P < 0.05) for High versus Moderate GS, but BW at kidding  and 3 days later  was similar. Litter size , kid birth weight , and litter weight  were similar between GS diets. However, kid birth weight  and litter weight  were greater (P < 0.05) for multiparous versus primiparous goats. Dry matter intake during lactation was greater for Moderate than for High GS (P ≤ 0.051) in kg/day, % BW, and g/kg BW0.75. However, milk fat  and protein concentrations , and raw  and energy yields of milk  were not affected by GS, LD, or their interaction. Dry matter intake, milk and its component yields, and heat energy (MJ/day) were higher (P < 0.05) for does than for doelings, but BCS and milk protein and fat concentrations were lower (P < 0.05) for does. Blood nonesterified fatty acid concentration was not affected by any diets, but there was interaction (P < 0.05) between GS and LD for betahydroxybutyric acid concentration. In conclusion, minor to moderate magnitudes of difference in nutritional planes during gestation and lactation had little effect on reproductive and lactation performance, reflecting the considerable capacity of lactating dairy goats for compensatory changes such as feed intake and tissue mobilization and accretion.A study was conducted with 48 multiparous and 31 primiparous Alpine goats to determine the effects of different nutritional planes during gestation and lactation on feed intake, body weight, body condition score and mass index, blood constituent concentrations, and milk yield and composition. Two gestation supplement treatments  were imposed for approximately 5.5 months and two lactation diets  within each GS were fed for 16 wk. The Moderate GS  was given at 1.125% body weight  and the High GS (16.2% CP) was consumed ad libitum, with alfalfa hay available free-choice to all animals. Moderate and High LD contained 16.0 and 16.9% CP and 34.7 and 30.4% neutral detergent fiber, respectively. Body weight (77.5 vs. 72.0 kg) and body condition score  at 11 days before kidding were greater ( This is also true for other goat breeds with a litter size of at least two, but the magnitude of nutrient and energy deficits is relatively less than with dairy goat breeds depending of course on factors such as the quality and availability of the diet4. In fact, goats of dairy breeds, such as Alpine, Saanen, and Toggenburg, could be thought of as being genetically programmed for body tissue mobilization in early lactation regardless of nutritive value of the diet, presumably similar to dairy cattle breeds such as Holstein5. Even with a diet very high in nutritive value, at least some tissue will be mobilized because of high potential for milk production8.Goats of breeds highly selected for milk yield do not consume feed adequate to support the quantity of milk being produced in early to mid-lactation9. The other most obvious factor influencing this physiological process is the initial body condition, which is affected by quality and amount of diets7. A greater extent and perhaps longer period of tissue mobilization for support of milk production with a high whole-body energy status are possible7. This is important not only in relation to milk yield and quality but also as impacting feed requirements for tissue replenishment in the late lactation and(or) the dry period7. Therefore, diet quality and composition during lactation could influence lactational performance, which may also be further impacted by gestational nutritional status. Furthermore, negative energy balance, excessive tissue mobilization and(or) inadequate replenishment during lactation can adversely affect reproductive performance and health, such as a predisposition to metabolic diseases11. And, similar considerations exist for doelings in their first lactation for continued growth and development8. The nutritional plane and dietary composition during breeding and gestation may affect reproductive performances13. Further, nutritional planes and diet composition 3 to 4 wk before parturition may also influence the ruminal microbiome and ruminal fermentation, which subsequently could impact milk production when switched to lactation diets16. It was hypothesized that different nutritional planes during gestation may influence lactational performance and energy utilization in lactating goats fed different lactation diets. Therefore, the objectives of this experiment were to determine the effects of different nutritional planes during gestation and early to mid-lactation on feed intake, body weight, condition score, and mass index, reproductive performance, blood constituent concentrations, milk yield and composition, and energy utilization of Alpine does and doelings.As alluded to above, it is known that the diet nutritive value and nutritional planes during gestation affect tissue mobilization for support of milk production in early lactation17 was 2.47 ± 0.025 and 2.24 ± 0.030 for doelings and does, respectively. Also, age at kidding was 1.81 ± 0.020 and 4.43 ± 0.225 years for doelings and does, respectively. The treatment arrangement was a 2 × 2 factorial, with two nutritional planes during gestation and two diets fed while lactating . The experimental design was compatible with the ARRIVE  guidelines 2.0. Animals selected from larger groups were 31 Alpine doelings not