Lactobacillus-dominated flora seems to play a pivotal role in determining fertility, and in particular Lactobacillus crispatus showed a central role. Nonetheless, the presence of pathogens in the genital tract, such as Chlamydia trachomatis, Gardnerella vaginalis, Ureaplasma species, and Gram-negative stains microorganism, affected fertility also in case of asymptomatic bacterial vaginosis (BV). We failed to identify descriptive or comparative studies regarding tubal microbiome. The microbiome of the genital tract plays a pivotal role in fertility, also in case of ARTs. The standardization of the sampling methods and investigations approaches is warranted to stratify the fertility potential and its subsequent treatment. Prospective tubal microbiome studies are warranted.The human microbiome plays a crucial role in determining the health status of every human being, and the microbiome of the genital tract can affect the fertility potential before and during assisted reproductive treatments (ARTs). This review aims to identify and appraise studies investigating the correlation of genital microbiome to infertility. Publications up to February 2021 were identified by searching the electronic databases PubMed/MEDLINE, Scopus and Embase and bibliographies. Only full-text original research articles written in English were considered eligible for analysis, whereas reviews, editorials, opinions or letters, case studies, conference papers, and abstracts were excluded. Twenty-six articles were identified. The oldest studies adopted the exclusive culture-based technique, while in recent years PCR and RNA sequencing based on 16S rRNA were the most used technique. Regardless of the anatomical site under investigation, the  The human microbiome plays a significant role in determining the health status of every human body and in fact, bacterial communities coexist in mutualistic symbiotic relationships with the host ,2,3. Thelactobacilli dominate the microbial community and help defend women against infectious disease, hence playing a potential pivotal role in reproductive outcomes, such as fertility and gestational length [In recent years, the microbiota of various anatomical sites, such as the gastrointestinal (GI) and urogenital tracts, have been investigated, and notably, it was found that the GI tract accounts up to 29% of the whole human microbiome, while the urogenital tract contributes up to 9% [l length .The aim of this systematic review is to report the current evidence regarding the relationship between genital female microbiome and fertility issue and eventual potential implication on assisted reproductive treatments (ARTs).The literature search for articles regarding microbiota/microbiome/microfilm/microflora and fertility or infertility was performed using three following databases: PubMed/MEDLINE, Scopus, and Embase. The search strategy was properly adapted to each database. Moreover, the authors hand-searched the references of the eligible studies in order to obtain a full view on the topic. Details on the search strategy are summarized in -Population: women or couples with infertility (any type) or non-pregnant condition.-Intervention: genital tract microbial assessment-Comparison: optional comparison with microbiome of fertile women.-Outcomes: composition of the microbial flora correlated with infertility or ARTs failure-Study design: only full-text original research articles written in English were considered eligible for analysis, whereas reviews, editorials, opinions or letters, case studies, conference papers, and abstracts were excluded.The last search was performed on February 2021 and there were no restrictions on the date of publication. This study aimed to ask the following PICOS questions:This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . No InstThe above described search strategy retrieved 3295 articles. After deletion of duplicates and careful overview of the abstracts and full-texts if needed, 20 articles were selected. Moreover, 6 additional articles were found during the hand-searching of its references. Finally, 26 articles that constituted the final pool were discussed in the following paragraphs. The study selection process is reported in We briefly introduced the sampling and analyses methods and subsequently discussed the findings mainly based on the principal anatomical site under investigation that produces relevant results in every study. A synoptic overview was reported in Lactobacilli can eventually impair ARTs outcomes. The evaluation of the genital microbiome is not yet standardized nor systematically implemented in any guidelines.In this review, we took into account the relevant literature regarding genital tract microbiome and its potential impact on fertility. According to our review, the majority of data suggests a not negligible role of the genital microbiome in infertile women and dysbiosis and the lack of The first experiences of microbiome assessment in infertile women were performed with classical methods, such as either vaginal or cervical swabs . The mosClassical analysis consists of culture-dependant methods; in fact, after a certain period of culturing, different bacterial species can be identified using characteristics cell staining, morphology or observed biochemical reactions ,14. CultClassification based on gram staining and cell morphology is possible using microscopy of clinical specimens, and today this method is still adopted to identify the clue cell or to assess the Nugent Score in genital microbiome samples. However, this technique is time-consuming and requires not-negligible know-how and training .Over the past decade, there has been an explosion of interest in molecular-based, culture-independent techniques to study the microbiome, and sequencing of 16S ribosomal RNA (rRNA) related genes largely changed the approach to study the microbiome . In factThe quantitative polymerase chain reaction (qPCR) is a sensitive method to identify a specific group of bacteria and is a well-established tool for detection, quantification, and typing of different microbial species . qPCR caAfter the introduction of next-generation sequencing (NGS) technologies, massive parallelisation of bacterial sequencing of 16S rRNA was possible in combination with bioinformatics pipelines that provided final clustering of the results according to similarity concepts; currently, 99% is proposed as the optimal threshold for similarity to correctly assign a taxonomic unit . The whoFinally, another method adopted to study microbiomes is the intergenic spaces (IS)-pro technique, which is another amplification approach on the IS regions, whose lengths are specific for each group of bacteria . IS-pro Candida, Enterococcus, and Escherichia coli) in infertile patients and, when compared to healthy women, a pronounced lower rate of Lactobacillus colonies [The majority of evidence derives from the assessment of vaginal microbiome, that is the easiest anatomical site to sample. The proof of concept of all the studies performed is to identify those patients with an abnormal vaginal microbiome and highlight the differences related to successful ARTs or pregnancy success. The paradigmatic study with culture-based technique is an Indian study, where the vaginal flora of infertile patients was assessed by routine aerobic, anaerobic, and fungal culture with the aim to detect asymptomatic vaginosis and to compare the vaginal microbiota of infertile women versus healthy women. The authors found a prevalence of 28% of asymptomatic bacterial vaginosis  was correlated with a worse outcome of ARTs and hence generalization regarding the possible beneficial effects of Lactobacilli on fertility should be avoided, given that different species of the latter may differently affect ART outcomes. Campisciano et al. [Lactobacillus iners resulted as a marker of healthy vaginal microbiome, while Lactobacillus crispatus levels were lower in idiopathic infertile women when compared to healthy women and these findings is only partially in contrast to the previous study. In fact, on one hand, the drop of Lactobacillus crispatus may lead to an increased susceptibility to pathogens, hence favouring BV; on the other hand, the simple presence of the latter is not a favourable factor, but the degree of domination of Lactobacillus crispatus in the vaginal microbiome is probably the key of lecture.Beside a culture-based approach, the diagnostic performance of qPCR for abnormal microbiome compared to Nugent Score criteria in infertile women was firstly assessed by Haarhr et al.  in 130 went ARTs . Moreoveo et al.  adopted Ureaplasma parvum was found in 59% of women and its prevalence was higher in women whose partners had inflammatory prostatitis; nonetheless, the same pathogen was found in half of the male partners. After intercourse, a median of four and two new species emerged, respectively, and disappeared in women, and the authors noted that these changes were less frequent in the presence of a normal vaginal microbiota and more prominent in the partners of men affected by inflammatory prostatitis, arguing that this microbial shifting can interfere with fertilization.An interesting study by Borovkova et al.  clarifieThe embryo implantation rate was not significantly decreased by the presence of BV in a study of 307 women who underwent in vitro fertilization (IVF), whose vaginal microbiome was investigated with a validated diagnostic test by qPCR using sterile cytobrush and cotton swabs . In thisMycobacterium tuberculosis was the only one with a higher occurrence in infertile patients; again, bacterial culturing [Chlamydia trachomatis antibodies on the serum. A further confirmation derived from the study of Cheong et al. [Chlamydia trachomatis, in contrast with a lower prevalence of the infection in the fertile group of women (88% vs. 28%) after correction of the results according to demographics parameters. Moreover, many further associated pathogens were isolated more frequently in those women with Chlamydia trachomatis infection. Given the evidence that Chlamydia trachomatis is linked with infertility, Graspeuntetner et al. [Chlamydia antibodies in patients with infectious infertility, non-infectious infertility and healthy volunteers. A higher rate of Chlamydia trachomatis was observed in infectious infertility women when compared to non-infectious group, while a progressive decrement of Lactobacillus species was detected in healthy volunteers, non-infectious, and infectious infertility women , respectively; on the contrary, Gardnerella vaginalis was seen with an increasing trend in the same groups  and a similar trend was observed also for Prevotella and Sneathia.One of the first studies  describiulturing  on cervig et al.  that assr et al.  adopted Lactobacillus had a higher chance