Since the COVID-19 pandemic, telehealth has been widely adopted in outpatient settings in the United States. Although telehealth visits are publicly accepted in different settings, little is known about the situation after the wide adoption of telehealth from the perspectives of adults with type 2 diabetes mellitus (T2D) and their providers.This study aims to identify barriers and facilitators of maintaining continuity of care using telehealth for patients with T2D in a diabetes specialty clinic.As the second phase of a multimethod study to understand missed appointments among adults with T2D, we conducted semistructured, individual, in-depth phone or Zoom interviews with 23 adults with T2D  and 10 providers from diabetes clinics in a tertiary academic medical center in Maryland. Interviews were audio-recorded, transcribed, and analyzed using thematic content analysis by the research team.Adults with T2D and their providers generally reported positive experiences with telehealth visits for diabetes care with some technical challenges resulting in the need for in-person visits. We identified the following 3 themes: (1) “perceived benefits of telehealth visits,” such as convenience, time and financial efficiencies, and independence from caregivers, benefits shared by both patients and providers; (2) “perceived technological challenges of telehealth visits,” such as disparities in digital health literacy, frustration caused by unstable internet connection, and difficulty sharing glucose data, challenges shared by both patients and providers; and (3) “impact of telehealth visits on the quality of diabetes care,” including lack of diabetes quality measures and needs and preferences for in-person visits, shared mainly from providers’ perspectives with some patient input.Telehealth is generally received positively in diabetes care with some persistent challenges that might compromise the quality of diabetes care. Telehealth technology and glucose data platforms must incorporate user experience and user-centered design to optimize telehealth use in diabetes care. Clinical practices need to consider new workflows for telehealth visits to facilitate easier follow-up scheduling and lab completion. Future research to investigate the ideal balance between in-person and telehealth visits in diabetes care is warranted to enhance the quality of diabetes care and to optimize diabetes outcomes. Policy flexibilities should also be considered to broaden access to diabetes care for all patients with T2D. It is estimated that there are more than 37 million people in the United States with diabetes mellitus, and 90% to 95% of those cases are type 2 diabetes mellitus (T2D) . WorkingTelehealth, the use of telecommunication technologies to provide health care remotely , has beeSpecific to diabetes care, the transformation from in-person to telehealth visits has the potential to democratize routine diabetes care provision, such as providing care to those with limited transportation who otherwise could not be at the clinic regularly ,16. A prHowever, some endocrinologists believed telehealth visits were more helpful for people with type 1 diabetes mellitus (T1D) compared with those with T2D because people with T1D are more closely monitored by continuous glucose monitoring (CGM) and insulin pumps . AdditioThis qualitative narrative study took place in the Johns Hopkins Diabetes Center, a multidisciplinary team  providing comprehensive diabetes care across multiple locations in the greater Baltimore area affiliated with a tertiary academic medical center in Maryland. There were no telehealth (video or phone) visits before the COVID-19 pandemic. During COVID-19, appointments at the Johns Hopkins Diabetes Center were transferred to telehealth visits on March 23, 2020, after the expansion of coverage by the Centers for Medicare & Medicaid Services . The cliIn normal circumstances, the telehealth visits at Johns Hopkins are through MyChart (Webex by Cisco). A medical assistant usually calls a day before the appointment to verify patients’ physical locations to meet individual state regulations. On the day of the appointment, vital signs and medical history are verified again through a phone call after a patient completes the electronic check-in through MyChart. Before the scheduled appointment time, the link to “start your video visit” appears to initiate the visit. The link for the video visit can be sent via text message if a patient does not use MyChart. A simple phone call may be used if the patient does not have devices with video capabilities .The findings for this manuscript were the second part of a multimethod study focusing on missed appointments among adults with T2D. In short, the first part of the study used electronic health records (EHRs) to examine if predictors of missed appointments differ (1) between pre-COVID-19 (January 2019 to March 2020) and COVID-19 (March 2020 to December 2020) periods and (2) by health care delivery modes  during COVID-19 among adults with T2D; more information is described elsewhere .Based on the results of the first phase, the eligibility criteria for this qualitative study included a diagnosis of T2D, age greater than 18 years, residence in the state of Maryland, and at least one appointment with either a physician or an NP marked as a no-show in the EHR in the past year at the time of recruitment (February 2022 to July 2022). Adults who met the inclusion criteria were identified from the EHR and then were contacted via emails, phone calls, or text messages. We used purposive sampling with maximum variation to include adults from different physicians and NPs with diverse characteristics  based on our quantitative results .Potential provider participants were invited through a study presentation by one of the authors (CAS) at the monthly diabetes center meeting. CAS then emailed the study information to all potential provider participants. All physicians and NPs working at the Johns Hopkins Diabetes Center were eligible to participate.The Johns Hopkins Medicine Institutional Review Board  approved the study design and procedures. Verbal consent was obtained from each participant.The study team developed a semistructured interview guide to explore perceptions among people with T2D and their providers regarding the barriers and facilitators of keeping appointments for both in-person and telehealth visits, with a focus on interpersonal relationships. The initial interview guide drafted by CAS was based on the findings of our previous quantitative study on missed appointments during the COVID-19 pandemic  and prevOne-on-one 30-minute to 45-minute phone or Zoom interviews were conducted by 2 trained interviewers (CAS and ZS) from February 2022 to July 2022 until thematic saturation was reached. In total, we contacted 52 eligible people with T2D; 28 refused , and 24 agreed to participate. Of those participants agreeing to participate, 23 completed the interview, and 1 participant was excluded due to a mislabeled T2D diagnosis on the EHR. Among 12 eligible providers, 10 (8 physicians and 2 NPs) agreed to participate and completed the interviews. All phone interviews were audio-recorded; all Zoom interviews were recorded using Zoom’s recording features. Only audio recordings were saved and sent to a professional transcription vendor approved by the Johns Hopkins IRB for verbatim transcription. After verifying the accuracy and removing identifiable information, transcripts were imported into f4analyse for coding and analysis.The analysis began after the transcription of the first interview and continued throughout data collection. We conducted a thematic content analysis of the interview transcripts, a common method of analysis when coding categories are derived directly from data ,27. EachReflexivity was achieved through discussions between interviewers and written notes after the interview. Trustworthiness was maintained through team discussions and audit trail documentation; all documentation was kept using Microsoft Word. The transferability of the study was enhanced by providing a thorough description of the study method, study setting, and our processes of data collection .Details of characteristics of persons with T2D included in this study can be found in Among 10 provider participants , there were 7 female and 3 male providers, with an average service time at the institution of 7.2  years.We identified 3 themes with 13 subthemes addressing patients’ and providers’ perspectives on telehealth visits in T2D care see . Both paIn the following sections, we first describe the first theme, “perceived benefits of telehealth