having previously lactated  and 48 does , based on factors such as body weight (BW) and anticipated birth date as noted below. Initial BW (mean ± standard error) was 51.4 ± 0.96 and 60.3 ± 1.15 kg and body condition score 18, had 5.57 m × 3.06 m pens. An area of 5.57 m × 1.33 m at the front of each pen had an elevated expanded metal floor, with a flush manure system used once daily. Diets were offered free-choice (120% of consumption on the preceding few days) at 08:00 h before measuring orts in Calan gate feeders  for individual feeding and recording. Feed intake was calculated subtracting orts from feed offered in each day. Ambient temperature and relative humidity were determined every 30 min with two Hobo® Temperature/RH Data Loggers  placed in different areas of the facility. A temperature-humidity index was calculated as described by Amundson et al.19.For the lactation phase, the treatment arrangement was a 2 × 2 factorial, with two GS and two lactation diet treatments (LD). Animals were assigned to two LD treatments Table  with 15–17. Linear measures also were determined at this time, which included height at the withers (Wither), length from the point of the shoulder to the hook bone (Hook) and pin bone (Pin), and circumference from heart girth (Heart). Four of the 13 body mass indexes (BMI) described by Liu et al.20 were estimated, as noted below.During gestation, BW using digital portable weighing balance, average daily gain (ADG), and BCS were measured at 11 ± 0.09 days before kidding, with the same three individuals assessing BCS in a 1 to 5 scale11 based on concentrations of fat, protein, and lactose. Milk yield and composition data were averaged over 4-wk periods for 16 wk. Body weight, BCS, linear measures, and BMI were determined at the beginning of the lactation period and end of each 4-wk period.During lactation, milk yield was determined every day at 07:00 and 1600 h in automatic milking machines  connected to a computerized system  for milk production recording of each doe. Milk samples collected every 2 wk at both times were analyzed separately for fat, protein, and lactose at the certified Dairy Herd Information Laboratory for Goats at Langston University with a MilkoScan 400 analyzer . Somatic cell count (SCC) was determined with a Fossomatic 5000 analyzer (Foss Electric). Milk energy concentration was determined with the equation of NRC21, CP , neutral detergent fiber (NDF) with use of heat stable amylase and containing residual ash22 , acid detergent fiber (ADF)22, and gross energy21 using a bomb calorimeter .The gestation supplements and lactation diets were sampled weekly and composites were formed for 4-wk periods. Samples were dried at 55º C in a forced-air oven, ground to pass a 1-mm screen, and analyzed for DM, ash24. During the last week of each period, HR was recorded for 48 h with six animals per pen, three of each parity, fitted with 10 cm × 10 cm electrodes prepared from stretch conductive fabric , glued to Vermed PerformancePlus ECG electrodes  and attached to the chest just behind and slightly below the left elbow and behind the shoulder blade on the right side. Electrodes were connected by ECG snap leads  to T61 coded transmitters . Human S610 heart rate (Polar) monitors with wireless connection to the transmitters were used to collect HR data at a 1-min interval. Heart rate data were analyzed using Polar Precision Performance SW software.Heat energy (HE) was determined by use of heart rate (HR) for prediction, as described by Puchala et al.24. Oxygen concentration was measured using a fuel cell FC-1B O2 analyzer , and CH4 and CO2 concentrations were measured with infrared analyzers . Prior to gas exchange measurements, analyzers were calibrated with gases of known concentrations. Ethanol combustion tests were performed to ensure complete recovery of O2 and CO2 produced with the same flow rates as used during measurements. Heat energy was determined according to the Brouwer25 equation without consideration of urinary nitrogen, and was expressed relative to kg BW0.75 during the measurement period. Heart rate measured during the periods was multiplied by the ratio of HE to HR to estimate HE, with HE in MJ/day based on average kg BW0.75 in the 4-wk periods.The ratio of HE to HR was determined with the same animals used for HR measures while in group pens for 24 h in periods 2 and 3, following 1 day of adaptation to housing in an adjacent room, in four metabolism crates fitted with head-boxes of an indirect, open-circuit respiration calorimetry system . The LD treatments continued to be imposed during this period. Measures were similar to those in previous studiesg and 10º C for 20 min and stored at -20º C. Plasma was analyzed for glucose and lactate with a YSI 2300 Plus Glucose & Lactate Analyzer . Serum was analyzed for nonesterified fatty acids (NEFA) with a Vet Axcel® Chemistry Analyzer  according to the manufacturer’s instructions and for β-hydroxybutyrate (BHB) by the EnzyChrom™ Ketone Body Assay Kit (EABD-100) of BioAsssay Systems .Blood samples were collected via jugular venipuncture in wk 5, 10, and 15  during lactation in the morning at approximately 3 h after feeding into two tubes. One tube contained sodium fluoride and potassium oxalate. Plasma and serum were harvested after centrifuging