of getting pregnant [Escherichia coli and streptococcus species with clinical and ongoing pregnancy rates and implantation rates significantly lower when compared to women with negative culture .Bacteria culturing of cervical canal swab performed before embryo transfer in 204 women demonstrated a significant correlation between the presence of any gram negative colonization and the failure of conception; notably, women with sterile cervical culture or demonstrating pregnant . Similarpregnant  instead Bacteroides and Pelomonas taxa, and in a few cases, they noted the presence of Lactobacillus crispatus and Iners associated more frequently with Bacterioides species. Moreno et al. [Lactobacillus-dominated flora (<90% of Lactobacillus species with >10% of other bacteria) was associated with decreased implantation, pregnancy, ongoing pregnancy, and live birth rates. The authors suggested that the lack of Lactobacillus-dominated flora can be considered as an emerging cause of implantation failure and pregnancy loss. A subsequent pilot study conducted in 102 infertile Japanese women [Lactobacilli both in endometrial and vaginal samples and also in the following cycle, confirming that Lactobacillus-dominated flora is independent of hormonal changes during the fertile period. The authors investigated the endometrial versus vaginal microbiome of different groups of patients, finding rates of Lactobacillus-dominated flora of 38% (30/79) versus 44.3% (44/79), respectively, in IVF patients, and 73.9% (17/23) vs. 73.9% (17/23) in the non-IVF patients. Considering the percentage of abnormalities in the microbiome of IVF patients, compared to the non-IVF patients or healthy volunteers, the authors believed that endometrial microbiome might be related to unexplained recurrent implant failures. Another comparative study [Lactobacillus-dominated flora was seen more frequently in the RIF group, than in the control group, although without significant statistical difference, both in the endometrial fluid and vaginal samples. Gardnerella Vaginalis was detected more frequently in endometrial fluid of the RIF group, even though without statistical significance; noteworthy, Burkholderia was detected in 25% of the RIF group and none in the control group. A great limitation of this study is the unpredictable longitudinal RIF in the control group, making the results less generalizable. A study by Liu et al. [Lactobacillus was greater in non-CE patients (1.89% vs. 80.7%) with a less abundance of Lactobacillus crispatus in the CE group of patients while Anaerococcus and Gardnerella were negatively correlated with the relative abundance of Lactobacillus in CE microbiome.The first study assessing the microbiome of the endometrium in infertile women was conducted by Ilesanmi et al.  with a co et al.  demonstrse women  assessedve study , charactu et al.  systematEscherichia coli was implicated in primary infertility, even though it was not the only isolated pathogen; hence, the authors suggested adopting therapeutic managements strategies of couples with primary infertility such as antibiotics and a parallel treatment to avoid cross-retransmission. A pilot study by Wee et al. [Lactobacillus genus was the most frequently observed overall and the abundance of taxonomic units was the same both in cervical and vaginal specimens; the dominant microbiome was consistent also in regards to the endometrium, even though in different relative proportions. There was a trend for infertile women that demonstrated Ureaplasma in the vagina and Gardnerella in the cervix. The test for the expression of selected genes in the endometrium failed to show any correlations with case–control status, or with microbial community composition, although Tenascin-C expression was correlated with a history of miscarriage.An Indian study by Mishra et al.  includede et al.  comparedLactobacillus species in human follicular fluid was associated with embryo maturation and transfer, and conversely the presence of contaminants  affected adversely the IVF outcomes without however identifying a single species associated with decreased fertilization rates.Pelzer et al.  comparedLactobacilli and lactic acid-producing bacteria among women with ongoing pregnancy against who did not have a pregnancy. These couple of studies represent a proof of concept for the characterization of the microbiome at the time of embryo transfer and could potentially be prospectively employed to understand the need of probiotics in a subsequent successful pregnancy event.Notably, a couple of studies included in our review undertook both RNA sequencing on the distal part of the catheter used for embryo transfer  and one Lactobacilli can potentially impair ARTs and partially explain implantation failures. A complex interaction of the Lactobacillus species plays a pivotal role for the equilibrium of the normal vaginal flora and in particular appropriate levels of Lactobacillus crispatus are involved as protective factor for asymptomatic BV  that is recognized as a potential impairing factor of fertility. Similarly, the presence in the cervical flora of Gram-negative bacteria, Chlamydia trachomatis and Gardnerella vaginalis, and the eventual coexistent lack of Lactobacillus is linked with infertility condition. The lack of a Lactobacillus-dominated flora in the endometrium seems linked with recurrent implant failures, and the latter is supported by the prevalence of Bacteroides species in the endometrium of non-pregnant women, given the fact that hormonal changes do not impact the variety of endometrial microbiome, including the relative abundance of Lactobacilli. Of note, Gardnerella vaginalis was also isolated in the endometrium of infertile women. Embryo transfer seems not influenced by vaginal dysbiosis, even though the strength of this affirmation is very weak, whereas the success of the embryo transfer is conversely impacted by abnormal cervical flora.The available data suggest a not negligible role of the genital microbiome in infertile women and further, dysbiosis and the lack of Another point of discussion is the total lack of data regarding microbiome of the tube(s); in fact, we failed to identify studies investigating this anatomical site. Of course, we believe that the sampling of the tube is a more invasive procedure that cannot be performed as easily as a vaginal swab, even though an outpatient procedure with an in-office hysteroscope might be feasible and well tolerated by the woman. In literature, we found examples of brush cytology of the fallopian tube ,43,44 usMicrobiome profiling requires international consensus regarding sampling and investigation analyses that should be performed without culture-dependent methods, and large prospective studies with homogeneous inclusion and exclusion criteria are needed to explore this field with a robust clinical and translational outlook.


Ample evidence generated over the past two decades underlines the crucial role of nutrition to achieve healthy aging. Numerous dietary strategies and food components have increasingly been investigated as interventions to preserve function and compress morbidity and disability to a period later in life. Findings from preclinical investigations, as well as cross-sectional, longitudinal, and intervention studies indicated that well-established ‘holistic' healthy diets [e.g., DASH  and MediAmong these dietary strategies, caloric restriction (CR), an ambiguous term often synonymously used with energy restriction (ER), has proven to be a very robust and broadly applicable intervention that affects aging-relevant molecular pathways and induces a range of beneficial effects involved in the maintenance of physiological functions throughout the life course , 7. GeneThis Research Topic contains 11 articles covering the specific parts of the above-mentioned aspects.Liu et al. summarize evidences on the impact of CR and alternative approaches on frailty syndrome, highlighting potential underlying mechanisms. Besides frailty, older adults are particularly vulnerable to cardiometabolic disease and unhealthy diet is a leading risk factor for the development of cardiometabolic disease  diet on parameters of cardiometabolic health in a cohort of sedentary obese older adults. They found that a DASH-like diet with restricted calories is an effective approach to improve cardiovascular, metabolic, and inflammatory biomarkers. Besides calories, macronutrients play an important role in shaping a diet's effects on health and aging  that could mimic the cardiometabolic benefits of CR in animal models and humans. The authors also summarize emerging potential CR mimetics, such as spermidine, NAD+ precursors, and metformin, highlighting the mechanism underpinning their cardiometabolic and health-promoting effects. Similarly, Stadler and Marsche provide an insightful overview, detailing how dietary strategies and various nutritional components may improve the atheroprotective functions of high-density lipoproteins (HDL). They discuss the clinical efficacy of Mediterranean diet, CR, and IF to increase HDL functionality and promote cardiovascular health. Furthermore, these authors address this topic by focusing on phenolic compounds that could exert positive effects on HDL function.In this scenario, Voglhuber et al., as well as Stadler and Marsche, CR and fasting applications in real-life contexts harbor significant challenges. Hence, the concept of CR mimetics (CRMs) was developed to identify bioactive substances that mimic the molecular effects induced by CR  on the excretion of heavy metals and glyphosate in 109 healthy subjects. The results of the study provide first insights into the changes in heavy metal excretion after fasting and show a reduction in the urinary levels of arsenic and nickel, as well as a reduction in hair lead levels.Although religious fasting is practiced by millions of believers around the world, scarce data exist on its impact on human health. For centuries, humans have adopted various forms of religious fasting as regimens of spiritual purification. Bahá'í fasting is a specific form of intermittent dry fasting characterized by abstaining from food and liquids during daylight hours every year in March for 19 consecutive days. Ostojic discusses the importance of the creatine transporter (CT1), which is located on the plasma membrane of various energy-demanding cells and whose dysfunction is associated with movement and behavior disorders. A potential but barely explored cellular effect of CR could be an increase in CT1 activity, facilitating creatinine uptake.The opinion article from Wahl and LaRocca present a detailed review of the transcriptomic effects of healthy nutritional interventions, including CR, IF, ADF, prolonged fasting, time-restricted feeding, and protein and amino acid