (28.3%) had extrapulmonary coccidioidomycosis. The majority, 131 (90.3%), received antifungal therapy during their hospital stay. The median hospital length of stay was 18 days (10-37). Almost half (48.3%) died during the study period, with liver cirrhosis and age ( >60 years) resulting in statistically significant mortality, 12/13 (92.3%), p-value < 0.001, and 31/43 (72.1%) p-value =0.001, respectively. Mechanical ventilation and/or intravenous vasopressor support was associated with a high risk of mortality 66/113 . Failure to receive antifungal therapy before ICU admission was associated with increased mortality, 46/70 .Of the 392 hospital encounters with positive Patients with coccidioidomycosis admitted to the ICU face an increased risk of mortality. Risk factors associated with ICU mortality include advanced age, cirrhosis, and delay in the administration of antifungal therapy. Future studies are needed to evaluate these risks further.Tirdad Zangeneh, DO, AiCuris: Grant/Research Support Mohanad Al-Obaidi, MD, MPH, La Jolla Pharmaceuticals: Honoraria


Immunotherapeutic targets in multiple myeloma (MM) have variable expression height and are partly expressed in subfractions of patients only. With increasing numbers of available compounds, strategies for appropriate choice of targets (combinations) are warranted. Simultaneously, risk assessment is advisable as patient’s life expectancy varies between months and decades.We first assess feasibility of RNA-sequencing in a multicenter trial . Next, we use a clinical routine cohort of untreated symptomatic myeloma patients undergoing autologous stem cell transplantation  64 months) to perform RNA-sequencing, gene expression profiling (GEP), and iFISH by ten-probe panel on CD138-purified malignant plasma cells. We subsequently compare target expression to plasma cell precursors, MGUS (n=59), asymptomatic (n=142) and relapsed (n=69) myeloma patients, myeloma cell lines (n=26), and between longitudinal samples (MM vs. relapsed MM). Data are validated using the independent MMRF CoMMpass-cohort .de novo (LfM-HRS) defined risk scores. LfM-HRS delineates three groups of 40%, 38%, and 22% of patients with 5-year and 12-year survival rates of 84% (49%), 67% (18%), and 32% (0%). R-ISS and RNA-sequencing identify partially overlapping patient populations, with R-ISS missing, e.g., 30% (22/72) of highly proliferative myeloma.RNA-sequencing is feasible in 90.8% of patients (GMMG-MM5). Actionable immune-oncological targets (n=19) can be divided in those expressed in all normal and >99% of MM-patients , those with expression loss in subfractions of MM-patients , aberrantly expressed in MM , and resistance-conveying target-mutations e.g., against part but not all BCMA-directed treatments. Risk is assessable regarding proliferation, translated GEP-  and RNA-sequencing based assessment of risk and targets for first choice treatment is possible in clinical routine. Clinical signs and symptoms relate to displacement of normal hematopoiesis, generation of osteolytic bone disease, and renal impairment . TreatmeMM is treated by combination treatment whenever possible , 13: effThe situation is different for immune-oncological therapies in development or recently approved. Bispecific antibodies or CAR-T cells against e.g., BCMA, GPRC5D, or FCR5H show single agent remission rates of 60-80% , 30–38. Presence or absence and height of target expression is an evident selection criterion for treatment choice, as shown, e.g., for CD38  and GPRCin situ hybridization [iFISH])  incorporating clinical factors  and molecular alterations in malignant plasma cells , t assessed by interphase fluorescence [iFISH]) . Innovat[iFISH])  or “scor[iFISH]) –52.de novo risk score by RNA-sequencing (termed LfM-HRS). Findings are validated in the independent MMRF CoMMpass-cohort (n=767 patients).In this manuscript, we first assess applicability of RNA-sequencing in the GMMG-MM5 multicenter phase III clinical trial setting (604 patients) based on our low-input RNA-sequencing protocol . Secondl22.16 cells (Patients (n=604) were included in the prospective GMMG MM5-trial , 54 betw6 cells .iFISH using cytospins from CD138-purified plasma cells was performed centrally . Data could be obtained for 556/573 patients with available bone marrow aspirates (97%) and 556/559 patients with available CD138-purified plasma cells, respectively (99.5%). The median proportion of malignant plasma cells determined per iFISH, i.e., the highest percentage of a chromosomal aberration, was 95% .Samples for RNA-extraction followed by quality control were collected over two weeks and subjected to GEP by DNA-microarrays. In total, n=458 transcriptome datasets are available, i.e., 81.9% of patients with available CD138-purified plasma cells. Of these, two patients were excluded from further analysis for not fulfilling the trial’s inclusion criteria. Gene expression profiling could not be performed in 53 cases due to low RNA quality (9.5%) and further 48 cases (8.6%) in which not enough RNA was available .Using our standardized RNA-sequencing protocol  , asymptomatic , symptomatic, therapy-requiring myeloma , relapsed myeloma , as well as healthy donors (n=10) as comparators were included in the study approved by the ethics committee  after written informed consent. For patient characteristics, see + memory B-cells (n=4) were FACS-sorted and polyclonal plasmablasts (n=4) were in vitro differentiated as described  and myeloma cells were purified using anti-CD138 microbeads . Peripheral blood CD27escribed . A totalRNA-sequencing data of 52/142/535/69 patients with MGUS/AMM/MM/MMR and 26 HMCLs were used. GEP-data of 534 patients with MM were used for score definition and validation .2.3Independent validation of risk assessment and target identification was performed using the Multiple Myeloma Research Foundation (MMRF) CoMMpass trial (NCT01454297), i.e., n=767 previously untreated myeloma patients with RNA-sequencing data available (release 13).2.42.4.1RNA was extracted using the Qiagen AllPrep DNA/RNA kit  according to the manufacturer’s instructions. Quality control and quantification was performed using an Agilent 2100 bioanalyzer .2.4.2RNA-sequencing was performed as published . In brie2.4.3Gene expression profiling (GEP) using U133 2.0 plus arrays  was performed as published , 56–59. 