visits,” shared by both patients and providers, followed by the benefits noted by providers only. We then describe the second theme, “perceived technological challenges of telehealth visits,” shared by both patients and providers. Finally, we describe the third theme, “impact of telehealth visits on the quality of diabetes care,” as perceived by both patients and providers, though mainly from providers’ perspectives with some patient input. Direct quotes are presented in the following sections.The majority of persons with T2D and provider participants described positive experiences with telehealth visits due to several benefits, mainly noting increased convenience and efficiency as compared with in-person visits. We identified the following 5 subthemes: (1) diabetes care “in the comfort of your home” at a time of one’s convenience; (2) saving money and time due to no need for transportation; (3) relief from relying on one’s caregiver and less “juggling to get it in our schedule”; (4) efficient visits, fewer delays, and more time with patients; and (5) a good fit for data-driven diabetes care.Regarding the first subtheme (diabetes care “in the comfort of your home” at a time of one’s convenience), many adults with T2D specifically cited the convenience of being able to conduct telehealth visits from their homes or at a private location conducive to their schedule. Similarly, from providers’ perspectives, many providers acknowledged the added convenience of telehealth visits for their patients, citing reasons largely in alignment with what patient participants mentioned:It's really convenient, I don't have to take off from work, I don't have to park. Based on the time of the day, any time prior to like 3 o'clock, the parking garage is pretty well filled up. So, it just really alleviates a lot of additional stress, and a lot of the times, I can either do it at work in a secluded area. I think it's just great, very convenient.Adult09I think the benefit of telehealth is patients who are not coming in because of either distance or they can't find the time to come in at least we have this as a resort to say, “Well, if you can take 20 minutes out of your workday even at work, we can at least still see you and try to do some management.” I think it's useful in that sense.Provider09Regarding the second subtheme (saving money and time due to no need for transportation), people with T2D who drive to in-person visits expressed contentment about not having to pay for parking or gas. Adults who take public transportation to attend in-person visits were satisfied with telehealth visits due to saving money and decreased wait times for both transportation as well as in the provider’s office. Many providers empathized with people’s economic and time constraints that often hindered in-person visit attendance. The following quotes from a person with T2D and a provider reflect the mutual understanding of the perks of being able to conduct diabetes care visits irrespective of their physical locations:Yeah, I do like the video visits. I mean, because it saves money. You know, you don't have to worry about transportation to and from. You know, you could be in the comfort of your own home.Adult18I think it (video visit) is a fantastic way to extend care to people who don't have to drive into our clinic, don't have to park, don't have to waste probably an hour to 2 hours of their day.Provider06Regarding the third subtheme (relief from relying on one’s caregiver and less “juggling to get it into our schedule”), several people with T2D shared their emotional burden of having to rely on their caregivers  to attend in-person visits for a variety of reasons. For them, sharing one vehicle meant that family members had to miss time from work or skip their own medical appointments to help people with T2D with transportation to in-person diabetes visits, or sometimes the adults with T2D would need to skip their visit in lieu of their caregivers. Hence, when telehealth visits were available, these adults with T2D felt content as they no longer needed to rely on others for in-person visits. This quote highlights the experience of 1 participant who had a right leg amputation:To me, it’s convenient that you don't always have to go into the hospital because my fiancée works 9 to 5, which is most of the time that appointments are, so she doesn't have to miss time from work to take me. Normally I could drive, but now with this amputation, I can't do that myself. So, they help a lot, that everything can be done right through a video call, don't actually have to be there.Adult10A provider also acknowledged the barriers of in-person visits, saying:The patients, I think, though, have more of a struggle (doing in-person visits) than we do because of transportation and coming in. If they’re older and they don’t drive, and yet they need to be driven there, that kind of thing.Provider04The fourth subtheme  was unique to providers. Providers described how telehealth visits can be conducted more efficiently than in-person visits, thereby reducing delays in their daily schedule and allowing them to maximize their time spent with each patient. One provider participant contrasted their use of time during in-person and telehealth visits and the beneficial impact on their daily workflow:The person has to get transportation to (the clinic), and then maybe if they have a vehicle, they have to park it. There’s the process of getting signed in, and my 1:00 patient who arrives a couple minutes after 1:00, and then the medical assistant is a little busy, may not get them in the room until 1:25, which can then set my schedule behind. Whereas on telemedicine, I'm running it, I can say to a patient, if we need to wrap-up, like “We only have 5 more minutes,” and I know I’ll have somebody coming into the queue, who will be ready to go ahead and have their appointment. It’s easier to structure the patient to the amount of time you have and also make use of that full amount of appointment time, because you immediately sign onto them, so there’s no delay at all.Provider041c) measurement for the telehealth visits as compared with in-person visits, where a point-of-care HbA1c is taken. Advances in diabetes technology allow most people with diabetes to share their blood glucose data before telehealth visits.The fifth subtheme (good fit for data-driven diabetes care) was unique to providers. Most providers mentioned that diabetes care was suitable for telehealth visits as it focused more on the behavioral and cognitive perspectives. However, providers also specifically expressed the requirement of having home blood glucose data to provide optimal diabetes care and a treatment plan to their patients. This practice is particularly important in telehealth visits as most adults might not have an available glycated hemoglobin  can share their readings from home, it can be just as good and preferable from the patient’s perspective.Provider02Despite the aforementioned benefits, patient and provider participants all faced some challenges related to technology during telehealth visits. To complete a successful telehealth visit in diabetes care, people with T2D needed to have a digital device, know how to get online, navigate the patient portal to the nested telehealth platform, upload their glucose data via a cloud or patient portal, and have familiarity with manipulating the video camera and volume. Any disruption could happen during this process, which could result in a suboptimal experience. We identified 3 subthemes related to technological challenges from both adults and providers and 1 subtheme unique to providers.Regarding the first subtheme , when navigating technology aspects of telehealth  throughout COVID-19, some people with T2D were proficient from the beginning, while others required additional support from staff at the diabetes clinics or other family members. For other patient participants, the repeated practices over time made them more comfortable with telehealth-related technology:I've got a desktop that we've had for some time, and my wife is a technical genius in the house, she helped me get it set up three times now, I'm an old veteran; I could do it solo now.Adult04However, 2 people with T2D specifically cited computer illiteracy as the reason for not utilizing the patient portal . In this case, they would rely on providers to contact them using alternate video platforms  without going through the patient portal. All providers acknowledged that the use of telehealth required digital health literacy and were prepared to use different ways to connect with their patients. A provider