restriction. They describe gaps in the research, highlighting the importance of transcriptome/multi-omic studies to better understand the effects of these dietary interventions.Finally, Despite the richness and importance of the topics covered in the papers published in this e-collection, the complex impact of CR and CR-alternatives on aging and health is still insufficiently understood and there are many aspects to be clarified in this fascinating research field.Both authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The central nervous system (CNS) undergoes immunosurveillance despite the lack of conventional antigen presenting cells and lymphatic vessels in the CNS parenchyma. Additionally, the CNS is bathed in a cerebrospinal fluid (CSF). CSF is continuously produced, and consequently must continuously clear to maintain fluid homeostasis despite the lack of conventional lymphatics. During neuroinflammation, there is often an accumulation of fluid, antigens, and immune cells to affected areas of the brain parenchyma. Failure to effectively drain these factors may result in edema, prolonged immune response, and adverse clinical outcome as observed in conditions including traumatic brain injury, ischemic and hypoxic brain injury, CNS infection, multiple sclerosis (MS), and brain cancer. Consequently, there has been renewed interest surrounding the expansion of lymphatic vessels adjacent to the CNS which are now thought to be central in regulating the drainage of fluid, cells, and waste out of the CNS. These lymphatic vessels, found at the cribriform plate, dorsal dural meninges, base of the brain, and around the spinal cord have each been implicated to have important roles in various CNS diseases. In this review, we discuss the contribution of meningeal lymphatics to these processes during both steady-state conditions and neuroinflammation, as well as discuss some of the many still unknown aspects regarding the role of meningeal lymphatics in neuroinflammation. Specifically, we focus on the observed phenomenon of lymphangiogenesis by a subset of meningeal lymphatics near the cribriform plate during neuroinflammation, and discuss their potential roles in immunosurveillance, fluid clearance, and access to the CSF and CNS compartments. We propose that manipulating CNS lymphatics may be a new therapeutic way to treat CNS infections, stroke, and autoimmunity. Lymphatic vessels are required for tissue homeostasis, where they typically reside in the tissue parenchyma and serve as a conduit for the clearance of excess, fluid, cells, antigens, nutrients, and waste . Consequin vivo imaging.Phylogenetically, the lymphatic system with separate vasculature is believed to first appear in vertebrates. A primitive lymphatic system with evolutionarily conserved structural and cellular features was discovered in zebrafish . AmphibiBrain lymphatics were shown for the first time in 1787 by Mascagni . Since tDevelopmentally, lymphatic endothelial cells arise from venous endothelial cells through a complex process involving several signaling molecules and transcription factors that are reviewed by others . BrieflyAn extensive network of meningeal lymphatics surrounding the CNS and spinal cord have been identified , which aMost lymphatic vessels in mice develop by birth, and once lymphatics have developed VEGFC is no longer needed for lymphatic vessel maintenance . So far,Anatomical characterization reveals that the meningeal lymphatics near the base of the brain are in closer proximity to the subarachnoid space than the dural lymphatics above the sinuses when immunolabeling the epithelial cells that make up the arachnoid barrier with E-Cadherin , despite257–264-OVA323–339-GFPfl/fl transgenic mouse with CNPase-Cre to drive oligodendrocyte expression or Nes-Cre to drive neuronal/glial expression of OVA257–264 and OVA323–339 peptides, OVA257–264-specific CD8 OT-I and OVA323–339-specific CD4 OT-II T cell proliferation can be observed in the draining lymph nodes , suggesting that the drainage is dependent upon CCL21+ lymphatic vessels and CCR7+ dendritic cells  of VEGFC in the dura and near cribriform plate meningeal lymphatics may be different, which may explain why lymphangiogenesis during EAE is unique to cribriform plate lymphatics. During steady-state conditions, smooth muscle cells provide enough VEGFC to maintain baseline levels of lymphatics in the dura , while tukocytes , cribrifukocytes , it is uAccess to the CNS and CSF compartment may also be different between the different sites of meningeal lymphatics. Anatomical studies in developing rats revealed the lack of an arachnoid barrier near the cribriform plate , suggestAnother theory is that the amount of VEGFC needed for lymphangiogenesis by the different meningeal lymphatic networks may be different. Although the meningeal lymphatics in the dura above the sinuses can undergo lymphangiogenesis in the presence of AAV-VEGFC , the amoIt is also important to note that meningeal lymphatics can also be found at the base of the brain and spinal cord , and thaNotably, lymphangiogenesis within CNS-draining lymph nodes has also been reported during reperfusion in a mouse model of stroke . IntriguFluid accumulation and swelling often accompanies inflammation, which in the case of neuroinflammation may be life-threatening due to the non-expansive nature of the skull. We have reported that lymphangiogenesis by vessels near the cribriform plate serves to clear excess fluid, cells, and antigens from the CSF and CNS to maintain homeostasis and promote recovery during later stages of EAE . Lymphan+ macrophages and conventional dendritic cells, in the dura in close proximity to dural lymphatics that can uptake CSF-delivered antigens to recruit and present to antigen specific CD4 T cells during steady-state conditions, with no significant changes in antigen presenting cell identity or numbers during neuroinflammation  the location and unique access of cribriform plate lymphatics to CSF; (2) the adaptability of cribriform plate lymphatics to respond to neuroinflammation by rapid lymph angiogenesis; and (3) the phenotypic adaptation of cribriform plate lymphatic to crosstalk with immune cells and induce an immunomodulatory niche within the meningeal lymphatics. Future research using multiple modalities involving imaging, anatomical, functional and phenotypic studies will be important to understand the full potential for cribriform meningeal lymphatic therapies in CNS disease.MH, CL, MS, and ZF wrote the manuscript. MH generated the figure and tables. All authors edited the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Transgender and gender diverse individuals may seek gender-affirming medical care, such as hormone therapy or surgery, to produce primary and/or secondary sex characteristics that are more congruent with their gender. Gender-affirming medical care for transmasculine individuals can include testosterone therapy, which suppresses circulating estrogen and can lead to changes in the vaginal epithelium that are reminiscent of the post-menopausal period in cisgender females. Among transfeminine individuals, gender-affirming medical care can include vaginoplasty, which is the surgical creation of a vulva and neovaginal canal, commonly using penile and scrotal skin. The effect of gender-affirming medical care on the vagina of transmasculine individuals and on the neovagina of transfeminine individuals is poorly characterized. This review summarizes what is known of the epithelium and local microbiota of the testosterone-exposed vagina and the neovagina. We focus on potential pathogens and determinants of gynecological health and identify key knowledge gaps for future research. Transgender and gender diverse (TGD) individuals have a gender identity that is incongruent with the sex/gender they were assigned at birth. Other key terminology used in this review is listed in Although not all TGD individuals identify as a binary gender (either a man or woman), gender-affirming medical care, including exogenous sex hormones, hormone blockers and/or surgeries, is sometimes used by TGD people to either masculinize or feminize the body. In this respect, we use the terms transfeminine (tF) for individuals assigned male at birth but who do not identify as male and may undergo feminizing gender-affirming medical care, and transmasculine (tM) for individuals who were assigned female at birth but do not identify as female and may undergo masculinizing gender-affirming care. Likewise, we use the terms cis female (cF) for individuals who were assigned female at birth and identify as female and the term cis male (cM) for individuals who were assigned male at birth and identify as male.Hormone therapy is a common component of gender-affirming medical care for TGD individuals. The 2015 US Transgender Survey (USTS) reported that 49% of TGD individuals have received hormone therapy and a further 29% desired it . FeminizGenital surgery may also be a component of gender-affirming medical care. The 2015 USTS reports that 10% of tF individuals had completed vaginoplasty  and a further 45% of respondents reported wanting to have the procedure in the future . Vaginectestosterone dominant vaginas (TDV) and vaginas of reproductive-aged individuals who are not taking testosterone therapy  as estrogen dominant vaginas (EDV). The field of transgender medicine is relatively new, and little is known of the effects of testosterone therapy on the TDV nor of estrogen therapy on the neovagina, but it is clear that both genital microenvironments are distinct from the comparatively better studied EDV. As social acceptance increases and access to gender-affirming medical care continues to improve, the number of TGD individuals who will need tailored gynecological care is increasing. The provision of inclusive healthcare is necessary to achieve optimal health and reduce inequities experienced by TGD communities  as munities .This review summarizes what is known of the epithelium and local microbiota of the TDV and the neovagina. We focus on potential pathogens and determinants of gynecological health and identify key knowledge gaps. Our review raises more questions than it provides answers, underscoring an urgent need for research on these distinct genital microenvironments.Lactobacillus spp., but also of non-desirable anaerobic bacteria   , to eventually reach full maturation in the superficial layers . Maturatbacteria . Lactobasis (BV) . In addifactants . In the nerella) . Communinerella) . Even innerella) .Testosterone therapy is highly effective in allowing TGD individuals to develop the secondary sex characteristics associated with masculinity, but the suppression of estrogen Table 2 Prevotella, Gardnerella, Dialister), but is clearly distinct, with higher abundance and prevalence of genera