at 3,000 × 27. Fixed effects for measures during gestation were GS, parity, and GS × parity, with the random effect of animal within GS × parity. The GLIMMIX procedure of SAS was used for the categorical variable of litter size. For measures during the lactation phase, 4-wk period was a repeated measure, with the subject of animal within GS × parity × LD. Different covariance structures were compared via Akaike’s Information Criterion, but values were usually lower for Variance Components. Fixed effects were GS, LD, parity, period, and all interactions. Because overall effects were of interest regardless of the significance of interactions involving period, for some variables main effect means are presented along with interaction means. Means were separated by the least significant difference when the treatment F-test was significant (P < 0.05). Pearson correlation coefficients between BW, BCS, BMI, ADG, DM intake and milk energy yield (NEl) were determined using SAS27.Most data except litter size were analyzed by mixed effects models with the Statistical Analysis SystemThe ingredient and chemical composition of the gestation phase supplements were not markedly different Table . The onlThe main differences in ingredients of two LD were a lower level of grass hay and higher levels of wheat middlings, rolled oats, rolled corn, soybean oil, and molasses in the High LD than in the Moderate LD. The concentration of CP was 0.9 percentage units higher in High LD, and levels of NDF and ADF were greater for Moderate LD than for High LD . As for the GS, the Moderate LD were not formulated to greatly restrict performance, again with the intent to simulate common and practical farm settings.28.Temperature (12.9 to 27.8 ºC) and the temperature-humidity index (55.8 to 77.7) increased as the lactation period progressed, without marked change in the relative humidity (Table P < 0.05) for High GS than for Moderate GS, with magnitudes of difference of 6–8% (Table P > 0.05). Similarly, BMI on day 1 were similar between GS treatments (P > 0.05). The GS supplement treatment did not affect reproduction measures of litter size, kid birth weight, or litter weight (P > 0.05).At 11 days before birth, BW and BCS were greater (P < 0.05) for multiparous than for primiparous goats at 11 days before kidding, on the day of birth, and at the start of the lactation phase (Table P < 0.05) for multiparous than for primiparous animals before birth but not different (P > 0.05) at the start of the lactation phase. The four BMI on day 1 were greater (P < 0.05) for multiparous than for primiparous goats. Litter size was numerically (P > 0.05) greater for multiparous versus primiparous goats . This numerically higher litter size coupled with greater (P < 0.05) kid birth weight for multiparous goats resulted in greater litter birth weight (P < 0.05), with a difference of 1.22 kg.Body weight was greater (se Table . Body coP = 0.001) but not parity or their interaction (P > 0.05), as was also true for that attributable to tissue and fluid other than associated with fetuses .In addition to evaluation of BW at the times of 11 days before and at birth, differences were considered Table . The degP > 0.05), although there were effects of GS on DM intake (Tables P = 0.051), % BW (P = 0.042), and g/kg BW0.75 (P = 0.034). Dry matter intake in g/day was influenced by period and parity (P < 0.05), although there was an interaction between these factors for each expression of DM intake (P < 0.05). Magnitudes of difference relative to BW were not substantial or consistent among periods. Although, it would appear that DM intake by multiparous animals rose faster with advancing time and peaked earlier than that by primiparous animals.Dry matter intake was not influenced by LD , was affected by period and parity (P < 0.05), and there was a period × parity interaction  of period 1 > 2 > 3 and 4 for multiparous animals. Neither GS nor LD affected ADG (P > 0.05), but there were effects of period, parity, and GS × period (P < 0.05), and there was a tendency for a period × parity interaction (P = 0.053). Overall, ADG ranked period 1 < 2 < 3 and 4 and average BW loss was greater for parity 2 versus 1 (P < 0.05). The primary factor responsible for the period × parity interaction tendency was considerable BW loss by multiparous animals in period 1 relative to multiparous animals in other periods and primiparous goats . Somewhat similarly, the GS × period interaction was primarily a result of relatively large BW loss in period 1 by High GS animals.Body weight was not influenced by GS or LD P > 0.0, was affP < 0.05; Tables P < 0.05) and greater for primiparous than for multiparous goats (P < 0.05). The concentration of BHB was influenced by two and three-way interaction factors. For the two-way interaction between GS and LD, the level was greater for High GS-Moderate LD than for Moderate GS-Moderate LD and High GS-High LD (P < 0.05). There were three-way interactions between GS, LD, and parity and GS, LD, and period (P < 0.05). The interactions were mainly due to relatively high values for Moderate GS-High LD and High GS-Moderate LD for multiparous but not primiparous goats and in period 2 but not periods 3 or 4. The only factor influencing the NEFA concentration was period, with a lower value for