discussing the limitations of telehealth visits mentioned the following:Not everybody has a computer at home, which is a problem. Or they don’t have iPhones, so, we can’t do a Facetime call with them. (...) Any of these technical issues mean that we can’t cover as much in that half an hour as I would if I saw them in person because you don’t have those limitations in person.Provider10Both people with T2D and providers acknowledged that the lack of digital devices was a barrier to telehealth visits. At the time of the interview, 3 adults did not have a digital device with a camera capacity . Of these adults, 2 had only phone visits during the peak of COVID-19, while the other person had only in-person visits as he established care after in-person visits resumed. One person who only had experiences with phone visits stated the following:No. I don't even know how to work that (video visit), uh-uh. I just have telephone calls. I don't know how to do none of that virtual stuff. (...) I just upgraded my phone, but I'm saying I still don't know how to work it real good.Adult07Regarding the second subtheme (frustration caused by unstable internet connection), once people with T2D and providers were connected, echoing in voices and delay in transmission due to unstable internet connection were other issues that undermined the quality of conversation and sometimes caused frustration for both parties involved. As most of the allotted time was spent on nonmedical issues , people did not have enough time to ask questions, and providers were unable to properly deliver care. A provider provided the following quote when discussing the disadvantages of telehealth visits:It really comes down to the connection and the person’s savvy with it. I had a lady, lives in Virginia, and she’s elderly, and a friend had to drive her over the line into Maryland. So, they were in the car trying to get a connection with me, and where they were, it wasn’t good connection. So, I’m seeing her frozen face, she sees my frozen face, we halfway hear each other, and finally it had to degrade into a phone conversation.Provider04A person with T2D discussing this frustration in her previous telehealth experience mentioned the following:It (video visit) didn’t go through. We were talking and then it kept disconnecting. The call kept dropping, so we had to wind up just texting. So, 1 out of 5, I’d give it a 1.  (...) I will not give it (the video visit) a try.Adult21The third subtheme (phone visits not encouraged) was unique to providers. At the time of the interview, phone visits were not encouraged due to the complexity of the reimbursement and compliance issues. Although phone visits were the least preferred method for providers to connect with their patients, it was a necessary backup when connection issues or the other abovementioned technical issues persisted.You can't bill for phone visits. (...) Or you can bill for it, but you won't get reimbursed for it. So, then why did I go to all that trouble? Then, I can just have my secretary set up a phone call, and I can just have a phone call, which will work easier, instead of doing this thing of getting onto EPIC—it's a nightmare. Not good.Provider06Regarding the fourth subtheme (difficulty sharing glucose data), both people with T2D and providers mentioned the potential obstacles of sharing glucose data in telehealth visits. Depending on the devices  a person uses, sharing glucose data can be either easy or very troublesome. Patient participants with a CGM generally reported a smooth and easy process for sharing data compared with those with a traditional glucometer. However, not everyone with T2D was eligible for insurance coverage for a CGM, which is expensive for a person paying out of pocket. Many adult participants using a glucometer reported sending handwritten documents ahead of the telehealth visits or reading their daily glucose data in the past few weeks aloud during the telehealth visits. A person with T2D with experience using both glucose monitoring systems shared his experience:Before, it (sharing glucose data) was really easy. Now that I've got different insurance, it's not as easy as it was before, because before I had a CGM and it could just upload the information. So, I just uploaded the information to my dock . Now I'm back to pricking my finger (glucometer), I can't (upload my data), it (the glucometer) didn’t do the same. I've got to keep a record of it myself and share it with my doctors.Adult04Sometimes, if a person did not have their glucometer with them, a provider would rely on the person’s memories of their glucose trends to decide on the treatment plan. Either way, this process took extra time for providers to make sense of the glucose data  before a clinical judgment was made. Those practices specific to telehealth visits either increased the time needed by providers or limited the length of a visit to address adults’ questions and concerns:I had to have them  grab their glucometer and scroll through the numbers and read to me what those were, but for a 20-minute visit, if they're doing that for more than 10 minutes, it really leaves us not much time to go over other things.Provider09The aforementioned benefits and challenges of telehealth had clinical implications for diabetes care. We identified 4 subthemes mainly from providers’ perspectives with support from patient input, including “a double-edged sword for care continuity,” “perceived incomplete visits due to no diabetes quality measures,” “compromised care quality due to unavailability of glucose data and/or unpreparedness of their patients,” and “needs for and preferences of in-person visits.”The first subtheme (a double-edged sword for care continuity) was unique to providers. With all the needed information on hand, telehealth visits allowed providers to offer more frequent quality diabetes care to adults with T2D who traditionally could not attend in-person visits often due to geographic barriers or other transportation-related issues:I think this model  has some advantages in that way, I mean they can touch base more frequently, they might be shorter communications, but they're more frequent as opposed to spaced out longer in-person visits.Provider07Provider participants also noticed that telehealth visits decreased missed appointments, which increased care continuity. Adults with T2D scheduling a telehealth visit received at least one extra reminder because current regulatory requirements mandated the verification of a person’s location before the visit. Additionally, due to the unpredictable nature of technical issues in telehealth visits, providers were more likely to outreach to adults despite an initial absence on the telehealth platforms. Most of their patients were able to remotely engage immediately in telehealth visits when prompted by a provider’s phone or video call. A provider described missed appointments and provided the following quote:I will say, with telemedicine, it’s easier, because you can just call them and say “Hey, you have an appointment, let’s just talk right now.” A lot of people will say “Okay, that’s fine.”Provider03On the other hand, the current telehealth workflow in the diabetes clinics requires adults with T2D to take the initiative to schedule their next appointment after a telehealth visit, instead of scheduling the next appointment at the front desk on the way out of the office after an in-person visit. Although it did not bother people with T2D in this study, a person described how her other health conditions delayed her scheduling the next appointment:I know I need to schedule an appointment. In fact, I was gonna call this week, but I'm getting a medical procedure, so Monday I was seeing other health care providers, so probably next week, I'll call the scheduling line and set up something or try and do it through MyChart to set up (the next appointment).Adult13The delay in scheduling the next appointment could sometimes lead to discontinuity in diabetes care because there was no follow-up mechanism at the time of the interview by the clinics after each visit. A provider discussing the impact of telehealth in diabetes care described this phenomenon:Often, I will say they fall through the cracks, because we don't have the staff to follow-up on every patient and see if they scheduled a follow-up, and so it's sort of like I tell them “Please schedule a follow-up,” and I put in the order so that they'll get a prompt in MyChart, but beyond that we're not following-up to see what happens, and so they may not schedule it themselves. Provider051c, lipid panel, microalbumin) quarterly or annually [1c or other biofeedback at their in-person visits , the responsibility of completing the required lab work shifted to adults with T2D after a telehealth visit; they must remember to make an additional trip to a lab facility. Additionally, it is not feasible to assess diabetes-related complications and other physical exams via telehealth. A person weighing in on telehealth visits mentioned:Regarding the second subtheme, , both people with T2D and providers viewed being unable to complete a thorough physical evaluation as a major limitation of telehealth visits. The American Diabetes Association recommends each person with T2D undergo a physical exam  and biofeedback  good, but I can’t come in getting my instant test, how “boom,” they give you the A1c. It was awesome. I liked that.Adult22Providers admitted the same limitation, adding this additional effort sometimes led to incomplete diabetes quality measures. Without the information, providers might not be able to provide timely treatment recommendations, which could ultimately compromise their patients’ health outcomes. When comparing in-person and telehealth visits, a provider provided the following quote:We can’t do a point-of-care A1c at those visits, and those are problems because we care about all of those and it impacts our decision making . (...) We try to reach out to patients who haven’t had labs done in a while to try to get their labs before their (video) visit, but that’s challenging because the point-of-care A1c makes it very (easy)—it’s a 5-minute test result.Provider10The third subtheme  was unique to providers. Although telehealth visits had the potential to enhance care continuity through proactive outreach from a provider, provider participants felt that sometimes their patient was distracted during a telehealth visit—they might be driving with an intermittent internet connection, walking down the street, or having other commitments—so it was difficult to assess their lifestyle management during that environment. In addition to the inattention, people with T2D might not have their glucose data ready to share, as mentioned previously. Therefore, provider participants sometimes felt that a telehealth visit could compromise the care quality. A provider discussing frustration in telehealth visits mentioned the following:There are times when telehealth visits are not productive. It really, I think, depends on patient engagement. I certainly have had patients who are taking the call while they're driving, or they forgot that they had a visit with me. So, in some ways, people take the telehealth less seriously, in which case, it's a waste of their time and so they're not ready for the visit and so sometimes they don't have labs, no glucometer data (...).Provider09Regarding the fourth subtheme (needs and preferences for in-person visits), both patient and provider participants shared the need for in-person visits. Although people with T2D in this study generally perceived that the conversations and interpersonal relationships during both telehealth and in-person visits were similar, only 5 participants noted a preference for telehealth visits; more than one-half of the participants specifically noted a preference for in-person visits because of the challenges and clinical implications discussed above:Personally, I like face-to-face with my doctors, a checkup to see how you’re doing, with diabetes care. (...) It’s not like I have any kind of feet issues or circulation issues, hopefully never, but it’s good to go through that kind of stuff (check my feet) and just have them check that stuff, and it’s hard to do that with a virtual visit.Adult20Similarly, provider participants also mentioned that adults with T2D should have an in-person visit at least once a year:I do think that patients do have to be seen at least annually, in-person, for a comprehensive foot exam, and other parts of the exam that need to be done as well. (...) What I was finding with telemedicine is that a lot of time, though the visits were great and the recommended frequency would continue, often, the labs would lag behind. Patients wouldn’t feel comfortable going to get their labs done.Provider08This qualitative study outlined the perspectives of both providers and patients with T2D on the benefits and challenges of telehealth in diabetes care. Although people with T2D and their providers acknowledged the convenience and efficiency of telehealth visits for promoting care continuity in diabetes care, telehealth also had challenges that could compromise the quality of diabetes care.Consistent with previous literature , both adGiven health care systems’ rapid increase in telehealth capacities since the COVID-19 pandemic , it is kSeveral temporary policy flexibilities broadened access to diabetes care during the COVID-19 pandemic ,16, inclOur study revealed concerns about glucose data availability impacting the quality of diabetes care in telehealth visits. Of the patients in this study, 70% 16/23) used insulin at the time of their interview, and glucose monitoring is integral to guiding individualized treatment plans in this population . Sharing6/23 used1c, lipid panel, microalbumin [1c and nephropathy monitoring declined and did not recover to the prepandemic volume in the primary care setting [1c measurements was also a risk factor for missed appointments in the diabetes-specific setting [Both patient and provider participants in this study acknowledged that telehealth visits promote care continuity because of convenience and efficiency, but both indicated the need for in-person visits in T2D care. Attending in-person visits allows people with T2D to check diabetes quality measures  within  setting . A gap i setting . To ensuThis study has a few limitations. All participants were from diabetes clinics within a large urban academic medical center in the mid-Atlantic region of the United States. Additionally, the study was designed to focus on missed appointments and interpersonal relationships, and thus, themes presented in this study might not apply to the people with T2D who do not miss appointments. Last, this study collected data from participants who spoke English and responded to our phone calls, text messages, or emails. Although we maximized variations in recruiting participants , the themes derived may not apply to people lacking a working phone number or who do not speak English.In summary, telehealth implementation during the COVID-19 pandemic has expanded access to diabetes care. Adults with T2D and providers generally reported positive experiences with telehealth visits, although some definite technical challenges exist. To ensure equitable access to diabetes care, legislation should provide more flexibility regarding geographic boundaries and telehealth delivery modes (audio-only versus video-audio visits). Telehealth-related technology design also needs to consider user experience and user-centered design to optimize the use of telehealth; a person-oriented telehealth workflow has the potential to address concerns about the negative effects of telehealth visits on the quality of diabetes. Future research to investigate the ideal balance between in-person and telehealth visits in diabetes care is warranted to enhance the quality of diabetes care to optimize diabetes outcomes.


Podarcis lilfordi) and two geckos (Tarentola mauritanica and Hemidactylus turcicus). Balearic lizards have proven to be potential community-level pollinators by interacting with many different plant species to varying degrees. Although in some plant species lizards damaged reproductive structures by feeding directly on them, legitimate visits were significantly more frequent. Intraspecific differences were found in these wall lizards and even indications of gecko–flower interactions. These findings expand our knowledge not only on the magnitude of lizard–plant community interactions but also in their complexity.The role of lizards as potential pollinators is increasingly recognized, especially on islands. However, there are very few studies at the community level that have also addressed intraspecific variations related to the consumption of floral resources. We pursued this objective on the island of Cabrera Gran  where there are the Balearic wall lizards (Podarcis lilfordi) with flowers of 44 plant species, 72.7% of which were unknown to date. Although florivory occurs in some of these species (35%), the majority of visits were legitimate (65%); in addition, we found intraspecific differences in the interactions related to the sex and age of lizards. Our findings support the role of Balearic wall lizards as