such as Streptococcus, Corynebacterium, Finegoldia, Peptoniphilus, Anaerococcus, and Bifidobacterium and lower abundance of BV-associated genera Atopobium, Sneathia, and Megasphaera  . Decreasasphaera . The impasphaera . In TDV,asphaera . Recentlasphaera . Transmaasphaera . These s tablets . While l tablets .Lactobacillus-dominated microbiota; instead, the majority of TDVs had microbiota composed of a diverse set of anaerobic taxa, more like microbiota observed in post-menopause cF than molecular BV . Despite sharing some similarities with the post-menopausal vagina, the microbiota observed in the TDV was also clearly distinct, with higher abundance of Campylobacter, Fusobacterium, Parvimonas, and Porphyromonas, indicating testosterone augmentation may influence the composition of the vaginal microbiota beyond that of estrogen reduction. It is notable that, of the three individuals who had a Lactobacillus-dominated microbiota, two were prescribed topical estradiol . Despite limited statistical power in this relatively small study, the correlation between vaginal estrogen therapy and presence of a Lactobacillus-dominated microbiota was statistically significant (p=0.045). This study provides an important first assessment of the TDV microbiota, suggesting it is distinct from the microbiota observed post-menopause, and that Lactobacillus-dominated microbiota are rare.To our knowledge, there has been a single study describing the TDV microbiome . In thisDespite the progress made in recent years, several key gaps remain in the literature. Additional studies are warranted to confirm and expand on the seminal publication by McPherson et al. . Larger Lactobacillus colonization in tM individuals without interfering with the masculinizing effects of testosterone. Local estrogen therapy is commonly recommended to treat vaginal atrophy post-menopause , regional and isolated skin flaps , peritoneal flaps, and the incorporation of urethral mucosa into the inverted skin flap are all identified in the literature. Despite the multiple options available to line the neovagina, the penile scrotal flap is by far the most commonly used , with thPrevotella, Finegoldia, Peptotreptococcus, Peptoniphilus, Porphyromonas, Dialister, Murdochiella, and Negativococcus) and increases aerobes and facultative anaerobes . However, in addition to the environment, characteristics of the epithelium itself can have a dramatic influence on the local microbiome. For example, during puberty estrogen induces changes in the vaginal epithelium, increasing thickness and glycogen content, which is associated with a dramatic shift in the local microbiome, from one dominated by a diverse set of strict and facultative anaerobes to Lactobacillus domination and an acidic pH (<4)  shapes the local microbiome, unambiguously demonstrated by the effect of penile circumcision on the composition of the coronal sulcus microbiota . Elimina pH (<4) .Similar to the vaginal epithelium, penile skin is a stratified squamous epithelium that is constantly renewing through proliferation of basal cells. However, the epithelial layer of penile skin is thinner than that of the pre-menopausal EDV (100 vs 300μm) , expressLactobacillus-dominated microbiota. While a neovagina constructed from entirely penile skin and one that includes sigmoid colon may have similar environmental exposures , factors such as residual cornification or the presence of goblet cells producing mucus may dictate what bacteria colonize the neovagina microenvironment, and what bacteria are beneficial vs. pathogenic. Therefore, different treatment courses may be required for individuals suffering from neovaginal symptoms, depending on the tissue used to create their neovaginal canal. Altogether, our knowledge of the epithelia used for vaginoplasty does not support the notion that an optimal neovaginal microenvironment would comprise Lactobacillus spp. and an acidic pH.Very little is known of the influence of surgical invagination and exogenous estrogen on the differentiation pattern of epithelial cells in the neovagina. It is possible that reduced water loss from surgical invagination may alter the epithelial differentiation patterns of once-penile skin, for example, through reduced lamellar body and corneodesmosome formation, resulting in an epithelial surface more similar to the EDV. However, while vaginal epithelial cells have the ability to differentiate into corneocytes in response to hormonal or mechanical signals, potentially owing to their expression of both K4/K13  and K1/K10 , epithelLactobacillus spp.) ; Peptoniphilus and Corynebacterium ; and Porphyromonas and Campylobacter . Interestingly, these genera are also highly abundant/prevalent within the foreskin fold of the uncircumcised penis. The skin under the foreskin fold is usually colonized with a diverse set of strict and facultative anaerobes, the most prevalent and abundant being Prevotella, Porphyromonas, and Peptoniphilus, while the circumcised penis is usually dominated by Corynebacterium  . These aus spp.) Table 3.acterium . The abuacterium ; it remaacterium  and one Prevotella and instead defined by taxa common in the gut microbiota, Bacteroidaceae and Enterobacteriaceae , a national survey of the TGD population in Canada, show nearly half of participants with vaginoplasty experienced gynecological symptoms in the past year, including malodor, abnormal or disturbing discharge, and itching . Such symptoms are frequently associated with BV in the EDV; however, the underlying cause of these symptoms in the neovagina remains uncharacterized. Neovaginal swabs sent for clinical diagnostics frequently return the results “altered vaginal flora inconsistent with bacterial vaginosis” and treatments established for the EDV (metronidazole) are frequently ineffective . CandidiLactobacillus, and thus helps to promote an optimal microbiome that is resistant to re-colonization with inflammatory/pathogenic anaerobes  or Bacteroidaceae (sigmoid-lined).There is paucity of data on the kind of practices that promote an optimal neovaginal microenvironment, both in the immediate post-operative period and for long-term hygiene and care. Due to a lack of evidence-based guidelines, neovaginal care recommendations vary substantially between centers . Frequennfection ] are alsLactobacillus-dominated vaginal microbiota are common. Further research is warranted to establish the role of testosterone augmentation beyond that of estrogen deprivation. Anecdotal evidence suggests topical estrogen therapy may promote a Lactobacillus-dominated microbiome, justifying further studies to investigate if this approach can alleviate symptoms. In tF individuals with a neovagina, gynecological symptoms such as abnormal discharge, itching and malodor are common, but the etiology of these symptoms remains unknown, and treatments designed for cF may be ineffective. The limited data we have of the neovaginal microbiome (n=5) suggests that it is very unlike that of reproductive-aged or post-menopausal cF and may have more commonalities with the microbiota of the uncircumcised penis of cM or the vagina of tM on testosterone therapy. Importantly, the limited available data suggests the tissue used to create the vaginal canal may have a substantial impact on the subsequent microbiota and should be considered and reported in future research. What defines optimal vs. non-optimal microbiota in different types of neovaginas, and what bacteria are pathogenic, is yet to be defined and this information is critically needed to improve clinical management and treatment options.As access to gender-affirming hormone therapy and surgery increases, a growing number of TGD persons will need access to effective and evidence-informed gynecological care. There is an urgent and growing need to identify the causative agents of the unique gynecological concerns of TGD populations and to define clinical guidelines to promote gynecological health. In tM individuals on testosterone therapy, vaginal pain, bleeding, atrophy, and non-JP, JR, GB, YK, EP, HW, JH, and BM contributed to literature review, manuscript writing, and editing. All authors contributed to the article and approved the submitted version.JP was supported by a Canada Research Chair ; funds from the Schulich School of Medicine and Dentistry, Western University; and the National Institute for Allergy and Infectious Diseases of the National Institutes of Health (R01AI123002). GB is supported by a Canadian Institutes of Health Research Sex and Gender Science Chair (GSB-171372). JR and BM were supported by the National Institute for Allergy and Infectious Diseases of the National Institutes of Health (R01NR015495)The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Serotonin-norepinephrine reuptake inhibitors (SNRIs) inhibit the presynaptic neuronal uptake of serotonin and norepinephrine and prolong the effects of the monoamines in the synaptic cleft within the central nervous system, leading to increased postsynaptic receptor activation and neuronal activities. Serotonin-norepinephrine reuptake inhibitors can have multiple clinical indications, including as the first-line agents for the management of depression and anxiety, and as analgesics in the treatment of chronic pain. The effects of reuptake inhibition of norepinephrine and serotonin are often dose-dependent and agent-dependent. There are five FDA-approved serotonin-norepinephrine reuptake inhibitors  currently being marketed in the United States. As the COVID-19 pandemic significantly increased the incidence and prevalence of anxiety and depression across the country, there are significantly increased prescriptions of these medications perioperatively. Thus, anesthesiologists are more likely than ever to have patients administered with these agents and scheduled for elective or emergency surgical procedures. A thorough understanding of these commonly prescribed serotonin-norepinephrine reuptake inhibitors and their interactions with commonly utilized anesthetic agents is paramount. There are two potentially increased risks related to the continuation of SNRIs through the perioperative period: intraoperative bleeding and serotonin syndrome. SNRIs have some off-label uses, more new indications, and ever-increasing new applications in perioperative practice. This article aims to review the commonly prescribed serotonin-norepinephrine reuptake inhibitors and the current clinical evidence regarding their considerations in perioperative anesthesia and analgesia. Serotonin-norepinephrine reuptake inhibitors (SNRIs) are among the most commonly prescribed medications in the United States annually . As theiSNRIs are a versatile class of medications with a wide variety of clinical applications . SpecifiApproved by the Food and Drug Administration (FDA) in 2008, desvenlafaxine