2.5iFISH analysis was conducted on CD138-purified plasma cells using probes for chromosomes 1q21, 5p15, 5q31 or 5q35, 8p21, 9q34, 11q22.3 or 11q23, 13q14.3, 15q22, 17p13, 19q13, IgH-breakapart, as well as translocations t, t, and t according to the manufacturer’s instructions  and data were analyzed as published .2.6https://www.r-project.org/) and Bioconductor (https://www.bioconductor.org/) versions 3.3.2 and 3.4 (score implementation) and versions 3.4.4 and 3.6 .GEP and RNA-seq analysis were performed as previously described , 51, 58 Overall (OS) and event-free (EFS) survival were investigated for symptomatic multiple myeloma undergoing high-dose therapy using Cox’s proportional hazard model as published .Survival curves were computed with nonparametric survival estimates for censored data using the Kaplan-Meier method . DiffereEffects were considered statistically significant if the P-value of corresponding statistical tests was below 5%. For comparisons of parameters , or ADC, antibody-radio-conjugates, bispecific antibodies, or CART-products in trials .Based on the expression pattern, we divided targets in those expressed in normal and almost all (>99%) malignant plasma cell samples , those constitutively expressed in all normal plasma cells with expression loss in a subfraction of malignant plasma cells , and targets aberrantly expressed in malignant plasma cells, i.e., not expressed in normal bone marrow plasma cells . CD70 is expressed in half of BMPC decreasing to 24.5% in MM. Of assessed targets, CD1B is not expressed, CD25 at very low frequency and expression height only (2.9%). Results for expressed targets are summarized in RNA-sequencing allows detection of somatic variants and mutated transcripts; e.g., for BCMA, we found in 25% of patients coding non-synonymous single nucleotide variants present  with a median allele frequency of 1 in patients harboring the aberration. If present, a resistance conveying mutation would thus have been detected but expectedly could not, as none of the patients has been treated with BCMA-targeting agents prior to analysis.Targets expressed in all myeloma patients show high inter-patient variation, e.g., 6.8 (CD38), 6.9 (BCMA), 9.9 (GPRC5D), and 10.9 (FCRH5) log-fold variation . Of targets aberrantly expressed in malignant plasma cells, i.e., not expressed in BMPC , NY-ESO1 shows significantly higher expression from MGUS to MMR. Regarding a potential use of immune-oncological agents in early-stage myeloma, we assessed differences between AMM to MM to MMR, (instead of MGUS-AMM-MM-MMR) yielding similar results , BCMA, GPRC5D, FCRH5, TACI, CD74, CD44, CD37 and CD79B, seven show significant lower expression from MGUS to MMR , i.e., SLAMF7 (CS1), BCMA, GPRC5D, FCRH5, TACI, CD74, and CD37. If adjusted for multiple testing by Benjamini-Hochberg correction, significance is maintained for BCMA, FCRH5, TACI, CD74, and CD37. Targets with expression loss in a subfraction of malignant plasma cells of previously untreated patients  are all significantly lower expressed from MGUS to MMR , a change in expression of any of the investigated antigens could be found in 56 patients (88.9%) with both losses and gains occurring ; median OS was 35 vs. 86 vs. 130 months , we “translated” these. The RS-, UAMS70- and SKY92-score delineated a population of 10%, 19%, and 13% of high risk and 67% of medium risk (Rs-score) patients. High- (medium) risk patients showed significantly inferior EFS and OS, i.e. the RS-score - RSGEP and RNA-sequencing based scores showed a concordance of 71.7% - 92.5% regarding patients identified as high risk (3.4de novo generated a RNA-sequencing based proliferation index (RPI). In comparison to normal bone marrow plasma cells or non-proliferating memory B-cells, malignant plasma cells showed a significant and stage-dependent increase from early disease MGUS vs. asymptomatic vs. symptomatic, therapy-requiring multiple myeloma , to 2nd (61%), 3rd 38%, 4th(15%) and 5th line (1%). Furthermore, use of γ-secretase inhibitors  . This first relates evidently to targets not expressed in all myeloma patients, as being either lost in a subfraction of malignant plasma cells, i.e., BAFF-R, CD19, CD20, and CD22, or gained, i.e., NY-ESO1/2, MUC1, and CD30. Secondly, it relates to high inter-patient variation of target expression. Considering targets expressed in all myeloma patients, 10.9 log-fold (FCRH5) differences were found. With reported relation of expression height and response for CD38  and GPRCacestat)  in case acestat) . It exemdifferent BCMA-targeting agents. As downregulations and mutations discussed here occur primarily under selection pressure of the respective treatment and, in part, different aberrations occur in a subclonal manner . Genes with stage-dependent loss of expression, like CD19, CD22, and BAFF-R, showed high dynamics with both gains and losses of expression occurring. The cancer testis antigens MUC1 and NY-ESO1/2 were predominantly gained in MMR. These findings are in line with a subclonal architecture in myeloma leading to clonal tides  and spat4.3Introduced in myeloma research in 2002  and 2011®, Signal Genetics™   , suggestart.org)  or the Mart.org) . But thea priori evident.Immediate usefulness would be perceived if either response could be predicted, or targets selected in for personalized treatment. Despite factors associated with response have been identified , 25, it GEP/NGS-based approaches would be significantly fostered by the use of appropriated clinical trial designs, especially for regulatory and approval purposes , 95 espe5RNA-sequencing is applicable in 90% of patients (comparable to iFISH), is of overall equal predictive power as the current gold standard R-ISS, but identifies a further fraction of myeloma patients, e.g., with highly proliferative myeloma cells. It allows personalized target identification for immune-oncological drugs based on presence and height of expression. RNA-sequencing used for “educated first guess” could be considered as “IOnc drug and risk advisor” in analogy to other decision tools.https://www.ebi.ac.uk/arrayexpress/, E-MTAB-4715; https://www.ebi.ac.uk/arrayexpress/, E-MTAB-4717; https://www.ebi.ac.uk/arrayexpress/, E-MTAB-5212; https://www.ebi.ac.uk/arrayexpress/, E-TABM-937; https://www.ebi.ac.uk/arrayexpress/, E-TABM-1088; https://www.ebi.ac.uk/ena, PRJEB37100; https://www.ebi.ac.uk/ena, PRJEB36223.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: Patients were included in the study approved by the ethics committee of the medical faculty of the Ruprecht Karls University Heidelberg, Germany,  after written informed consent. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.ME-R: Conceptualization, Formal Analysis, Investigation, Methodology, Validation, Writing – review & editing. SB: Formal Analysis, Writing – review & editing. VB: Writing – review & editing, Investigation, Methodology. HS: Investigation, Writing – review & editing. UB: Investigation, Writing – review & editing. CS: Investigation, Writing – review & editing. MH: Investigation, Writing – review & editing. KW: Investigation, Writing – review & editing. TH: Investigation, Writing – review & editing, Methodology. MR: Investigation, Writing – review & editing. HG: Investigation, Writing – review & editing, Funding acquisition. AJ: Investigation, Writing – review & editing. KM: Investigation, Writing – review & editing. EB: Investigation, Writing – review & editing. EM: Investigation, Writing – review & editing. KD: Investigation, Writing – review & editing. JM: Investigation, Writing – review & editing. KV: Investigation, Writing – review & editing. AS: Conceptualization, Formal Analysis, Funding acquisition, Investigation, Supervision, Writing – original draft. DH: Conceptualization, Formal Analysis, Funding acquisition, Investigation, Methodology, Supervision, Validation, Writing – original draft.