potential pollinators across the entire plant community, and their contribution to particular plant species, for instance the endangered Cistus heterophyllus carthaginensis. This study also documents the first record of another sympatric lizard (Tarentola mauritanica) visiting flowers and contributes to the few existing records of flower interactions involving geckos in the Paleartic ecozone.The role of lizards as potential pollinators on islands has been documented for either one or a few plants in different parts of the world, but it has never been assessed for an entire plant community. Here, we quantified interaction rate by lizards and evaluated intraspecific differences in the use of flowers on Cabrera Gran  by means of visual observations, automated cameras and the analysis of pollen grain samples. Overall, we recorded interactions of the Balearic wall lizard ( Scaly reptiles (Squamata), named “lizards”, are typically characterized as predators that consume plant matter anecdotally ,2,3, witThe interactions of lizards with flowers have been documented in continental environments ,11,12,13Lizards that interact with flowers can damage the reproductive structures by feeding directly from them , a lacertid that was originally largely distributed but is now restricted to the smaller islands. In areas where they have disappeared, the distribution of some lizard-depending plants for pollen and/or seed dispersal have undergone radical changes [The Cabrera archipelago is, today, the largest territory of the Balearic lizard ( changes . Althoug changes ), the re2, 39°08′31″ N 2°56′45″ E), from 5 April to 6 May 2022, coinciding with the flowering of a good part of the vegetal community. The data were collected throughout the entire island based on flower availability.Fieldwork was carried out on Cabrera Gran, the largest island of the archipelago  from the island of Cabrera Gran [Tarentola mauritanica, and the Turkish gecko, Hemidactylus turcicus. Although there are no records of visiting flowers by these geckos (nor of any herbivorous behavior anywhere in the world), Ficus carica seeds have been found in stomach contents of Moorish geckos precisely in this island [Of the three lizards present in the Cabrera archipelago, the predominant species is the Balearic lizard, an endemic lacertid which spreads over all habitats, from extensive pine forests to minuscule islets without vegetation cover but seasonally occupied by colonies of seabirds . The Balera Gran . In addis island ,49. ThisTo document lizard–flower interactions, we used three sampling techniques: direct observation censuses, automatic cameras and pollen smears. The censuses consisted of 10 min observations, alternating different days, hours and areas, until completing 60 min per plant species, in daytime conditions of clear skies and little or no wind. In each census, we recorded the total number of flowers available, the number of flowers observed and the number of flowers visited, as well as the species, sex and age  of lizards and the type of the interaction . Individual lizards were then grouped into one of three groups  to account for intraspecific size differences that may have functional effects. Any flowering plant was censused , althougWe constructed a binary quantitative ecological network, using data from surveys and automatic cameras, to illustrate the two types of interaction, using the IR values  pooled into the three lizard groups , with the ‘bipartite’ package in R .We explored whether the frequency of legitimate visits versus florivory varies for each lizard group , using a Pearson’s Chi-squared test with Yates’ continuity correction (package ‘CrossTable’ of the R ‘gmodels’ library ).Plantago sp., one Apiaceae species, and four morphospecies whose identification was not possible. The most frequently visited species (higher IR) were Daucus carota, Euphorbia dendroides and Lobularia maritima, followed by Cistus monspeliensis, Lavatera arborea, Lomelosia cretica and Paronychia capitata.Through direct censuses, the analysis of recorded images, the identification of pollen samples and non-systematic observations we reported interactions between lizards and flowers of 44 plant species (n = 57), 41 of which are new to the island of Cabrera . OverallPapaver somniferum) produced a voracious attack, in other common species, such as euphorbias (Euphorbia spp.) or the jaguar (Cistus monspeliensis), a meticulous nectar-licking behavior was shown. The interaction with this last genus, not reported until now, was revealed as one of the most frequent in Cabrera. At noon, a multitude of lizards expose themselves to potential predators by climbing over the sage of this species to collect nectar and pollen with their tongues, moving from one flower to another.Lizards did not interact with all plant species in the same way; legitimate visits were more frequent  than florivory (35%). Interactions of lizards with flowers were either casual , or intentional . In any case, we considered these interactions as legitimate visits as long as there was no damage to the reproductive organs of the flower. It could also be seen that some flowers were systematically bitten while in others the contact almost always occurred with the tongue. For example, while an infrequent encounter with the opium poppy , with legitimate visits being more frequent than florivory for females (p = 0.02) and juveniles (p < 0.001). . .No direct observations of flower visits by geckos were recorded; however, one sample (n = 3) contained more than 100 pollen grains of a species that could not be identified.Balearic lizards have proven to be potential community-level pollinators by interacting with many different plant species to varying degrees. Although, in some plant species, lizards damaged reproductive structures by feeding directly on them, legitimate visits were significantly more frequent. Intraspecific differences were found in these wall lizards and even indications of gecko–flower interactions. These findings expand our knowledge not only in the magnitude of lizard–plant community interactions but also in their complexity.Daucus sp. and Lobularia sp. . In addition, on partially isolated rocks on steep shores, the flowers of plants such as Daucus carota attract the full attention of local lizards as they are often the only resource available in these habitats. This could, to some extent, overshadow the relevance of other plant species belonging to habitats of greater diversity and whose flowers are large and well isolated from each other, such as those of Lavatera spp. and Cistus spp.Quantitatively, the lizards have a much higher frequency of interactions in plant species with flowers that appear very close together or are grouped in inflorescences with a certain density, such as Cistus. In particular, Cistus monspeliensis is extremely abundant on the island of Cabrera and the legitimate interaction of lizards with its flowers, ignored until now, is one of the most important quantitatively. During the study, we also found the world’s largest population of Cartagena rockrose (Cistus heterophyllus carthaginensis), previously undescribed in the Balearic Islands [Due to their relative abundance and generalist behavior, lizards seem to play an important ecological role in the reproduction of the plant community. A particular case is that of rockroses of the genus  Islands . It is a Islands ,54. Its Medicago arborea, Lavatera maritima and Allium subvillosum were observed, even climbing the branches or jumping directly from the ground and attacking flowers voraciously (pers. obs.). In this island, the Balearic lizard is a legitimate flower visitor of Lavatera maritima but can eat the flowers of this same species under dry conditions when other food resources are scarce [The fact that some flowers are systematically bitten, and, in others, nectar is sipped by reptiles may be due to the characteristics of the flower. The sensitivity of lizards to be guided by odors is known , as is te scarce . Thus, iDespite this appreciation, analyses showed a significantly higher frequency of legitimate visits than florivory by female and juvenile lizards . It indiSilene vulgaris flower is illustrative, introducing its snout to feed inside it, while the male with which it shared territory was not interested in it. For larger lizards, sometimes the only alternative that allows them to obtain pollen and/or nectar from flowers is to break the structures by biting. However, it can also happen that, if these structures are not attractive and the reward is minimal, the flower does not arise sufficient interest. In this regard, we