is a potent SNRI that potentiates neurotransmitter activity of serotonin and norepinephrine within the CNS. The drug is the synthetic form of the SNRI venlafaxine’s major active metabolite, and is principally used in the treatment of major depressive disorder (MDD). Desvenlafaxine is renally eliminated, but first undergoes hepatic conjugation with minor metabolism through the CYP3A4 pathway. Current evidence suggests equal efficacy between desvenlafaxine and venlafaxine in treatment of MDD . HoweverDuloxetine is amongst the mostly commonly prescribed drugs annually in the United States. Accordingly, anesthesiologists are likely to encounter patients taking this drug, which was approved by the FDA in 2004 and is currently the first-line therapy for a variety of psychiatric diagnoses including MDD, generalized anxiety disorder, fibromyalgia, diabetic peripheral neuropathy and musculoskeletal pain. Additionally, duloxetine has a number of off-label uses, including treatment of peripheral neuropathy secondary to chemotherapy administration and urinary incontinence . Like maLevomilnacipran is the most recently FDA-approved SNRI (2013), and is currently indicated for the treatment of MDD. However, additional applications for levomilnacipran are currently under investigation . The druMilnacipran is an older SNRI that obtained FDA approval for use in the treatment of fibromyalgia in 1996, and is the first-line treatment for this indication. An additional off-label use includes the treatment of MDD, and is often a second-line therapy for this use . CurrentSibutramine is an SNRI that prevents dopamine reuptake, in addition to blocking the reuptake of serotonin and norepinephrine. Sibutramine reduces the reuptake of norepinephrine (by 73%), serotonin (by 54%), and dopamine (by 16%). The drug was initially approved for use in 1998 as an appetite suppressant for the treatment of obesity. However, it was voluntarily withdrawn from the US markets in 2010. Studies were suggestive of an increased risk of cardiovascular adverse events including non-fatal stroke and non-fatal heart attack . DespiteTramadol was patented in the 1960s but was not approved by the FDA until 1995. The drug’s principle mechanism of action is through opioid µ-receptor agonism; however, the drug also functions as a serotonin and norepinephrine reuptake inhibitor. Although not a traditional SNRI, tramadol’s partial SNRI mechanism of action merits consideration in this paper. Accordingly, tramadol’s principle mechanism of action as a µ-receptor agonist precludes its use as a first-line antidepressant, unlike most other drugs in the SNRI class. Instead, tramadol is FDA-approved for the management of both acute and chronic pain.Due to its unique mechanism of action and prolonged time on the market, tramadol has been extensively investigated for off-label uses, more so than other drugs with an SNRI mechanism of action. These include treatment of cancer pain, adjunct therapy for peripheral nerve blocks, and neuraxial anesthesia. Additionally, tramadol has also been extensively evaluated for the treatment of neuropathic pain. However, a recent meta-analysis suggested only modest benefit . The comTramadol is more widely utilized in the preoperative, intraoperative, and postoperative period compared to other medications with serotonin-norepinephrine reuptake pharmacodynamics. Intraoperative use of tramadol is limited in favor of other pure opioid agonists; however, tramadol may be administered in the perioperative period as part of an effective multimodal pain regimen . TramadoIn addition to applications as an adjunct to neuraxial anesthesia, tramadol has been utilized in combination with local anesthetics for applications in regional anesthesia. While tramadol does not have efficacy as a solo agent for regional anesthesia, it may improve the efficacy of local anesthetics . This haApplications of tramadol in the postoperative period are related to its successful prevention of postoperative shivering ,50,51. AVenlafaxine is amongst the most widely used drugs of the SNRI class, despite only obtaining FDA-approval in 2005. It is currently approved in the treatment of generalized anxiety disorder, MDD, social phobia, and panic disorder. Additionally, venlafaxine is utilized off-label for the treatment of attention deficit hyperactive disorder, bipolar disorder, diabetes-induced neuropathy, obsessive compulsive disorder, peripheral neuropathy due to chemotherapy, post-traumatic stress disorder, and tension headache prophylaxis. In addition to reducing serotonin and norepinephrine reuptake, venlafaxine also inhibits the reuptake of dopamine. Venlafaxine is metabolized by P450 CYP2D6, and is subject to variations in metabolism related to enzyme activity levels. Overall, the drug has a favorable side effect profile; however, patients should be closely monitored for serotonin syndrome amongst other issues which may be encountered in the pre-, intra-, or postoperative setting . AdditioCurrent guidelines regarding the continuation of SNRIs in the perioperative period remain incomplete; however, patients are generally encouraged to continue taking their medication as prescribed . Our curSNRIs are not commonly administered as part of the routine maintenance of anesthesia. However, anesthesiologists may encounter the effects of these medications intraoperatively. In one study, Kimura et al. found that patients taking SNRIs were more likely to experience refractory hypotension as compared to treatment by phenylephrine and ephedrine, although these patients responded appropriately to dobutamine or norepinephrine . The groApart from the risk of intraoperative hemorrhage and hypotension, anesthesiologists must be vigilant for the development of serotonin syndrome, discussed further below. This is a feared sequela of SNRIs, and must be managed in a timely and appropriate manner to prevent adverse outcomes.The principle considerations of SNRIs in the acute postoperative period are related to their efficacy, as part of a multimodal postoperative pain strategy and as a risk factor for the development of serotonin. Multimodal analgesia has emerged as a central component of pain management following surgery ,67. AddiCommonly prescribed SNRIs are summarized in Serotonin syndrome is a collection of symptoms that develops following the administration of some serotonergic drugs, including SNRIs. In addition to SNRIs, a number of other medications and drugs can trigger the development of serotonin syndrome . FurtherMost cases of serotonin syndrome develop following administration of two agents that both cause serotonergic release . The synRecognizing and treating serotonin syndrome is a significant challenge, in part because of a broad differential which includes anticholinergic toxicity, meningitis, neuroleptic malignant syndrome, malignant hyperthermia, encephalitis and sedative-hypnotic withdrawal, amongst others. This differential is particularly challenging for anesthesiologists as many of these conditions may be encountered during or following general anesthesia.Serotonin syndrome remains a clinical diagnosis, and lacks specific diagnostic testing at this time. Accordingly, a number of screening guidelines have been developed to assist with the diagnosis. The Hunter Toxicity Criteria Decision Rules is the most commonly utilized and best-validated tool to aid in this process, although this remains controversial ,76. The One of the challenges in the prevention, diagnosis, and treatment of serotonin syndrome is the variety of medications that may precipitate a crisis. Furthermore, serotonin syndrome can be precipitated at any point during the preoperative, intraoperative, or postoperative period. Therefore, constant vigilance is required. In the perioperative period, serotonin syndrome may manifest in atypical ways, and should be considered with any abnormal response to preoperative medications ,77,78. MSerotonin syndrome may also present intraoperatively, and may be due to interactions with a variety of agents routinely administered during anesthetics, such as methylene blue ,81. An aSerotonin syndrome may also present postoperatively where the differential diagnosis also includes postoperative delirium, residual neuromuscular blockade and delayed onset malignant hyperthermia. As previously discussed, differentiating between these diagnoses is important as management varies. Another challenge is that serotonin syndrome following surgery may have a delayed presentation, complicating diagnosis . Due to the nature of serotonin syndrome, the breadth of the precipitating agents, and the relative rarity of the event, most research in surrounding the administration of anesthesia is based on case reports. Larger multi-patient studies evaluating this syndrome are lacking. The treatment of serotonin syndrome is principally based on supportive care. This involves the discontinuation of serotonergic agents, normalization of hemodynamics, treatment of hyperthermia, benzodiazepines for sedation, and serotonin antagonists such as cyproheptadine. Cyproheptadine functions as a histamine-1 receptor antagonist that also has 5-HT1A and 5-HT2A antagonistic properties combined with anticholinergic activity . With eaAs previously alluded to, SNRIs continue to gain further acceptance as first-line agents for the treatment of a variety of conditions. Furthermore, SNRIs are under investigation for new and emerging applications. This is most evident in their use for the treatment of chronic pain conditions, with a particular emphasis on the use of SNRIs in the treatment of neuropathic pain ,90,91,92The SNRI duloxetine has also been investigated as an adjunct therapy in the treatment of osteoarthritis with modest results . While oSNRIs are a commonly utilized class of medications with an ever-increasing variety of applications. All of the SNRIs discussed above are likely to be encountered by anesthesiologists in perioperative settings. They have a variable side effect profile relative to their clinical benefits, and they are generally well-tolerated. The recognition of serotonin syndrome and the multitude of triggering agents commonly utilized by anesthesiologists is of critical importance. Emerging applications in chronic pain and use within multimodal analgesia protocols can reasonably be expected to augment use. Tramadol as a mixed opioid agonist with a combined SNRI mechanism of action has a variety of applications in the perioperative, intraoperative, and postoperative space. Large randomized trials evaluating the role of specific interactions of SNRIs with anesthetic agents are lacking, but are an area of active research. Anesthesiologists, as perioperative experts, must have an in-depth knowledge of SNRIs, their common applications, and the implications for anesthetics.