Bloodstream infections (BSIs) are major causes of morbidity and mortality for which prior analyses and validated scoring tools have attempted to stratify risk. This study investigated institutional and epidemiologic predictors of mortality with Gram-negative BSIs to better identify targeted antimicrobial stewardship efforts to improve outcomes.All patients with aerobic, monomicrobial, Gram-negative BSIs admitted and discharged from our academic medical institution between July 2022 and March 2023 were included. Data collected included patient demographics, microbiological data, clinical management, length of stay, ID consultation, and clinical outcomes . Univariate and multivariable logistic regression models were performed to identify variables that were primary drivers for inpatient mortality.E. coli (37.8%), K. pneumoniae (11.2%), P. aeruginosa (10.0%), S. marcescens (8.5%), and E. cloacae (6.2%). The majority (65.3%) were community acquired infections with 41.7% in the ICU, and 46.7% received an infectious diseases consult. The overall mortality was 14.7% with the highest mortality due to P. aeruginosa (34.6%) followed by S. marcescens (27.3%), K. pneumoniae (13.8%), E. cloacae (12.5%), and E. coli (8.2%). Overall mortality was significantly associated with several parameters in a univariate analysis (Table 1). In multivariable regression analysis hospital-acquired infection (0=0.002), cancer (p=0.012), qPitt > 2 (p< 0.001), SBP< 100 or vasopressor use at 72-96 hrs after positive blood culture (p=0.017) was associated with increased risk of mortality. The only parameter to reduce mortality within the multivariable regression analysis, by more than two-fold, was ID consultation (p=0.022).Overall, 259 patients  were identified. The most common organisms were Parameters Associated with Mortality in Univariate AnalysisThe only factor found to significantly reduce mortality was formal ID consultation. ID consultation should be considered part of routine care for all patients with Gram-negative bacteremia.Katie B. Olney, PharmD, BCIDP, The Society of Infectious Diseases Pharmacists (SIDP): Grant/Research Support


Prior literature establishes bidirectional associations between suicide and substance use disorders (SUDs), particularly opioid use disorder (OUD). However, the context of mental health services utilization remains under-investigated. This analysis examined patterns of mental health services utilization in patients with SUDs and suicidality, identified associated risk factors, and evaluated the impact of patient engagement on subsequent mental health outcomesSee above.Electronic health records (EHRs) derived from 7 health systems across New York City between 2010-2019 were analyzed. Suicidality was identified as any ICD-9/10 diagnosis of suicide attempt, suicidal ideation, or self-harm injury. SUDs were identified as any opioid, cannabis, cocaine, hallucinogen, inhalant, sedative/hypnotic/anxiolytic, amphetamine, or other substance abuse or dependence. Quasi-Poisson regression adjusted for age, gender, and chronic diseases was used to model associations between OUD exposure and the frequency of encounters and estimate the relative risk (RR) of significant covariates.A total of 6977 adults with suicidality and any comorbid SUD were selected, including 2203 (31.6%) with a diagnosis of OUD and 4774 (68.4%) without a diagnosis of OUD. Most patients were male (54.8%) and aged between 25-64 years (79.3%). Many (61.3%) had over 3 chronic diseases, including depression (80.8%), hypertension (60.6%), anemia (43.0%), and hyperlipidemia (41.9%). Compared to patients with other SUDs, those with OUD had higher odds of self-harm injury [OR: 1.26 (95% CI: 1.13-1.41)], depressive disorders [1.47 (1.29-1.67)], anxiety disorders [1.65 (1.48-1.84)], psychotic disorders [1.23 (1.11-1.37)], personality disorders [1.30 (1.16-1.48)], and post-traumatic stress disorder [1.37 (1.20-1.57)]. Patients with OUD were more likely to utilize all-cause outpatient (RR: 1.16), emergency department (ED) (RR: 1.43), and inpatient (RR: 1.60) services (p<0.001). Among OUD patients, males were less likely to have outpatient visits (RR: 0.79) and inpatient hospitalizations (RR: 0.88), and older age was protective against ED admissions (RR range: 0.62-0.71). Additionally, individuals with OUD were more likely than those with other SUDs to have SUD-related encounters, as well as suicide-related ED admissions and inpatient hospitalizations (p<0.0001). Those who had more mental health outpatient visits were less likely to have suicide-related ED admissions (RR: 0.85), however this association was weaker among younger or male patients with comorbid OUD.Among suicidal adults with comorbid SUDs, those with a diagnosis of OUD were more likely to utilize mental health services and have psychiatric comorbidity. Males and older adults were less likely to utilize services.None Declared


Serum anti-spike IgG and neutralizing antibody against SARS-CoV-2 are recognized as immune correlates of protection (ICP) for COVID-19. However, there are limited data available on the ICP after the introduction of BA.4/5 bivalent vaccine. Thus, our study aimed to investigate the antibody response as correlates of protection against COVID-19, and the effects of BA.4/5 bivalent booster vaccine.A prospective cohort of healthcare workers was enrolled at Asan Medical Center, a 2,700-bed tertiary care hospital in South Korea between December 2022 and January 2023. Study participants had received a booster vaccination and either planned to receive a bivalent BA.4/5 vaccine or not. Blood samples were collected from study participants. Immunological assessments were performed using ELISA to measure variant-specific SARS-CoV-2 S1-IgG antibodies, and virus reduction neutralization test (VRNT) to measure neutralizing antibody levels.A total of 483 participants were enrolled, of whom 45 (9.3%) underwent subsequent infection after study enroll, while 438 (90.7%) did not. Of these 483 participants, 166 (34.4%) received the BA.4/5 bivalent booster vaccination. There was a significant difference in Wuhan-Hu-1 S1-IgG, BA.5 S1-IgG and neutralizing antibody against BA.5 levels between individuals with and without subsequent infection . While Wuhan S1-IgG and BA.5 S1-IgG (both P < 0.001) were found to be independent protective factors against subsequent SARS-CoV-2 infection, neutralizing antibody against BA.5 did not show significant protective effects. Hybrid immunity was robust predictive factor for subsequent infection in all analysis based on each immune marker . The predictive sensitivity of neutralizing antibody for subsequent infection was improved from 80.0%  to 90.0%  when combined with hybrid immunity and 100%  with bivalent vaccine.Taken together, humoral immune responses seem to be reliable markers for immune correlates of protection against SARS-CoV-2 infection, and hybrid immunity showed independent protective effect from subsequent infection.All Authors: No reported disclosures