period 3 versus 2 and 4 (P < 0.05).The only factor influencing the concentration of glucose was period, with a lower value in period 2 than in periods 3 and 4 (P > 0.05), ranked period 1 > 2 > 3 and 4 (P < 0.05), and was greater for primiparous versus multiparous goats , which appeared due largely to relatively high values in period 1 for High LD treatments and a low mean in period 2 for High GS-High LD. The protein concentration in milk also was not affected by GS or LD (P > 0.05) but varied among periods and between parities as did the milk fat concentration. There was an interaction between period and parity as well (P = 0.030), which related to a greater value in period 2 for primiparous versus multiparous goats and lower levels for both parities in period 2 than in periods 1, 3, and 4. There was an interaction in lactose concentration between period and parity (P = 0.011), the nature of which was similar to that in protein concentration. In partial accordance with concentrations of individual constituents, the level of total solids was not affected by GS or LD, ranked (P < 0.05) period 1 > 2 and 4 > 3 (P < 0.05), and was greater for primiparous than for multiparous animals (P = 0.004). However, again, there was an interaction between period and parity (P = 0.042), partially attributable to the greatest interaction mean for primiparous in period 1 (P < 0.05). Likewise, there was a three-way interaction involving GS, LD, and period (P = 0.031), with higher interaction means in period 1 for Moderate GS-High LD and High GS-High LD than for other treatments (P < 0.05) except High GS-Moderate LD. The milk energy concentration was similar among GS × LD treatments (P > 0.05) and ranked period 1 > 2 > 4 > 3 (P < 0.05). There was a three-way GS × LD × period interaction as well (P = 0.026). No factors influenced SCC (P > 0.05).Milk fat concentration was not influenced by GS or LD (P > 0.05), ranked period 2 > 1 and 3 > 4 (P < 0.05), and was greater for multiparous than for primiparous , which was due to greater values for primiparous animals in periods 2 and 3 versus 1 and 4 (P < 0.05) and a ranking for multiparous animals (P < 0.05) the same as for overall period means. There were no effects of GS, LD, or GS × LD on yield of any milk component (P > 0.05). There was only one significant GS × LD × period interaction (P = 0.040), which was in milk fat yield. Yields of all constituents, as expected, were greater for multiparous versus primiparous animals (P < 0.05), and there were significant overall period effects as well (P < 0.05). Yields generally decreased with advancing period, and in most cases the magnitude of change was greater for multiparous than for primiparous animals. Relatedly, period main effect means for milk energy yield ranked (P < 0.05) period 1 > 2 > 3 > 4. Milk energy yield for multiparous goats differed among periods in the same manner (P < 0.05), but for primiparous goats means for periods 1 and 2 were greater than for periods 3 and 4 (P < 0.05). The ratio of milk energy to DM intake was not influenced by GS, LD, or parity (P > 0.05) and ranked (P < 0.05) period 1 > 2 > 3 and 4. However, the P value for LD was 0.100, with the ratio tending to be greater for High LD versus Moderate LD.Whole milk yield was not affected by GS or LD (P > 0.05), but as for many other variables there were numerous differences between parities and among periods, as well as interactions (P < 0.05). For HR and HE determined in each period, values were greater for High LD than for Moderate LD (P < 0.05). There were three-way interactions (P < 0.05) in HR and HE relative to BW0.75 involving GS, parity, and period. With Moderate GS, these values were usually greater in period 1 than other periods for multiparous, but not for primiparous goats. Heat energy in MJ/day was greater for multiparous versus primiparous animals (P < 0.05) both during calorimetry measurements and all periods, although HE in kJ/kg BW0.75 tended to be greater during calorimetry measures (P = 0.051) but not in all periods based on HR (P > 0.05).Measures during the two times (periods 2 and 3) animals were in the calorimetry system are addressed in Tables P > 0.05), although in agreement with many other measures there were numerous differences among periods and between parities (P < 0.05), but no interactions were significant . Conversely, BMI-WH, GMI-WP, and BMI-GP were greater for multiparous than for primiparous animals (P < 0.05). The BMI-GH, however, was lower for multiparous versus primiparous goats (P < 0.05).There were no effects of GS or LD on BCS or any BMI (P < 0.05), with a lower value for BCS than for BMI (Table P < 0.05), although the correlation between DM intake and BCS was negative but low . There were lesser numbers of significant correlations between BMI and DM intake relative to BW and, in particular, BW0.75, compared with DM intake in g/day. All correlations between ADG:DM intake and BMI were nonsignificant. In contrast to the negative correlation between BCS and NEl, there were low but significant and positive r between NEl and the four BMI. There also was a negative relationship between BCS and NEl:DM intake (P < 0.001), but the relationship between NEl:DM intake and BMI were not significant (P > 0.05).The correlation between BW and BCS and BMI were all