Trust is the bedrock of research, built on honesty, responsibility, accountability, and transparency. When embraced by all researchers and embedded in all aspects of research, these values help ensure that research has a positive impact on the research community, public, and policy makers, thereby enabling discoveries and innovations to enhance the well-being of humanity.Responsible Conduct of Research (RCR) is a framework that describes ethical values, best practices and professional norms that guide the actions of the research community. It is a vital component of building trust in research. RCR education is essential for training researchers on how to apply this framework and adopt the tools and mindset to make ethical decisions when they face ethical dilemmas in their research . Unfortuwww.akademisains.gov.my/rcr-book-online). YSN-ASM is the official national young academy that represents top young researchers in Malaysia committed to fostering excellence in science, technology and innovation and advancing this area of the country’s development. This programme traces its genesis to the initial support of the US National Academy of Sciences, Engineering and Medicine (US NASEM), which provided training and seed funding to a group of young researchers in Malaysia to promote RCR [In recognition of the growing importance of RCR education, the Young Scientists Network-Academy of Sciences Malaysia (YSN-ASM) established the YSN-ASM RCR Programme in 2015 to promote RCR in Malaysia (mote RCR .Since its inception, the YSN-ASM RCR Programme has been actively conducting RCR workshops and training RCR instructors. The programme collaborates with various government agencies, universities, research institutions, and professional scientific societies across the country.Although RCR codes and handbooks written by the international scientific community exist, the Malaysian Educational Module on RCR was specially developed to provide contextualized educational content for the Malaysian research community . The modThese workshops are open to researchers in all stages of their research careers, but emphasis is placed upon early- or mid-career researchers. Although these researchers play a critical role in the advancement of science, technology and innovation in their respective countries, they face significant challenges and unique circumstances that influence their attitudes and practice . Since iOne of the key features of the YSN-ASM RCR Programme is the use of active learning pedagogy. This method of teaching RCR was introduced in Malaysia by the US NASEM RCR trainers at the inaugural institute . Active Whether face-to-face or online, we use case studies with fictional characters that are familiar to the participants. These case studies are written to reflect real-life situations in the Malaysian research and development ecosystem that are complicated by various ethical dilemmas to which researchers can easily relate. While the types of research misconduct and detrimental research practices are universally prevalent, there are nuances that are specific to culture and geography. Cultural appropriateness of case studies is key to ensuring that learning outcomes are achieved . These cAnother common active learning method in our workshop is role play. Like the case studies, fictional and relatable scenarios have been created to describe a story with various ethical dilemmas involving multiple actors with competing interests or biases. Role play encourages the participants to empathise with these actors, even if their actions are deemed inappropriate or wrong. By placing themselves in the shoes of these actors, they experience the complex nature of the decision-making process and the gravity of the consequences of their actions. Through these case studies and role playing, participants reflect on similar situations they may have encountered and identify opportunities to improve management of the situation at an individual and institutional level. These activities also offer ideal simulation exercises for early-career participants who may not have previously experienced these situations, helping them prepare to deal with similar scenarios in the future.Because of the active-learning pedagogy and contextualized content, workshop participants frequently express that these RCR workshops were very engaging and challenged them to think more profoundly about their social and professional responsibilities as researchers . Often tMore importantly, pre- and post-workshop surveys demonstrate that the workshops empowered participants to promote RCR, sparking a desire for formal training in RCR and a willingness to blow the whistle on RCR transgressions .Attention to differences across disciplines is of course critical to providing relevant information and professional standards, but the principles of responsible research span all disciplines. As such, RCR training need not necessarily be discipline specific . The YSNParticularly given the highly sensitive nature of many types of forensic sciences research, training in responsible conduct should be an integral component of the curriculum. For any discipline, we recommend an active learning method that facilitates ethical deliberation and self-reflection along the lines of the approach we have used in Malaysia. This approach not only addresses the universal values and norms that are inherent to the responsible conduct of research, but also encourages young researchers to thoughtfully address the many dilemmas and grey zones they will face as they embark upon their research careers.Department of Biomedical Sciences,Universiti Putra Malaysia, Selangor, Malaysia; Young Scientists Network-Academy of Sciences Malaysia, Kuala Lumpur, Malaysiachau.deming@gmail.comLay Ching ChaiInstitute of Biological Sciences, Faculty of Science, University of Malaya, Kuala Lumpur, Malaysia; Young Scientists Network-Academy of Sciences Malaysia, Kuala Lumpur, MalaysiaManraj Singh Cheema Department of Biomedical Sciences,Universiti Putra Malaysia, Selangor, Malaysia; Young Scientists Network-Academy of Sciences Malaysia, Kuala Lumpur, MalaysiaAbhi VeerakumarasivamSchool of Medical and Life Sciences, Sunway University, Selangor, Malaysia; Young Scientists Network-Academy of Sciences Malaysia, Kuala Lumpur, MalaysiaDe-Ming Chau


Internet coupled with agricultural development in full swing, green agri-food product e-commerce has become a hot topic in the development of e-commerce. However, due to the seasonality, territoriality, weak quality, difference, and dispersion of agri-food products, e-commerce of green agri-food products are facing difficulties. Based on the gap between consumers’ willingness and behavior to buy green agri-food products online, this paper quantitatively studied the factors that affect consumers’ behavior deviation to buy green agri-food products online. The method of constructing the binary Logistic regression model was adopted, and analysis tools such as SPSS and Excel were used for analysis, to study the influence of various factors on consumers’ purchase willingness and behavior. The research conclusion shows that: consumers’ gender, age, understanding of online agri-food products, and monthly disposable income have a positive impact on the consistency of consumers’ behavior and willingness, while the price of green agri-food products and online purchasing frequency have a negative impact on consumers’ willingness and behavior of online purchasing. The results are discussed in the context of existing studies. Suggestions and research prospects are presented at the end of the article. With the coming of the “Internet Plus” era, online purchasing plays an increasingly important role in economic development around the world. The enhancement of consumers’ attention to food safety promotes the increasing proportion of green agri-food products in online purchasing. In particular, the e-commerce model of green agri-food products is growing quickly in some regions of China with the improvement of rural infrastructure, information construction, and relevant policies. Many platforms have emerged to accelerate the development of the e-commerce model of green agri-food products in China. The e-commerce model of green agri-food products is contributed to the transformation of modern agriculture, the improvement of farmers’ livelihood, and the realization of rural revitalization.The Chinese government has issued several national policies to support the e-commerce model development of green agri-food products. However, there are many problems still restrict the development of the e-commerce model of green agri-food products, including consumers’ trust, quality assurance, and storage cost. In addition, consumers have a higher perceived risk for green agri-food products during online purchasing due to their lack of physical perception of product quality, which has negative impacts on the development of e-commerce models of green agri-food products. Hence, it is urgent to analyze the deviation between consumers’ willingness and behavior and its influencing factors, to provide the basis for promoting the development of the e-commerce model of green agri-food products.Consumers’ food purchase decision is multifaceted and complex, which is not only influenced by product and process characteristics, but also by the present decision-making circumstances. Among the nine food purchase criteria (e.g. country-of-origin (CoO) labeling, production methods, chemical residue testing (CRT) information, price, shopping location, visual appearance, sense of touch, package size, and a recommendation given by a significant one), CRT information is the most important criteria in consumers’ purchase decision, followed by CoO, production methods and hedonic characteristics . The stuIt was found that, in terms of influencing factors affecting consumers’ willingness to purchase green agri-food products, consumers’ perceptions of the health attributes of green agri-food products and the environmental role of green agri-food products, and the marketing efforts of companies are the significant influencing factors . There aIn recent years, the rise of online shopping and the development of the logistics and transportation industry has brought a new development direction to the sales and production of agricultural products, and Zhan believes that the online sales of agricultural products have considerable multiplier effects in terms of improving market competitiveness and product brand awareness . Shang bStudies have found that consumers will have inconsistencies between their intention and behavior when making purchases. Jin pointed out that even though consumers have high consumption intentions, they do not translate them into actual consumption behavior to a large extent, which means that there are significant differences in consumption intentions and behavior. As for the factors that influence the difference in willingness behavior, the main ones are individual characteristics, product perception, supply channel income level, product price, quality certification, and social environment .Overall, previous research more focused on the influencing factors of consumers’ online purchasing of agri-food products, while the influencing factors of the transformation of purchasing willingness to the purchasing behavior of agri-food products remain unclear. Under the background of the new retail era, this paper studies the transformation of consumption intention and behavior of green agri-food products based on the framework of perceived benefit and perceived risk. Specifically, this paper aims to: a) study the deviation between consumers’ online purchasing intention and actual purchase behavior of agri-food products, and predict the purchase behavior of the consumers from the perspective of behavioral economics plan; b) quantitatively analyze the deviation in consumer intention and behavior, and explore its correlation with basic characteristics, and c) study the factors influencing consumer agri-food products online purchasing intention and behavior deviation, and some suggestions countermeasures.According to the theory of planned behavior, individual cognition is mainly represented by behavioral attitude, subjective norm, and perceived behavior. Previous research showed that individual characteristics of the consumers significantly affect their willingness and behavior on purchasing green agri-food products, which include cognition, agri-food product acceptance, agri-food product atmosphere and the preference for online purchasing, etc. Based on the above analysis, this study constructed the basic framework of consumers’ willingness and behavior change to purchase green agri-food products in the new retail era .Individual characteristics include the gender, age, occupation, education, and monthly disposable income of the consumers , 18. TheThe consumers’ cognition degree of online purchasing green agri-food products could be divided into 5 levels, including completely unknown, not very familiar, general, relatively well familiar, and very well understood . The conThe consumers’ acceptance of online purchasing green agri-food products could be represented by trust degree and frequency , 20. WheLi pointed out that in an online shopping environment, reference groups (expressed by the number of people who have purchased online) significantly and positively affect consumers’ perceived value and willingness to purchase online . In contPreferences can influence a buyer’s purchase decision and also have an impact on the purchase decision . In thisThere are many methods that can be used to study the above problems, such as multiple regression model, structural equation model, etc. In this paper, "consumers’ willingness to purchase agricultural products online and behavioral deviation" is used as the dependent variable to investigate the factors influencing consumers’ willingness to purchase agricultural products online and behavioral deviation, so this paper regards the positive consistency and negative consistency of willingness and behavior as consistent, and the deviation of willingness and behavior as inconsistent, so the dependent variable in this study is a dichotomous variable, and it is suitable