Globally 20-50% population suffer from periodontal diseases. Bidirectional link exists between periodontal diseases and comorbidities. Limited evidence is available on antibiotic effectiveness in patients of dental infections with comorbidities.This retrospective, multi-centric, observational electronic medical record study gathered real world Indian evidence to assess effectiveness of cephalexin-clavulanic acid  fixed-dose combination (FDC) compared to amoxicillin-clavulanic acid (amoxicillin CV) FDC and cefuroxime in adults with dental infections. Following data represents effectiveness in subset of patients with and without comorbidity.Overall, 89% (316/355) patients were without comorbidity ; while 11% (39/355) patients had comorbidities .Time to overall clinical improvement was less in patients without comorbidities compared to those with comorbidities .In patients without comorbidity, 98.13% (157/160), 100% (70/70), and 97.67% (84/86) showed overall clinical improvement within 10 days, in cephalexin CV, cefuroxime, amoxicillin CV groups, respectively.In patients with any comorbidity, 100% (14/14) patients showed improvement in cephalexin CV against 94% (16/17) in cefuroxime and 87% (7/8) in amoxicillin CV group within 10 days (p >0.05).Overall clinical improvement in patients with and without comorbidities on Day 5 and 7 is presented in Table. In metabolic and cardiovascular disorders subsets, 100% patients showed improvement within 10 days in cephalexin CV group, while 92% (12/13) and 100% (5/5), respectively in cefuroxime group; and 88% (7/8) and 67% (2/3), respectively in amoxicillin CV (p >0.05).In patients with dental infections, presence of comorbidities delays overall clinical improvement. All patients with comorbidity treated with cephalexin CV showed overall clinical improvement within 10 days of treatment. No significant difference was observed between treatments for overall clinical improvement.Archana Karadkhele, MBA, Sun Pharma Laboratories Limited: Full time employee Shruti Dharmadhikari, MSc, Sun Pharma Laboratories Limited: Full time employee Chintan Khandhedia, MD, Sun Pharma Laboratories Limited: Full time employee Neeraj Markandeywar, MD, Sun Pharma Laboratories Limited: Full time employee Amey Mane, MD, Sun Pharma Laboratories Limited: Full time employee Suyog Mehta, MD, Sun Pharma Laboratories Limited: Full time employee


Pseudomonas aeruginosa high-risk clones pose severe threats to public health. Here, we characterize the imipenem/relebactam (IR) resistance mechanisms in P. aeruginosa high-risk clones sequence type 235 (ST235) and ST463 in China. Minimum inhibitory concentrations (MICs) were determined, and Illumina short-read sequencing was performed for 1,168 clinical carbapenem-resistant P. aeruginosa (CRPA) isolates. The gene copy number and expression level were analyzed by Illumina sequencing depth and reverse transcription-quantitative PCR, respectively. Resistance conferred by blaGES-5 was evaluated by cloning experiments. ST463 and ST235 accounted for 9.8%  and 4.5%  of total isolates, respectively, and showed high frequencies of extensively drug-resistant and difficult-to-treat resistant phenotypes. The overall IR-resistant rate in CRPA was 21.0% . However, the IR resistance rate was 81.7% (94/115) in ST463-PA and 52.8% (28/53) in ST235-PA. Of the ST463 isolates, 92.2% (106/115) were Klebsiella pneumoniae carbapenemase-producing P. aeruginosa (KPC-PA), and all 94 IR-resistant ST463-PA produced KPC-2. Compared to IR-susceptible ST463 KPC-2-PA, IR-resistant ST463 KPC-2-PA exhibited significantly higher blaKPC-2 copy numbers and expression levels. In ST463 KPC-2-PA, 16 mg/L relebactam resulted in additional fourfold reductions in imipenem MIC50/90 values compared to 4 mg/L relebactam. In ST235, 1.9% (1/53) carried blaIMP carbapenemase and 54.7% (29/53) carried blaGES carbapenemase. Other than the IMP producer, all 27 IR-resistant ST235-PA produced GES-5. Cloning experiments revealed that imipenem resistance in blaGES-5-carrying PAO1 transformants was generally unaffected by relebactam. In conclusion, IR-resistant CRPA isolates in China were mainly distributed in P. aeruginosa high-risk clones ST463 and ST235. The major underlying IR resistance mechanisms were blaKPC-2 overexpression and blaGES-5 carriage. Pseudomonas aeruginosa (CRPA) has emerged as an urgent public health issue. Although P. aeruginosa isolates usually exhibit great clonal diversity, the dissemination of certain high-risk clones is an essential step for CRPA to maintain an antibiotic-resistant phenotype. Among the high-risk clones detected globally, sequence type 235 (ST235) has been identified across five continents and is considered the most widespread  5. The hP. aeruginosa. In a multicenter study involving 4,927 MDR-PA isolates from adult patients, although 13.5% of samples produced metallo-β-lactamases (MBLs), nearly 70% of isolates were still susceptible to IR (Imipenem/relebactam (IR), a novel β-lactam-β-lactamase inhibitor (BLBLI) combination, has been developed and applied clinically to treat CRPA infections. Relebactam exerts strong inhibitory effects on many class A and class C β-lactamases and is almost unaffected by OprD inactivation or efflux pump extrusion , 10. Conle to IR .in vitro activity of IR against P. aeruginosa, the IR resistance mechanisms in CRPA high-risk clones remain largely unexplored. In this study, we evaluated the IR resistance profiles in clinical CRPA isolates from China, with a particular focus on the IR activity against ST235 and ST463 CRPA strains. Notably, we identified a surprisingly high IR resistance rate in ST235 and ST463 CRPA isolates. The underlying IR resistance mechanisms were further explored in detail.Currently, although many studies emphasize the A total of 1,168 clinical CRPA isolates, defined as resistant to either meropenem or imipenem according to the Clinical and Laboratory Standards Institute (CLSI) breakpoints , were inEscherichia coli ATCC 25922, P. aeruginosa ATCC 27853, and Klebsiella pneumoniae ATCC 700603 and ATCC BAA-1705 were used as quality controls. For all antimicrobials except fosfomycin, CLSI breakpoints  phenotype were defined according to the criteria established by Magiorakos et al. and Tamma et al. respectively  of amikacin, imipenem, meropenem, IR (relebactam fixed at 4 mg/L), ceftazidime, cefepime, ciprofloxacin, levofloxacin, piperacillin/tazobactam, aztreonam, fosfomycin, and polymyxin B were determined using the broth microdilution method with Thermo Scientific Sensititre System. To facilitate comparison between different antimicrobials in ST463 KPC-2-producing and ST235 GES-5-producing strains, the MICs of imipenem and IR (relebactam fixed at 4 mg/L or 16 mg/L) were simultaneously obtained by the agar dilution method described in CLSI standard M07 . Escheriakpoints  for P. aakpoints  for Enteectively , 15.De novo assembly was accomplished