cite the case of Cneorum tricoccon, whose small yellow flowers are sucked by small lizards  while the males focus their attention on the relatively large fruits. This mutualistic interaction is the most important [Males were the most florivorous group, showing no significant differences with legitimate visits. Male lizards have larger heads and therefore cannot access the floral cavities where the smallest ones  can. The case of a female lizard that repeatedly visited a mportant  althoughmportant .Lobularia maritima, only frequented by juveniles, and therefore different age classes or sexes can act as differentiated functional groups for the purposes of pollination. Juveniles can also show ethological differences associated not only with size but also with energy demand and ease of obtaining animal prey: as they are developing, they need a higher protein intake than adults and therefore have to invest more in foraging  and less in the consumption of vegetable matter including floral structures . The change in diet towards a higher vegetable fraction in adulthood is typical in generalist species of many families of lizards and is precisely positively associated with greater body size, not only because of the relative energy demand, but also because of the difficulty involved in feeding. Large prey are rarer and more difficult to obtain except for species from highly specialized predatory families, such as monitor lizards or chameleons, which can successfully capture them [We know that reptiles ,22, inclure them .This fact was also reflected in the behavior of the Balearic lizards during hunting: on multiple occasions, the lizards made unsuccessful attempts to catch large insects such as diurnal lepidoptera, while small and low-mobility insects were caught effortlessly. A great need for food not covered by the availability of arthropods for large lizard males can lead them to feed more frequently on floral structures and also to visit fewer plant species, disregarding both those in which they do not have access to nectar for their body dimensions (and the structures themselves are not attractive), such as those whose only interest for lizards is the presence of small pollinating insects.Tarentola delandii in Euphorbia lamarckii) had already been discovered on islands in the Palearctic ecozone [Phelsuma sp. in Mauritius and Reunion [Like the Balearic lizards, geckos present intraspecific variations in diet , but unl ecozone . However Reunion ,67,68,69The discovery of new interactions with flowers for the Balearic lizard—a species that has received much attention so far —demonstr


IntroductionSyphilis is a sexually transmitted infection caused by Treponema pallidum which has protean manifestations. The cutaneous presentation of syphilis can mimic many dermatologic conditions. Materials & methodsWith an aim to describe palmoplantar involvement in syphilis, a retrospective study of case series was done with 11 patients having palmoplantar skin lesions in syphilis within a period of two years. Only serologically confirmed cases were included.ResultsThe prevalence of palmoplantar involvement in syphilis was 47.85% and all of them except one patient  were secondary syphilis. A major proportion of cases (72.8%) studied had no history or presentation of genital lesions. Biett’s collar which is an indicator of palmoplantar syphilis was seen only in 45.5% of the cases.ConclusionThe clinicians must be aware that palmoplantar skin lesions might be the only clinical presentation of syphilis and a high index of suspicion is needed to correctly diagnose and treat the condition in such a setting. Syphilis, an ancient disease caused by Treponema pallidum showed decreased incidence in the 1990s following increased awareness among the population and better screening and diagnostic tests . WHO estThe origin of syphilis has been postulated by the pre-Columbian, Columbian, and unitarian hypotheses dating back to 15,000 B.C. It has always been stigmatized, each country that was affected by the infection blamed the neighboring and enemy countries for the outbreak. The term ‘syphilis’ was coined by Girolamo Fracastoro, a medical personality in Verona. Later, Schaudinn and Hoffman discovered the etiologic agent of syphilis and named it Spirochaeta pallida, which they subsequently changed to Treponema pallidum . Syphilis is transmitted by sexual contact , but it can also be spread congenitally 65%) by vertical transmission  between June 2021 to July 2023 were selected. Among 23 patients who were diagnosed with syphilis, 11 patients were selected based on the criteria of the study. Patients who were serologically negative for syphilis were excluded. The available data such as age, sex, duration, clinical presentation, treatment history, and results of serological tests were recorded, tabulated, and analyzed. High-risk behavior (HRB) such as substance abuse , men who have sex with men (MSM), and commercial sex workers was noted. Nearly half of the patients diagnosed serologically with syphilis (47.82%) were found to have palmoplantar involvement. Male predominance was noted and the median age is 35 Table . The onlSyphilis, a sexually transmitted infection is classified into primary, secondary, latent, and tertiary syphilis. If the primary infection is not properly diagnosed and treated, after four to 10 weeks, the disease evolves into secondary syphilis as seen in our case series. Syphilides are eruptions of secondary syphilis presenting as asymptomatic coppery papules whose palmoplantar localization is very suggestive . Among 2Syphilis is famously known for being a great imitator, physicians must be familiar with all potential clinical forms of syphilis . A PubMeNail involvement includes nail plate changes like brittleness, splitting, fissuring, pitting, onycholysis, elkonyxis, Beau's lines, onychomadesis, and nail loss. Additionally, nail matrix change is mainly represented by syphilitic painless paronychia .On dermoscopy, an orangish background is seen which is likely due to hemosiderin deposits in the dermis because of extravasation of red blood corpuscles (RBCs) in secondary syphilis. The Biett’s collar is visualized on the dermoscopy as a circular, thin, scaling edge that progresses in an outward direction and is surrounded by an erythematous halo. With dermoscopy, the evolution of syphilide is marked by the progressive extension of the Biett’s collar towards the periphery until the disappearance creating a tartar-like appearance, with a remarkable attenuation of the erythema and the orange background after one week . The eliA nontreponemal test like VDRL is a simple and inexpensive screening test that detects antibodies from two weeks till about six weeks after infection. Though the VDRL is 100% sensitive in secondary syphilis, it could become negative after treatment or false negative due to the prozone phenomenon. The prozone phenomenon was found to have less than 2% incidence in syphilis which could be corrected by serial dilution of the serum as seen in our case . Highly As per CDC guidelines, secondary syphilis should be treated by benzathine penicillin G 2.4 million units intramuscular (IM) in a single dose regardless of HIV status. In areas of high prevalence of HIV, those persons with primary or secondary syphilis with negative HIV test results should be offered HIV PrEP and retested in three months. On follow-up, clinical and serologic evaluation should be performed at six and 12 months after treatment. Re-infection and treatment failure should be considered in patients who have signs or symptoms that persist or recur and those with at least a fourfold increase in nontreponemal test titer persisting for >2 weeks . Apart fAs seen in our study, palmoplantar skin lesions could be the only sign of syphilis as the patient may not reveal the relevant history due to the sensitive nature of the information. It is imperative that clinicians know this manifestation of syphilis for the correct diagnosis of syphilis because, from a public health perspective, the secondary stage of syphilis is highly contagious, and early detection could lead to the prevention of irreversible systemic complications and further transmission of the condition. Further, physicians should be aware of the causes of false positive and false negative results of screening tests for syphilis and should take appropriate measures to aptly diagnose the disease. Small sample size, no record of dermoscopic or histopathological features, and lack of possible clinical correlation with serological titers are the limitations of this study and are the areas of need for future research.