to use the binary logistic model for analysis, the regression analysis model is,y was the deviation of consumers’ willingness and behavior to purchase green agri-food products online. P was the probability of consumers’ willingness and behavior to purchase agri-food products online; xi was the explanatory variable; βi was the effective coefficient of explanatory variable; β0 was the constant term.Where Transform Eq :P1‐P=eThe logarithm of both sides of Eq  is takenThe study and the associated data sourcing approach are approved by the Research Administration Department, Qingdao Agriculture University. The survey was conducted between December 2019 and May 2020 and was based on an online questionnaire, supplemented by a portion of fieldwork. The research data originated from the survey in six cities of Shandong Province in China. The questionnaire included consumers’ characteristics, online purchasing frequency of green agri-food products and its related perception. Firstly, six cities in different locations were selected using the multi-stage sampling method, including Weihai, Yantai, Qingdao, and Weifang in the eastern region, Jinan, and Jining in the central and western regions. Meanwhile, each city chose 4 townships, and each township selected 2 villages for the survey. Secondly, the sample farmers were selected using the method of equidistant sampling (k = 10) based on the village map. Equidistant sampling was carried out to supplement the number of samples if the farmers were away from home for a long time. Finally, the peasant household survey was conducted based on the questionnaire. A total of 1150 questionnaires were in the survey, and the valid questionnaire was 1090 with an effective rate of 94.78% .The descriptive statistics of each variable were shown in This study conducted the correlation analysis to explore the relationship between different variables and willingness and behavior bias. Results showed that only sex, occupation, age, education, and monthly disposable income of consumers had the higher correlations relationship with their willingness and behavior bias. Hence, this study only analyzed the influencing degrees of the above 5 variables to willingness and behavior bias using the Logistic regression model.There were 450 consumers whose purchasing willingness and behavior were consistent, accounting for 41.28% of the surveyed samples. 270consumers whose purchasing willingness and behavior were negatively consistent, accounting for 24.77% of the surveyed samples. Meanwhile, 370 consumers whose purchasing willingness and behavior were contrary, accounting for 33.9% of the surveyed samples.Purchasing willingness and behavior bias of the consumers with different gender(1) The deviation of female consumers’ purchasing willingness and behavior was greater than that of male consumers in the surveyed farmers. There were 210 male consumers and 240 female consumers with consistent purchasing willingness and behavior. The purchasing willingness and behavior of 140 male consumers and 130 female consumers were negatively consistent. There were 200 male consumers and 170 female consumers whose purchasing willingness and behavior were contrary .Purchasing willingness and behavior bias of the consumers with different occupation(2) The deviation of consumers’ purchasing willingness and behavior with different occupations were significantly different.Purchasing willingness and behavior bias of the consumers with different age.There were 150 students, 110 farming, 70 migrant workers, 80 freelance workers, and 40 other occupations who had consistent purchase willingness and behavior; There are 10 students, 70 farmers, 100 migrant workers, 70 freelancers, and 20 other professional consumers whose purchase intention and behavior are negatively consistent; There are 160 students, 70 farmers, 60 workers, 70 freelancers and 10 other professional consumers whose purchase intention and behavior are contrary to each other. Among all consumers participating in the survey, the number of students was 320, accounting for 29. 36%. The number of farmers was 250, accounting for 22.94%. Migrant workers accounted for 21.10%; There were 220 freelancers, accounting for 20.18%. There were 70 people in other occupations, accounting for 6.42%. It can be seen from the figure that among all the consumers surveyed, the number of students was the largest. Cross analysis of occupations and dependent variables were shown in Among all the consumers surveyed, the consumers who were willing to and have bought, the consumers between the ages of 20 and 35 were the most, and those under the age of 20 were the least .Purchasing willingness and behavior bias of the consumers with different education(4) Purchasing willingness and behavior bias of the consumers with different monthly disposable income.Among all the consumers who participated in the survey, the most consumers had a college degree or a bachelor’s degree, and the least consumers had a graduate degree or above . (5) PurAmong all the consumers surveyed, those with a monthly income of 2,000 RMB or less had the most, while those with a monthly disposable income of 6,000 RMB or more had the least .The logistic regression model was used to analyze the impact of different factors on the consumers’ willingness and behavioral bias to purchase green agri-food products online . Hosmer (1) The influence of individual characteristics of consumers. Consumers’ gender, age, and monthly disposable income positively affected their willingness and behavioral bias. The willingness and behavior of male consumers to purchase green agri-food products was more consistent than that of female consumers. Male consumers pay more attention to efficiency during the shopping, while female consumers would consider more factors during the shopping. Age also has a significant impact on consumers’ behavior and willingness to purchase agri-food products online. The younger the consumers were, the more likely they were to accept new things, and the more likely they were to accept the form of online agri-food products. Monthly disposable income also has a significant impact on consumers’ online purchasing behavior, the higher the income, the higher the frequency of online purchasing.(2) The influence of consumer cognition degree. Degree of understanding of online consumers in the 10% of significant level affects the consumers’ online purchasing the consistency of desire and behavior of agri-food products, agri-food product online there is a certain amount of unpredictability. Therefore, consumers’ purchase behavior and willingness deviate due to the uncertainty when they choose online agricultural products. Consumers have a higher understanding of purchasing behavior, and their behaviors deviate from their wishes.(3) The impact of consumers’ acceptance of online purchasing. Online purchasing frequency under the 1% significant level of negative affect consumers’ online purchasing willingness and behavior of agri-food products, the consistency that online purchasing frequency, the more the easier behavior willingness. Taking Beijing as an example, Ma studied the impact of consumers’ cognition of safe agri-food products and other factors on payment factors and purchasing behaviors . The pos(4) The impact of consumers’ preference for online purchasing of agri-food products. The price of agricultural products negatively affects the consistency of consumers’ willingness and behavior to purchase agricultural products online at a significant level of 10%, indicating that the more importance consumers attach to the price of agricultural products, the lower the consistency of their purchase willingness and behavior, and the price of green agricultural products purchased online tends to be higher than that of ordinary agricultural products due to the influence of production and logistics costs. The high price of agricultural products will reduce consumers’ purchase volume.This paper analyzed the deviation of consumers and their subgroups in their willingness and behavior to purchase green agri-food products online, we can see that:Firstly, the deviation of consumers’ willingness and behavior to purchase green agri-food products online was still relatively large. This is consistent with existing studies . There wSecondly, in terms of cognition degree of online purchasing, consumers’ understanding degree of agri-food products is generally low, and the understanding degree has a significant negative impact on the deviation of consumers’ willingness and behavior. When consumers do not often purchase green agri-food products online or have never bought agri-food products online, their understanding of online agri-food products will be very low. The less they know about agri-food products, the less they will choose online purchasing. Only when online purchasing has a full understanding of the online purchasing of agri-food product can it increase its ability to deal with purchasing risks. Naturally consumers will be more willing to purchase green agri-food products online, and the deviation of their behaviors and willingness will be smaller. This also reflects, to some extent, the positive effect of willingness on behavior .Thirdly, the frequency and price of online shopping have a negative impact on the consistency of consumers’ willingness and behavior, in which the higher the frequency of online shopping, the lower the consistency of online shopping willingness and behavior, which fully illustrates the problem of incomplete regulations of online sales of agricultural products in China , in addiAlthough the e-commerce market of agri-food products has not started for a long time, the rapid development of e-commerce of agri-food products breaks the geographical restrictions of the traditional market, shortens the time for agri-food products from the field to the dining table, and consumers can enjoy high-quality agri-food products without leaving home. What the e-commerce of agri-food products has is that the e-commerce of agri-food products has attracted the attention of many agri-food products sellers as soon as it came into being, But the competition is fierce. However, fundamentally speaking, the most important thing to do well in an e-commerce platform for agri-food products is to capture consumers. Based on the analysis of factors influencing the purchase behavior and willingness of agri-food products, the following enlightenments can be obtained.First of all, because of the large deviation of consumers’ willingness and behavior, if they are inconsistent, online sellers of agri-food products can not completely rely on consumers’ purchase willingness when formulating sales strategies. The seller should actively expand the market instead of completely dependent on online sales, and also should be properly set up some offline sales sites.Secondly, according to the characteristics of different consumer groups and the obvious differences between groups, we can analyze the personal characteristics of consumers to make a higher level of market segmentation for consumer groups, and divide the original market into more sub-markets to make the marketing and publicity for consumers more targeted, aiming to increase the consumption stickiness of agri-food products, and expand the market share horizontally and vertically.Thirdly, given the problem that consumers’ brand awareness of agricultural products is generally low, network operators should pay attention to the brand promotion of agricultural products, improve consumers’ awareness of agricultural products through network new media and other channels. Agricultural products and agricultural departments should improve the credibility and awareness of agricultural products through holding meetings, exhibitions, marketing, and other activities, to improve the competitiveness of agricultural products Stimulate consumers’ online demand for agricultural products, make consumers feel the convenience and benefits of online purchase of agricultural products, and speed up the construction of agricultural products.Fourthly, in response to the problem of the poor experience of consumer online shopping for agricultural products fee for the low trust of online shopping for agricultural products, relevant departments should first actively improve the quality certification standards and quality testing mechanism for agri-food products. It is necessary to constantly improve relevant laws and regulations on the quality and sailing procedures of agri-food products sailed online, establish unified standards on the quality and safety of agri-food products, and strengthen the supervision and management of agri-food product safety certification organizations, to improve the supply quality of agri-food product in China. Only by providing high-quality and food safety standards, e-commerce agricultural products can stimulate consumers’ purchasing intention and form a good reputation on the Internet .Fifthly, it has an important influence and deviation on the price of agricultural products and consumers’ online purchase of agricultural products. Agricultural institutions can provide production subsidies for high-standard agricultural products. At the same time, relevant government departments, chambers of e-commerce, cooperatives, and other institutions can provide some technical guidance services for farmers, help farmers reduce production costs, provide promotional services for farmers, and reduce the cost of farmers’ sales, so that high-quality agricultural products can be fixed in the sales, the price is more reasonable, to attract consumers to buy.In this study, the theoretical framework was constructed by using more existing indicators, and more micro indicators were selected, while the macro social environment indicators were neglected. For example, the impact of the new pneumonia epidemic on consumers’ online purchase of green agricultural products should be set to improve the theoretical framework. In addition, the empirical research results of this paper are based on the survey respondents, and it is necessary to further test whether the results can remain relatively consistent after the research sample changes, which also provides ideas for future research.