using shovill version 0.9.0 (https://github.com/tseemann/shovill). Multilocus sequence typing (MLST) was performed, and antimicrobial resistance genes were detected using mlst version 2.19.0 (https://github.com/tseemann/mlst) and ABRicate version 1.0.0 (https://github.com/tseemann/abricate). The oprD gene of clinical strains was compared with that of P. aeruginosa PAO1. OprD inactivation was confirmed if any of the following criteria were met: (1) truncation or absence of the oprD gene; (2) mutations leading to an OprD frameshift; and (3) mutations leading to the creation of a premature stop codon in OprD.The genomic DNA of all CRPA isolates was extracted using QIAamp DNA Mini Kit  and underwent short-read sequencing . blaKPC-2 copy number was further calculated based on WGS. For each sample, a SAM alignment file was obtained by mapping Illumina raw reads to references  using bowtie2 version 2.2.5 (https://github.com/BenLangmead/bowtie2) with the option “-I 0 -X 800 --fast -q.” After transforming the alignment results into BAM files, the sequencing depths of the blaKPC-2 gene and seven MLST alleles were analyzed by BEDTools version 2.30.0 (https://github.com/arq5x/bedtools2) with the option “bedtools coverage -mean.” Finally, the blaKPC-2 copy number of each strain was calculated as the depth of blaKPC-2 divided by the average depth of the seven MLST alleles.For KPC-2-producing strains, the P. aeruginosa isolates, genome assemblies were first annotated using Prokka version 1.14.6 (https://github.com/tseemann/prokka). Core gene alignment was then obtained by pangenome analysis using Panaroo version 1.2.9 . Reverse transcription was conducted using PrimeScript RT Reagent Kit . Quantitative PCR was performed in biological triplicates using TB Green Premix ExTaq . Each biological triplicate was assayed in technological triplicates. The housekeeping gene rpoD was chosen as the endogenous reference for normalization. The primers used for quantitative PCR are listed in Table S1.To compare the expression levels of blaGES-5 and blaGES-15 genes with the same upstream promoter sequences were amplified from clinical strains R16-15 and R20-99, respectively. The cloned sequences were homologously recombined into the pGK1900 plasmid. The constructed plasmids were then transformed into both E. coli DH5α and P. aeruginosa PAO1. Transformants verified by Sanger sequencing were eventually selected for antimicrobial susceptibility testing. The primers used for cloning experiments are listed in Table S1.The P < 0.05.Statistical analysis was performed using the Fisher’s exact test, the Mann‒Whitney U test, and the Kruskal‒Wallis test in SPSS version 25. The results were considered statistically significant when P. aeruginosa from other STs. The frequency of XDR/PDR phenotype was 88.7% (102/115) for ST463-PA and 73.6% (39/53) for ST235-PA ; the frequency of DTR phenotype was 90.4% (104/115) for ST463-PA and 52.8% (28/53) for ST235-PA . In contrast, the proportions of XDR/PDR-PA and DTR-PA in CRPA isolates from other STs were only 24.4%  and 24.5% , respectively. Therefore, the resistance status of ST463-PA and ST235-PA was significantly more severe.Among the 1,168 CRPA isolates included in this study, MLST analysis revealed 285 different STs (excluding 69 isolates belonging to unknown STs). In 21 out of these 285 STs, the CRPA strain numbers were more than nine . ST463  and ST235  were found to be the most prevalent STs. The resistance phenotypes of ST463-PA and ST235-PA to traditional antipseudomonal agents were compared with those of 50/90 of 16/>128 mg/L; however, only 245/1,168 (21.0%) isolates were resistant to IR with an MIC50/90 of 2/32 mg/L  isolates were resistant to imipenem with an MIC/32 mg/L . The add90 value ; Fig. 1.The phylogenetic tree was then constructed for IR-resistant isolates, and the clonal characteristics were analyzed. Among 245 IR-resistant isolates, 62 different STs were identified (excluding five strains with unknown STs). In 16 of these 62 STs, the IR-resistant strain numbers were more than one . As shown in P. aeruginosa (non-CPPA), while 106/115 (92.2%) isolates were KPC-producing P. aeruginosa (KPC-PA). The identified KPC alleles included blaKPC-2  and blaKPC-33 . In ST235-PA, in addition to 23/53 (43.4%) non-CPPA isolates, 54.7% (29/53) were carbapenemase-type GES-producing P. aeruginosa (GES-PA) and 1.9% (1/53) were IMP-15-producing P. aeruginosa. The carbapenemase-type GES alleles consisted of blaGES-5  and blaGES-15 .To further describe the molecular epidemiology and interpret the IR resistance data of ST463 and ST235 isolates, genomic analysis was subsequently conducted. As listed in Table S2, the strong association between class A carbapenemase types and STs could be clearly distinguished. In ST463-PA, 9/115 (7.8%) isolates were non-carbapenemase-producing blaKPC-33-carrying P. aeruginosa were IR intermediate, while 94/104 (90.4%) blaKPC-2-carrying P. aeruginosa were IR resistant  blaGES-5-carrying P. aeruginosa were IR resistant  esistant ; in ST23esistant . Overall50 and MIC90 values. However, with 4 mg/L relebactam, restoration of imipenem susceptibility was only achieved in 9/104 (8.7%) ST463 KPC-2-PA isolates, while the majority still exhibited high-level imipenem resistance (64 mg/L to 256 mg/L). Therefore, we proposed that 4 mg/L relebactam might be insufficient for inhibiting blaKPC-2 expression in ST463.IR resistance mechanisms were further explored in ST463 KPC-2 producers. As shown in 50 and MIC90 values were achieved by 16 mg/L relebactam  ST463 KPC-2-PA isolates became susceptible or intermediate to imipenem. Notably, with 16 mg/L relebactam, only three ST463 KPC-2 producers still exhibited high-level imipenem resistance (MIC: 64 mg/L). In comparison to 4 mg/L relebactam, additional fourfold reductions in imipenem MIClebactam .blaKPC-2 copy numbers were compared between ST463 KPC-2 producers showing different IR resistance phenotypes. Compared with ST463 KPC-2-PA isolates susceptible or intermediate to IR, IR-resistant ST463 KPC-2-PA isolates exhibited significantly higher blaKPC-2 copy numbers     . In stra 0.0001) . Besides < 0.01) . AltogetblaKPC-2 expression level was quantitively analyzed. In total, 18 blaKPC-2-carrying ST463 isolates were selected from three phenotypic groups . These strains shared similar genetic elements surrounding blaKPC-2 and the same blaKPC-2 promoter sequences. As shown in blaKPC-2 expression level differed significantly among these three groups , showing that blaKPC-2 overexpression was related to the attenuated inhibitory effects of 4 mg/L relebactam.Finally, to further verify our hypothesis, the relative mexE and mexY genes in ST463 KPC-2-PA, only the expression levels of mexA and mexD genes were analyzed. Interestingly, under 16 mg/L relebactam, compared with isolates susceptible to imipenem (MIC: 1 mg/L), ST463 KPC-2-PA isolates resistant to imipenem (MIC: 32 mg/L to 64 mg/L) displayed much lower mexA