This study analyzes the mycobiome in wild and captive Sumatran orangutans.Nine orangutan feces samples from the wild and nine from captivity were divided into three repeats from 11- to 15-year-olds in good health. The Illumina platform for analysis of ITS bioinformatics was used according to the Qiime2 and CCMetagen approaches.Neurospora (31%), Penicillium (10%), Aspergillus (3%), Fusarium (3%), Candida (2%), Cutaneotrichosporon (2%), and Limonomyces (2%) are found in wild orangutans. The most prevalent genus among captivity orangutans is Aspergillus (32%), followed by fungal sp. (11%), Lasiodiplodia (18%), Devriesia (2%), and Sordariomycetes (2%). According to the Chao1 diversity index and Shannon and Simpson, there was no significant difference between wild and captive Sumatran orangutans.Wild Sumatran orangutans include 53% Ascomycota, 38% uncultured fungi, and 4% Basidiomycota. Orangutans in captivity are 57% Ascomycota, 26% uncultured fungi, and 2% Basidiomycota. Based on genus level, uncultured Neurospora is unique to wild Sumatran orangutans, although Aspergillus predominates in captive orangutans. We hypothesize that the gut mycobiome of wild orangutans will resemble that of orangutans in captivity. The excellent range of food sources in the forest does not result in the prevalence of fungi in the typical gut microbiome. Pongo spp.). Orangutans are frugivores whose primary food source is fruit and insects [Pongo abelii and Pongo tapanuliensis) and Kalimantan (Pongo pygmaeus) [Orangutans are one of Indonesia’s endemic primates. Orangutans are one of Southeast Asia’s few remaining giant apes  ,4. The Sygmaeus) . This isygmaeus) .Sumatran orangutans are predominantly arboreal, or tree-dwelling or tree-working, mammals. The everyday activities of orangutans consist primarily of eating, relaxing, and social interaction. They are accustomed to spending most of their time eating in the morning and afternoon. The Sumatran orangutan’s eating habit involves tasting. Orangutans inhale the aroma and taste some of their food before ingesting it. If the orangutan does not like the food, it will discard it and search for other food. Orangutans engage in resting behaviors while sleeping at night and taking naps between activities. They typically construct their nests in the canopy of trees to avoid predators. Sumatran orangutans are semi-solitary animals. Typical orangutan social activity involves interactions between mother and offspring and young orangutans playing.Humans and orangutans share similar genetic and physiological traits. Orangutan research is focused on protecting forests as orangutan habitats, while orangutan health has gotten little attention . AccordiStudies have shown that fungi present in the gut microbiome of primates can control the immune responses of the host by either reducing or increasing local inflammation. Generally, fungi produce enzymes and antibiotics that aid the host’s metabolism. A healthy microbial environment in the digestive system stimulates the production of intestinal villi, which enhances the efficiency of the intestinal barrier and helps protect against harmful bacterial infections and nutrient absorption ,10. HoweThis study obtained a permit and a written recommendation letter from Kementerian Lingkungan Hidup dan Kehutanan Direktorat Jenderal Konservasi Sumber Daya Alam dan Ekosistem. Nomor: SK 433/KSDAE/SET.3/KSA.2/8/2021.P. abelii) in the wild and in captivity. Randomly combining nine samples from orangutans in the wild and nine samples from orangutans in captivity yielded three replicates, each containing three samples. The orangutans to be sampled are in good health, and none of the orangutans in custody is undergoing therapy. The feces of newly defecated orangutans are collected in the middle to avoid environmental contamination, sealed in a plastic bag, and stored in a cold box until the laboratory reaches a temperature between 2°C and 10°C.The samples were gathered from healthy 11 to 15-year-old orangutans  to mountainous regions . Almost 80% of the terrain has a gradient greater than 40%. In this jungle, orangutans live naturally without human intervention in health management, diet, immunization, or worm treatment. Their diet comprises fruits gathered and ingested directly from trees, and they live from 15 to 40 m above the ground, where feces are identified. Orangutan feces were collected when the orangutans defecated early in the morning [Meanwhile, fecal samples were taken from nine Sumatran orangutans in captivity at the Indonesian Safari Park in Bogor. This 168-hectare park is between 900 and 1,800 masl and has average temperatures between 16°C and 240°C. Orangutans in captivity were never administered antibiotics. The captive orangutans in this experiment had never received antibiotic therapy before.® High-Fidelity PCR Master Mix (New England Biolabs).The Qiagen DNeasy PowerSoil Kit was used to extract the feces of wild and captive Sumatran orangutans . Following the manual’s instructions, 250 mg of fecal samples were utilized to extract DNA. The internal transcribed spacer region (ITS) region was amplified by PCR using the primers ITS1F (5′-CTT GGT CAT TTA GAG GAA GTAA-3′) and ITS2 (5′-GCT GCG TTC ATC GAT GC-3′ with barcode) for 35 cycles at 95°C for 30 sec, 52°C for 30 sec, and 72°C for 30 sec . All PCRIn the process from DNA samples to the final data, each step, including sample testing, PCR, purification, library creation, and sequencing, will affect the quality and amount of the data. In contrast, the data quality would immediately affect the findings of the information analysis. Quality control is performed at each stage of the process to ensure the precision and dependability of the sequencing data.® UltraTM DNA Library Prep Kit for Illumina and quantified using Qubit and quantitative Polymerase chain reaction) would be analyzed on the Illumina platform. The Illumina NovaSeq was utilized to sequence a 150-bp at a depth of 1,100. Based on the specific barcodes of each sample, paired-end reads were assigned to them, and the barcode and primer sequences were deleted. To merge paired-end readings, FLASH (V1.2.7) was utilized [http://arb-silva.de/), and chimeric sequences were deleted [DNA libraries generated with the NEBNextutilized . Accordiutilized  quality- deleted . The Effhttp://arb-silva.de/). For each taxonomic level, provide species annotation. (Threshold:0.81) [Uparse software (Uparse v7.0.1090) evaluated sequences using all available tags . The simld:0.81) . The MUSld:0.81) . Utilizild:0.81) .Using clustering analysis and an evaluation of molecular variation to determine the commonalities between multiple specimens, a cluster tree was constructed. Principal Coordinates Analysis (PCoA) can be utilized to depict beta diversity . The BraWe employed the CCMetagen approach to increase the accuracy and speed of metagenome classifiers. Pipeline greatly outperforms other commonly used tools in recognizing bacteria and fungi and can efficiently use the entire National Center for Biotechnology Information nucleotide collection as a reference for discovering species with insufficient genome data .P. abelii) aged 11-15 years and randomly combining them into three replicates of three samples each. When collecting samples of wild orangutans, we scoured the forest for trees that provided orangutans with food. After seeing the orangutans eating, we followed them until they defecated. The read counts data reveal a maximum of 328,145 reads (Exsitu3) and a minimum of 87,574 reads (Exsitu2), both of which are from captivity Sumatran orangutans, as shown in The composition of the gut microbiota was effectively studied by collecting feces samples from nine wild and captive Sumatran orangutans (Neurospora (31%), Penicillium (10%), Aspergillus (3%), Fusarium (3%), Candida (2%), Cutaneotrichosporon (2%), and Limonomyces (2%). Aspergillus is the predominant genus among captivity orangutans (32%), followed by fungal species (11%), Lasiodiplodia (18%), Devriesia (2%), and Sordariomycetes (2%).The relative frequency of different microbial taxa in wild Sumatran orangutans is 53% Ascomycota, 38% uncultured fungi, and 4% Basidiomycota. Sumatran orangutans’ captivity phyla are 57% Ascomycota, 26% uncultured fungi, and 2% Basidiomycota. Based on the results of OTU identification and taxonomic annotation According to CCMetagen, the total fungi at the genus level from the phylum Ascomycota and Basidiomycota in wild Sumatran orangutans are uncultured P. abelii), as determined by CCMetagen analysis, Neurospora, Penicillium sp. SYFz-1, cf. Limonomyces roseipellis, uncultured Fusarium, and Candida albicans were identified. In captivity, Sumatran orangutans, Penicillium sp. SYFz-1, uncultured Fusarium, cf. Limonomyces roseipellis, C. albicans, and uncultured Aspergillus were the most prevalent species (At the five species level of wild Sumatran orangutans ( species  and 3.To examine the microbial community makeup in each sample, sequences classified as the same OTUs shared 97% similarity on the Effective Tags of all samples. The rarefaction curve depicts the relationship