Psychosis is associated with self-stigmatization and loss of social functioning that increase the severity of the disorder. Psychological inflexibility (PI)—an individual’s tendency to suppress undesirable private events—plays a fundamental role in the emergence and worst prognosis of psychosis. The main objective of this study was to analyze whether self-stigma and social functioning mediate the association of PI with the severity of psychosis in adults with chronic schizophrenia. The study was carried out with a sample of 103 outpatients. The Acceptance and Action Questionnaire, the Internalized Stigma of Mental Illness Scale, and the Social Functioning Scale were used for clinical assessments. Data analyses were performed by using the PROCESS macro for SPSS. Results showed that the link between PI and the severity of psychosis is not direct, but is better explained by mediation of the self-stigma and social functioning of those assessed. PI also predicts worse social functioning without the need to take self-stigma into account. Moreover, self-stigma alone does not predict the severity of psychotic symptoms; this relationship has to be mediated by social functioning. These findings suggest that interventions designed to increase psychological flexibility, such as Acceptance and Commitment Therapy (ACT), may offer an alternative to attenuate the negative impact of self-stigma and to improve the social functioning.  Mental illness stigma, which includes negative attitudes, beliefs, and actions directed towards persons with severe mental illness, has been implicated in a host of negative consequences. Specifically, stigmatization of people with a diagnosis of schizophrenia is a documented process of interest to research because of its repercussions on various domains of social functioning, quality of life, and social support received and perceived by those diagnosed ,2,3. TheAlthough it is not yet clear what the relationships between self-stigma and adverse results observed in different measures of recovery and functioning are , the redHowever, a number of studies have reported no impact on their primary outcome measures of internalized stigma ,15,16,17This conceptualization is consistent with the psychological inflexibility model proposed by Hayes et al.  to explaThe opposite of PI is the acceptance of private experiences and psychological flexibility. Psychological flexibility allows individuals to experience private events in a way that is accepting, defused, and mindful, and allows individuals to act on personal goals regardless of private events . ReductiAround 1/3 of patients with psychosis achieve clinical remission, but functional recovery may lag behind, often leading patients to significant deficits in social functioning   as distressing events that they must escape from. Furthermore, given that stronger self-stigmatization predicts worse social functioning , we hypoOur first objective was to study whether self-stigma and social functioning mediate the association between PI and the severity of psychosis in a sample of adults with chronic psychosis. Overall, we expected higher levels of PI to be associated with the severity of psychosis , H1. NevFollowing the testing of this mediation model, the second objective of this study was to establish which facets (dimensions) of internalized stigma are mediating in their indirect effects; that is, which dimensions predict deterioration in social functioning, leading to greater severity of psychosis. The study included 103 adult outpatients  with chronic psychosis from the Mental Health Public Service in Asturias, Spain. The patients consisted of 60 males and 43 females. Participants diagnosed according to ICD-10 criteria , as deteWritten informed consent was obtained from all subjects after the procedures had been fully explained. This study was performed according to the Declaration of Helsinki and was approved by the Research Ethical Committee of the Principality of Asturias, Spain. The Acceptance and Action Questionnaire–II (AAQ-II)  was usedInternalized stigma was measured using the Internalized Stigma of Mental Illness Scale (ISMI) , which hThe Social Functioning Scale (SFS) , specifiThe Clinical Global Impression–Schizophrenia Scale (CGI-SCH)  was usedEach responsible psychiatrist evaluated the participants using CGI-SCH. The other instruments  were administered by a nurse who specialized in mental health, with more than 11 years of clinical experience.The nurse ensured that all participants understood the questions included in the administered measures, and when necessary, that assistance was provided to facilitate their understanding.To examine the hypothesized mediation model, we used the PROCESS macro for SPSS  , Model 6The PROCESS macro for SPSS was also used to study the facets of internalized stigma that predict a decrease in social functioning, leading to greater severity of psychosis. As in the previous objective, the indirect effect was calculated using 10,000 bootstrap samples for the bootstrap confidence intervals (ICs). In addition to IV  and DV (severity of psychosis), the dimensions of internalized stigma were included as five parallel mediators: alienation (M1); stereotype approval (M2); discriminatory experience (M3); social withdrawal (M4); resistance to stigma (M5); and social functioning (M6) as a sequential mediator. The means, standard deviations, and correlations of the study’s dependent, independent, and mediator variables are shown in p = 0.0001).First, the influence of PI on severity of psychosis was analyzed. With regard to Hypothesis 1, the results of the total effect of PI (IV) on the severity of psychosis (DV) confirmed that higher PI predicted greater severity . Furthermore, as posed in Hypothesis 3, this level of internalized stigma negatively predicted social functioning . Hypothesis 4 was met, because decreased social functioning predicted greater severity of psychosis . Likewise, higher PI predicted worse social functioning . Self-stigma did not predict the severity of psychosis .Hypothesis 2 was also confirmed, because (as expected) PI predicted self-stigma of individuals with chronic psychosis  when mediation of internalized stigma and social functioning was included in that relationship, as expected in our proposal. Model mediation, shown in With regard to Hypothesis 5, the results showed that the direct effect of PI on the severity of psychosis disappeared , only stereotype endorsement and stigma resistance predicted social functioning. Higher stereotype endorsement predicted worse social functioning , and greater stigma resistance predicted better social functioning . Again, social functioning negatively predicted the severity of psychosis . In this mediation model, the direct effect of PI on the severity of psychosis disappeared .The results showed that only the stereotype endorsement and stigma resistance dimensions of ISMI were significant for predicting social functioning. Thus, although PI predicted all the dimensions of self-stigma  have on thoughts, feelings, emotions, and other internal events causing distress. This study demonstrated that people with an inflexible psychological style avoid and struggle to rid themselves of their negative self-evaluations , and that this struggle diminishes even more their social functioning and negatively impacts on evaluations of disorder severity. Acceptance and Commitment Therapy could be an appropriate treatment for testing the value of this line of reasoning.Like PI, stigma and self-stigma are also inherently rigid processes ,47. CognPromotion of psychological flexibility could be useful in buffering such relationships. People with chronic psychosis who show more psychological flexibility could learn how to relate differently to so-called self-stigma, because they would be more likely to experience self-stigmatizing thoughts  as passing events in their minds , and notAside from self-stigma, people with chronic psychosis who have more psychological flexibility would improve their social functioning. Psychological flexibility includes changing behavior that compromises personal or social functioning. As previous studies have shown , the infThe results reported here lead us to doubt the feasibility of directly changing the form and frequency of self-devaluating or stigmatizing thoughts. Focusing on the underlying verbal processes of categorization, association, and evaluation, rather than on the specific topographical content of self-stigmatizing thoughts, could weaken the penetrating and rigid nature of stigma/self-stigma. As Mittal et al.  suggesteIn this study, the facets of stigma that exerted the mediating role between PI and the severity of psychosis were also analyzed. Our results showed that only the stereotype endorsement (r = −0.333) and stigma resistance (r = 0.224) factors were able to mediate in this relationship. Psychological inflexibility showed this influence by increasing the stereotype endorsement dimension  and, at the same time, diminishing the stigma resistance subscale . Altogether, PI showed a capacity to strongly erode the social functioning of the participants.Stereotype endorsement refers to the set of thoughts plagued with self-criticism and contempt for one’s capacity to feel like a useful member of the community. As in other studies, the results seem to confirm that self-stigma in psychosis is characterized by dissatisfaction with social relationships, high levels of stereotyping, withdrawal, and alienation . This isIn brief, the development of strategies related to cognitive defusion—learning to relate to stigmatizing thoughts as just thoughts (not as literally true events—and self-compassionate acceptance—being open to non-defensive experience—would help to reduce the domain and useless functions of self-stigma. The same strategies would also help to improve the social functioning of the participants. Through these processes, people can become involved in more important, more valuable behaviors that were previously avoided due to due to the rigidity that also explains the pernicious effects of self-stigma in mental health.Some limitations in our study should be considered. Due to the study’s cross-sectional nature, causality among the variables could not be established, and the interpretation of the proposed paths should be regarded with caution. A longitudinal study of the model is required to confirm the observed links between psychological inflexibility, self-stigma, and social functioning. Using intervention-based designs, future studies could confirm the mediating mechanisms by examining whether the fostering of psychological flexibility among people with mental illness deactivates the damaging impact of self-stigma, improves social functioning, and contributes to the recovery of people with chronic psychosis. In spite of these limitations, the present study provides support for the potential of psychological flexibility interventions, such as ACT, in promoting personal recovery. The study also extends the existing literature by suggesting that the processes of psychological inflexibility—especially cognitive fusion—make it possible to explain the reasons for the harmful impact of self-stigma on people with chronic psychosis. Psychological inflexibility was presented in this study as a potential process for explaining the negative impact of self-stigma in psychosis. This study also demonstrates that the effect of this process on the severity of psychosis occurs through its influence on social functioning. According to our results, consequences such as isolation, invalidity, and decreased social adjustment result from self-stigma induced by an inflexible psychological style. The use of therapies that promote social connection by changing the patient’s focus could be effective. ACT would help to normalize the experience of disturbing thoughts and any other psychotic symptoms; as a result, active participation in areas of life that are genuinely important and valuable should be encouraged.