and mexD expression levels . This suggested that the IR resistance phenotype differences among ST463 KPC-2-PA could not be attributed to efflux pump overexpression. With regard to OprD inactivation, among imipenem-susceptible and imipenem-nonsusceptible ST463 KPC-2-PA (under 16 mg/L relebactam), the proportions of OprD-inactivating strains were 36.4% (4/11) and 96.8% (90/93), respectively (P < 0.0001). This significant difference indicated the potential contribution of OprD inactivation to imipenem resistance, which further led to IR resistance in ST463 KPC-2-PA.Although additional decreases in imipenem MICs were achieved when relebactam was increased from 4 mg/L to 16 mg/L, the majority  of ST463 KPC-2-PA were still not susceptible to imipenem. Previous studies have identified IR resistance associated with mutations in OprD and regulators of MexAB-OprM , 20. Thu50/MIC90 values or the cumulative inhibition curves of imipenem, suggesting that IR resistance in ST235 GES-5-PA could not be attributed to blaGES-5 overexpression.Mechanisms of IR resistance were also investigated in detail for ST235 GES-5-PA. As illustrated in blaGES allelic variants on imipenem and IR resistance were analyzed. The imipenem MICs were generally higher in ST235 GES-5 producers (32 mg/L to 128 mg/L) than in ST235 GES-15 producers (16 mg/L). The IR resistance rate was 100% (27/27) for blaGES-5-carrying ST235-PA isolates, with MIC50/MIC90 values of 32/32 mg/L. In contrast, all blaGES-15-harboring ST235-PA isolates were susceptible or intermediate to IR, exhibiting MIC50/MIC90 values of 4/4 mg/L. The above data demonstrated the potential involvement of blaGES-5 carriage in IR resistance.Subsequently, the impacts of blaGES-5 carriage  was acquired. In another in vitro study  were published. In one in vitro multistep selection study . Under these circumstances, clinical treatment choices would be greatly constrained.Generally, IR resistance related to KPC enzymes has seldom been reported. Until 2022, four studies investigating IR resistance development in KPC-producing on study , IR-resisistance –32, GaP. aeruginosa in previous studies . According to Hujer et al.’s study (Although GES producers were found among IR-resistant  studies , 33, the’s study , GES-20 exoU+ genotype and various resistance-related mutations. In a study on P. aeruginosa bacteremic pneumonia, a 29.8% increase in 5-day mortality and a 34.4% increase in 30-day mortality were noted in patients infected with ST235-PA (exoU and exoS genes, the ST463 clone also exhibits a hypervirulent phenotype. In a recent study by Zhang et al. (Galleria mellonella larvae infection model. The included ST463-PA isolates showed hypervirulence comparable to that of ST235-PA. Moreover, in a clinical retrospective cohort study conducted in East China (The poor outcome associated with ST235 and ST463 CRPA, mainly caused by their hypervirulence and MDR/XDR/PDR profiles, is concerning. Generally, hypervirulence is defined as the ability to cause higher mortality and more severe acute infections . ST235 CblaKPC-2 overexpression as the major driver of high-level IR resistance in ST463-PA. In addition, we also confirmed that blaGES-5 carriage mediated IR resistance in ST235-PA. Overall, this epidemiological survey systematically deciphered the IR resistance mechanisms in P. aeruginosa global high-risk clone ST235 and regional high-risk clone ST463.In conclusion, our data highlighted the distinct IR resistance characteristics between CRPA isolates from high-risk clones and other STs. Of particular concern is the association of high-risk clones with IR resistance phenotype and XDR/DTR phenotype, which may worsen clinical outcomes and restrict therapeutic options. Using whole-genome analysis methods and quantitative PCR, we identified


Author Correction: Genome Biol 24, 187 (2023)https://doi.org/10.1186/s13059-023-03023-7Following publication of the original article , the autThese errors do not affect the main results and conclusions of the paper. The original article  has beenAdditional file 2: Supplementary Methods [165-182]. Fig. S1. Imputation accuracy of individual samples for sites with MAF > 1%. Fig. S2. Median copy-number across the genome for wolves. Fig. S3. Repeatmasker classification of SINE variation. Fig. S4. Distribution of variation across the genome for breed and other dogs . Fig. S5. Nucleotide diversity along chr26. Fig. S6. Signature of a retrogene detected at the TEX2 locus.


Correction : Environmental Microbiome (2020) 15:3 10.1186/s40793-019-0348-0Microviridae viruses found in the metagenomes in the Abstract (Results), Results , Discussion , and Conclusions. Since the article’s publication it has come to light that the sequences associated with the Microviridae viruses belong to PhiX 174 (Genbank Accession Number NC_001422), a member of Microviridae family. These sequences were a contamination originating from the use of PhiX DNA as a control in Illumina sequencing platforms [Microviridae virus(es). After removing PhiX 174-associated sequences from the metagenomic data, the most abundant viral sequences were affiliated with Myoviridae, a viral family which includes phages that are suspected to affect Chlorobi [The original article briefly discusses Additional file 1. Supplementary Materials, Methods and Results. Figure S1.Natural blooms in Trunk River. Figure S2.Color and appearance ofsamples from all holes, depths, and timepoints. Figure S3.Filters thatwere used for biomass measurements and spectral analysis. Figure S4.Total cell count of three samples . Figure S5. Depthprofile representation of chemical data presented in Fig.2. Figure S6. Physicochemistry. Iron, nitrate, ammonium, acetate, Ca2+, and K+measurements. Figure S7. Individual diversity indices of all samples. Figure S8. Trajectories of community structure in hole A, E and K. Figure S9. Relative sequence abundance of the 20 most abundant clades onphylum, class, order, family and genus level, as well as the 20 mostsequence abundant ASVs (amplicon sequence variants). Figure S10.Relative sequence abundance of Chlorobiales ASVs. Figure S11.Relativechange of ASV abundance between surface (V1) and deeper layers (V2-4). Figure S12.Chlorobiales phylogeny. Figure S13. Circular map ofmetagenome-assembled genomes (MAGs). Figure S14. Chlorobiales phy-logenomics. Figure S15. Protein comparison of Bin 6. Figure S16.Pro-tein comparison of Bin 10. Figure S17. Genes involved in sulfurcycling. Figure S18. CRISPR arrays and cas genes predictions Bin 6.Figure S19. CRISPR arrays and cas genes predictions Bin 10. Figure S20. Relative sequence abundance of viral family-level clades. Table S1. Over-view of sequencing output and diversity indices. Table S2. Genome sta-tistics. Table S3. Average nucleotide identity (ANI) comparisons. Table S4. Oxidative phosphorylation and chlorophyll biosynthesis genes of Bin6 and Bin 10. Table S5. CRISPR-Cas system information for eachmetagenome-assembled genome.