between the number of species and the number of samples. Rarefaction can be used to verify if a sample has been sufficiently sequenced to represent its identity accurately. It can also be used to determine if a group of samples originates from the same community.p-value of 0.635 and a T-test statistic of 0.585; Shannon has a p-value of 0.798 and a T-test statistic of −0.386; and Simpson has a p-value of 0.891 and a T-test statistic of 0.032.According to the Chao1 diversity index, Shannon and Simpson found no significant difference between wild and captive Sumatran orangutans regarding microbial diversity. Chao1 has a p-value is 0.90. The microbial community composition of Sumatran orangutans in the wild and in captivity does not differ significantly. The cluster analysis aims to generate a tree diagram where the most comparable data points are placed on nearby branches. The investigation findings indicate that the hierarchical clusters of Exsitu1 are more comparable to Exsitu3 than Exsitu2.Beta diversity is a comprehensive comparison of microbiomes’ diversity based on their diversity. Therefore, beta diversity measurements are used to evaluate the differences between microbiomes. A cluster tree was constructed using clustering analysis to examine the commonalities among multiple specimens. PCoA can be utilized to depict beta diversity. Optimizing the linear correlation between sample values is the objective of the PCoA. The distance technique employs the Bray-Curtis index and PERMANOVA to establish statistical significance in this study. According to the PERMANOVA results, the R-squared value is 0.14629, and the This study is the first to investigate the mycobiome of both wild and captive Sumatran orangutans, although the fungal aspect of gut microbiota has received less attention compared to bacteria. Despite individual variations in gut microbiota, such as age, sex, geography, diet, and health, fungal commensals in the gut play critical roles in the mammalian immune response. This research sheds light on the dietary and digestive adaptations of orangutans, as the diversity of their gut mycobiome is comparable to that of other primates. Interestingly, the diversity of the gut mycobiome of wild orangutans is similar to that of captive orangutans, despite the wider range of food sources available in the wild.The gut mycobiome plays a vital role in digesting challenging-to-digest substances such as fiber and oligosaccharides. Through fermentative metabolism, the mycobiome generates various metabolites like short- and medium-chain fatty acids and gases. It also plays a significant role in safeguarding the epithelial barrier against pathogens and boosting immunity by activating T-cell 17 immune mechanisms. Thus, maintaining mucosal homeostasis is one of the critical functions of the gut mycobiome ,25.Penicillium sp. SYFz-1, cf. Limonomyces roseipellis, uncultured Fusarium, and C. albicans. However, wild orangutans had uncultured Neurospora, while captive Sumatran orangutans had the highest levels of uncultured Aspergillus.The ITS region of fungal rRNA varies in length among different fungal species, which can introduce bias when using next-generation sequencing technology. Moreover, ITS variation may not always be sufficient to distinguish between species, and few references are available to match sequences to organisms . AlthougAspergillus, Penicillium, and Fusarium fungi in their guts. These fungus genera produce enzymes that are useful for breaking down cellulose biomass in plant diets rich in cellulose and hemicellulose [Neurospora crassa, a species in the genus Neurospora, is known for possessing regulatory genes that express cellulase genes, cellulase activity, and cellulase secretion [Sumatran orangutans consume various food items, including fruits, young leaves, flowers, honey, shoots, stems, seeds, nuts, bamboo, mushrooms, bark, termites, and ant eggs. These food items are rich in cellulose and hemicellulose, which primates cannot digest independently due to a lack of the cellulase enzyme. Therefore, they rely on their gut microbiome to produce this enzyme. Fungi found in the guts of wild and captive Sumatran orangutans are believed to aid in metabolic processes, particularly the digestion of cellulose and hemicellulose. As a result, the mycobiomes of wild and captive Sumatran orangutans were not significantly different. Similar findings have been reported in studies of Tibetan macaques and Lemurs, which also had ellulose ,29. Furtecretion .Neurospora is a type of filamentous fungus belonging to the Ascomycota phylum. The name Neurospora refers to the appearance of its spores, which have striations resembling axons. This fungus is widely used in cellular research to study aspects of eukaryotic biology, such as development and differentiation [Neurospora is a valuable model organism for studying epigenetic phenomena, as it has various genome defense and epigenetic mechanisms. Neurospora is the only organism with repeat-induced point mutations, a unique feature among fungi [Neurospora has a secondary metabolism, some gene sequences have been identified as potential candidates for secondary metabolite production [ntiation . In adding fungi . While toduction .Candida albicans has been found in both wild and captive Sumatran orangutans. While most research on the mycobiome has focused on opportunistic pathogens like C. albicans, it is actually a common fungus in the gut of healthy humans and animals, making it a typical member of the human gut microbiota [C. albicans lacks a significant reservoir in the environment, it is believed to have coevolved extensively with its host and other microbes. Although Candida can also colonize other body parts, such as the mouth, skin, and vagina, it is a frequent cause of mucosal disease in otherwise healthy individuals [crobiota –38. Sincividuals ,40. Howeividuals ,42 and lividuals .Candida spp. has been found to influence the gut bacterial microbiome’s assembly and function through various mechanisms such as cellular contact, competition, collaboration for nutrients, and the production of secondary metabolites and antimicrobial peptides. These interactions between gut fungi, bacteria, and host immunity are essential for maintaining human immune homeostasis, which can influence overall health and disease outcomes [The mycobiome in the gastrointestinal tract, which is estimated to be around 0.1% of the total gut microbiome in humans ,44, likeoutcomes –47.Candida spp. In contrast, a protein-enriched diet is associated with a decreased abundance of Candida spp. and Methanobrevibacter bacteria in healthy individuals [The variability of the gut mycobiome is influenced by dietary and environmental factors and host factors such as genetics, age, sex, use of antibiotics, and antifungals. The gut mycobiome shows higher variability between individuals and instability over time than the gut bacterial microbiome. Individuals with different nutritional patterns have different gut mycobiome compositions. A carbohydrate-rich diet is associated with an increased abundance of ividuals ,48,49. OHowever, the study has limited samples of wild orangutans that reside in tall trees and has detected a population of approximately 30 wild orangutans dispersed across hundreds of hectares of forest. It is important to continue research on the mycobiome of wild orangutans and expand the sample size to gain a more comprehensive understanding of the gut microbiome in these animals. Such studies could also provide valuable insights into the role of the gut microbiome in the evolution of orangutans and their adaptation to changing environments. This information could also be used to develop strategies to support the conservation of orangutan populations, as changes in diet and habitat could affect the composition and function of their gut microbiomes, including the mycobiome.Neurospora is unique to wild Sumatran orangutans, although Aspergillus predominates in captive orangutans. We predict that the gut mycobiome of wild orangutans will be similar to that of captive orangutans. The greater diversity of food sources in the forest does not result in the presence of fungi in the normal microbiome of the gut flora. The synergistic, symbiotic, or antagonistic interactions between fungal and bacterial microbiota members should be understood.Wild Sumatran orangutans are composed of 53% Ascomycota, 38% uncultured fungi, and 4% Basidiomycota. In captivity, 57% of the orangutan phyla are Ascomycota, 26% are uncultured fungi, and 2% are Basidiomycota.


Funding statement. The original statement, “SB was supported by an AberDoc Ph.D. scholarship from Aberystwyth University, United Kingdom,” did not include the funding granted to author JS. The correct Funding statement appears below.In the published article, there was an error in the “SB was supported by an AberDoc Ph.D. scholarship from Aberystwyth University, United Kingdom. JS was supported by CACMS Innovation Fund (#CI 2021A05110) from China Academy of Chinese Medical Sciences, Beijing, China.”The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.