Moreover, Patients with AoAC showed a lower incidence of first-pass successful recanalization  and a higher incidence of postprocedural hemorrhage  than those without AoAC. On multivariate analysis, AoAC was independently associated with first-pass successful recanalization . Conclusions: AoAC on chest radiography can be used as a preoperative predictor of successful first-pass recanalization in patients undergoing EVT for AIS.Background: Vascular conditions can affect the recanalization rates after endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Chest radiography can assess the conditions of the aortic arch based on the presence or absence of aortic arch calcification (AoAC). The aim of this study was to investigate the relationship between AoAC on chest radiography and first-pass successful recanalization . Methods: We compared the rate of first-pass successful recanalization between patients with and without AoAC. A total of 193 patients with anterior circulation occlusion who underwent EVT between January 2017 and December 2021 were included. Results: AoAC was observed in 80 (41.5%) patients. Patients with AoAC were older (74.5 ± 7.78 vs. 63.9 ± 12.4 years,  Several randomized clinical trials have established the clinical efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) ,2,3,4,5.Recent retrospective studies have reported a relationship between the number of device passes and clinical outcomes and documented that recanalization with fewer device passes is associated with better clinical outcomes ,13,14,15Intracranial atherosclerotic stenosis (ICAS) and tortuous vascular anatomy are common causes of EVT failure ,18,19. IAtherosclerosis is a diffuse progressive disease characterized by vascular calcification, which is associated with disease progression ,21,22. CThe aim of this study was to investigate the relationship between AoAC on chest radiography and first-pass recanalization after EVT for AIS.n = 31) and (2) posterior circulation occlusions (n = 29). Eventually, 193 consecutive patients were included  symptomatic AIS, (2) large vessel occlusions confirmed using magnetic resonance (MR) angiography or computed tomography (CT) angiography, (3) less than 24 h from symptom onset to treatment, and (4) at least one-half mismatch between cerebral blood flow and cerebral blood volume map with MR perfusion imaging. A total of 253 patients who met the inclusion criteria were included. From the 253 patients, 60 were excluded because of (1) tandem occlusions , the imaging data and medical records of patients were reviewed. Data regarding the baseline characteristics of the patients, treatment characteristics, and radiological and clinical outcomes were obtained from the medical records. Baseline characteristics included age, sex, past medical history, occlusion side and site, etiology of stroke, AoAC on chest X-ray, type of aortic arch, National Institutes of Health Stroke Scale (NIHSS) at admission, onset-to-door time, and onset-to-puncture time. Treatment characteristics included intravenous thrombolysis, balloon guide catheter, EVT technique, and procedural time. Radiological and clinical outcomes included TICI grades, postprocedural hemorrhage, and the 3-month modified Rankin Scale (mRS) score.The occlusion sites were divided into three categories: (1) internal carotid artery (ICA), (2) M1 segment of the middle cerebral artery (MCA), and (3) M2 segment of MCA. The M1 and M2 segments were defined as the horizontal and vertical segments of MCA, respectively. The etiology of stroke was classified based on the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria. Two experienced radiologists (7 (KHR) and 6 (JB) years of experience) independently evaluated all chest X-rays in a binary manner. During the analysis, all radiologists were blinded to the radiological and clinical outcomes after EVT. AoAC assessments on chest radiographs are shown in There were three neurosurgeons who specialized in neurointerventions at our hospital. When EVT was planned for large vessel occlusion, it was performed by one of these three neurosurgeons. The procedures were performed under local anesthesia via femoral access. The primary EVT modality was at the surgeon’s discretion. The use of a balloon guide catheter  was based on the surgeon’s discretion.p-value of <0.05 was considered statistically significant. Multivariable logistic regression analysis was used to evaluate factors affecting first-pass successful recanalization and good clinical outcomes after EVT for AIS. Variables with a p-value of <0.20 in the univariate analysis were included in the multivariate logistic regression analysis. The interobserver agreement for each chest X-ray feature and the presence of AoAC between the two radiologists was assessed using the Cohen kappa statistic. The degree of agreement was classified using kappa values according to the Landis and Koch recommendation as follows [Baseline characteristics, treatment characteristics, and radiological and clinical outcomes were compared between patients with AoAC and those without, between patients first-pass successful recanalization and those without, and between patients with good clinical outcomes and those without. Categorical variables were analyzed using the chi-squared test or Fisher’s exact test. Continuous variables were analyzed using Student’s t-test or the Mann–Whitney U test. A  follows : kappa vn = 37, 19.2%), cardioembolic occlusion , and unknown . AoAC was observed in 80 (41.5%) patients, while aortic arch types 1, 2, and 3 were observed in 46 (23.8%), 99 (51.3%), and 48 (24.9%) patients, respectively. ICAS was observed in 49 (25.4%) patients. Intravenous tissue plasminogen activator was administered to 78 (40.4%) patients. A balloon guide catheter was used in 34 (17.6%) patients. As first-line EVT strategies, stent retrievers, catheter aspiration, and a combination technique were used in 44 (22.8%), two (1.04%), and 147 (76.2%) patients, respectively. The total number of EVT attempts was one (n = 76), two (n = 43), three (n = 28), four (n = 26), five (n = 12), six (n = 3), seven (n = 2), eight (n = 2), and 12 (n = 1). Successful recanalization was achieved in 162 (83.9%) patients, and first-pass successful recanalization was achieved in 69 (35.8%) patients. Good clinical outcomes were achieved in 110 (57.0%) patients.A total of 193 patients  were analyzed. Of the 193 patients, 41 (21.2%), 119 (61.7%), and 33 (17.1%) had occlusion in the ICA, M1 and M2 segments, respectively. Stroke etiologies included atherosclerotic occlusion (p < 0.001) and were more likely to have hypertension (52/80 (65.0%) vs. 43/113 (38.1%), p < 0.001) and atrial fibrillation (45/80 (56.3%) vs. 39/113 (34.5%), p = 0.003). Aortic arch type 3 was more frequently observed in patients with AoAC (34/80 (42.5%) vs. 14/113 (12.4%), p < 0.001). Patients with AoAC had more EVT attempts . Procedural time was significantly longer in patients with AoAC . Successful recanalization (60/80 (75.0%) vs. 102/113 (90.3%), p = 0.005) and first-pass successful recanalization (15/80 (18.8%) vs. 54/113 (47.8%), p < 0.001) were achieved less frequently in patients with AoAC. Postprocedural hemorrhage was observed more frequently in patients with AoAC (36/80 (45.0%) vs. 31/113 (27.7%), p = 0.015). Although ICH was observed more frequently in patients with AoAC (22/80 (27.5%) vs. 17/113 (15.0%), p = 0.045), the frequency of SAH did not differ significantly between the two groups (14/80 (17.5%) vs. 13/113 (11.5%), p = 0.293). Patients with AoAC had a higher incidence of good clinical outcomes (37/80 (46.3%) vs. 73/113 (64.6%); p = 0.013). On multivariate logistic regression analysis for factors affecting AoAC on chest radiography, including age, sex, hypertension, atrial fibrillation, occlusion site, and NIHSS at admission, age (adjusted odds ratios (OR): 1.106, adjusted 95% confidence interval (CI): 1.063–1.151; p < 0.001), and hypertension  were independently associated with AoAC on chest radiography (iography .p = 0.030). Patients with first-pass successful recanalization showed a lower incidence of AoAC on chest X-ray (15/69 (21.7%) vs. 65/124 (52.4%), p < 0.001). Intravenous thrombolysis was administered more frequently in patients with first-pass successful recanalization (35/69 (50.7%) vs. 43/124 (34.7%), p = 0.033). Patients with first-pass successful recanalization had a shorter procedural time . Postprocedural hemorrhage was more frequently observed in patients with first-pass successful recanalization (11/69 (15.9%) vs. 56/124 (45.5%), p < 0.001). Patients with first-pass successful recanalization had a higher incidence of both SAH and ICH (4/69 (5.8%) vs. 23/124 (18.5%), p = 0.016) (7/69 (10.1%) vs. 32/124 (25.8%), p = 0.009). Good clinical outcomes were achieved more frequently in patients with first-pass successful recanalization (53/69 (76.8%) vs. 57/124 (46.0%), p < 0.001). Multivariate logistic regression analysis for factors affecting first-pass successful recanalization after EVT for AIS, including sex, hypertension, occlusion site, AoAC on chest X-ray, and intravenous thrombolysis revealed that AoAC on chest X-ray  and intravenous thrombolysis  were independent factors ( factors .p = 0.003). Hypertension was observed less frequently for patients with good clinical outcomes (47/110 (42.7%) vs. 48/83 (57.8%), p = 0.043). Left-side occlusion was observed less frequently for patients with good clinical outcomes (42/110 (38.2%) vs. 46/83 (55.4%), p = 0.020). Good clinical outcomes were less frequently achieved for patients with ICA occlusion than for those with M1 or M2 occlusions (16/110 (14.5%) vs. 25/83 (30.1%), p = 0.012). Patients with AoAC achieved good clinical outcomes less frequently than those who did not (37/110 (33.6%) vs. 43/83 (51.3%), p = 0.013). Patients with good clinical outcomes had fewer EVT attempts , shorter procedural time , higher rates of successful recanalization (103/110 (93.6%) vs. 59/83 (71.1%), p < 0.001), and first-pass successful recanalization (53/110 (48.2%) vs. 16/83 (19.3%), p < 0.001). Postprocedural hemorrhage (26/110 (23.9%) vs. 41/83 (49.4%), p < 0.001) and ICH (13/110 (11.8%) vs. 26/83 (31.3%), p = 0.001) were observed less frequently in patients with good clinical outcomes; however, the frequency of SAH did not differ significantly between the two groups (13/110 (11.8%) vs. 14/83 (16.9%), p = 0.402). Multivariate logistic regression analysis of factors affecting good clinical outcomes after EVT for AIS, including age, sex, hypertension, diabetes mellitus, atrial fibrillation, occlusion side, occlusion site, AoAC on chest X-ray, aortic arch type 3, intravenous thrombolysis, total number of EVT attempts, procedural time, successful recanalization, first-pass successful recanalization, postprocedural hemorrhage, and ICH revealed that left-side occlusion , first-pass successful recanalization , successful recanalization , and ICH  were independent factors ( factors .p < 0.001).The interobserver agreement showed moderate agreement between the two radiologists  but not atherosclerotic occlusion (TOAST 1) . These results suggest that AoAC on chest X-ray may reflect atherosclerotic changes in a type 3 aortic arch but not intracranial atherosclerotic changes. Previous studies have reported that the pathophysiology of ICAS is different from that of extracranial atherosclerosis [Our results showed that AoAC on chest radiography was significantly associated with a type 3 aortic arch . Recent studies have reported that first-pass recanalization is strongly associated with favorable clinical outcomes ,16,33,34We believe that the ability to predict first-pass successful recanalization, which indicates the procedure’s difficulty before EVT for AIS, could be helpful in deciding the strategy for EVT. Observation of AoAC on preprocedural chest radiography allows neurointerventionalists to prepare for the possibility of longer procedural times and multiple EVT attempts. If the neurointerventionalists can predict the difficulty of the procedure in advance, they can select the techniques or devices that they are familiar with rather than unfamiliar new techniques or new devices; this can help achieve better radiological and clinical outcomes.During the initial examination of patients with AIS, brain CT angiography or MR angiography is performed, and brain CT angiography provides more information about AoAC than chest X-rays. Therefore, chest X-rays may be less useful when brain CT angiography is taken. However, neurointerventionalists try to check brain CTA focusing on intracranial lesions or carotid lesions, and they do not try to check brain CTA focusing on AoAC. Although our study was based on chest X-ray, we can suggest that we have to check AoAC on brain CT angiography as well as intracranial lesions or carotid lesions.First, this was a retrospective, single-center study, and selection bias cannot be ruled out. Second, the sample size was small. Therefore, the statistical power may be low. Third, we demonstrated a significant relationship between AoAC on chest radiography and first-pass successful recanalization after EVT for AIS; however, this was not a causal relationship. Fourth, AoAC was assessed based on the presence of calcification in a qualitative rather than quantitative manner. The impact of AoAC on first-pass successful recanalization should be evaluated quantitatively or semi-quantitatively using more detailed AoAC grades. More evidence with larger sample sizes is required to confirm these preliminary results.Our results suggest that AoAC on chest radiography is a useful predictor of first-pass successful recanalization after EVT for AIS; however, further evidence is required.