significant . There were significant differences in these measures between parities relative to ones for GS treatments.Even though GS supplements did not vary markedly in composition and all animals during the gestation phase had free access to alfalfa hay, the 5.5-kg difference in BW 11 days before kidding is appreciable. It reflects potential impact of even modest differences in feeding management practices during gestation. But it must be reiterated that the main difference in the nutritional plane resulting from the GS treatments was in the level of supplement feeding, 1.125% BW for the Moderate treatment and free-choice for ad libitum intake for the High treatment. It is notable that the difference in BCS at this time also was significant, although the slightly smaller magnitude may reflect the subjective nature of the measure and not necessarily reflect internal fat stores as noted in dairy cattleP < 0.05) for doelings than does. Although it can only be speculated upon at this point in time, this difference could involve a relatively greater proportion of body fat of does in internal versus subcutaneous storage sites compared with doelings as also suggested by results of Randby et al.8, with the latter having greater impact on BCS than the former. Perhaps in partial support of this postulate, BMI were greater for does than for doelings, again with the relative magnitude of difference greater for BMI based on Wither (BMI-WH and BMI-WP) than Heart (BMI-GH and BMI-GP).Despite the considerable difference in pre-birth BW between doelings and does , BCS was only slightly but yet significantly greater  without any effect on maternal placental tissues (caruncles) or fetal weight31. Although not addressed in this study, it would be interesting and probably relevant to total production system profitability and sustainability to determine subsequent effects on postnatal growth and development of progeny such as health, immunity, early and later life growth, and reproductive performance33. Additionally, this suggests an importance of considering the life-long effects of such treatments rather than only considering variables characterizing dam conditions such as in this experiment of litter size and kid and litter birth weight, which, case-in-point, did not differ between GS treatments32. But there is cognizance that such long-term research programs are difficult to initiate and even are more challenging to maintain. The parity effect on birth BW and litter weight was also observed in other studies34.Reproductive performances such as kid birth weight and litter size were similar between two GS, probably due to moderate differences in nutritional planes during gestation. Similar dam BW at birth for both GS treatments was the result of the much greater decrease in BW relative to the pre-birth for High GS than for Moderate GS. This cannot be explained by litter weight, which was not different between GS treatments . Hence, the most plausible and logical explanation is greater mass of placentome tissues and fluids, notably the placenta, as depicted by the difference in change in total BW minus litter weight. A low nutritional plane in early to mid-gestation when maximum placental growth takes place has been reported to restrict placental massDifferences between GS treatments and parities in the magnitude of change in BW between kidding and the start of the lactation period were relatively small. Although differences were not large, BCS at the start of the lactation phase was slightly lower for each GS treatment and parity, probably at least partially reflecting a greater whole body fluid content before than after kidding with impact on the subjective BCS assessment. Relatedly, an interesting and seemingly important aspect of these results determined at different times, before, at, and soon after kidding, is value of measures before kidding that may not be predictable based on later ones. Moreover, it would be worthwhile to study the development of unique differences between nutritional planes throughout the mid- to late-gestation period.Greater DM intake during the lactation phase for the Moderate than High GS treatment is in accordance with the difference in BW before kidding though not at that time or shortly thereafter. This is suggestive of a compensatory response for a difference in the nutritional plane during gestation. As alluded to before, this is notable since GS treatment did not significantly impact litter size or kid or litter weight, which may reflect the high priority of nutrient and energy use for pregnancy at the expense of other tissues of the dam. This difference in feed intake as well as that in pre-kidding BW indicates that conditions affected by the Moderate GS had an impact thereafter during lactation, which again very well could have also occurred in progeny development after birth.36. However, in similar studies no differences in feed intake between treatments were observed37 or intake was even greater for animals on a high plane of nutrition during gestation14. In the study of McNamara et al.14 with Holstein–Friesian cows, prepartum diets were grass silage and wheat straw in a 3:1 ratio, grass silage only, and grass silage plus 3 kg concentrate, with DM intake during the 4-wk pre-calving period of 7.4, 8.1, and 9.9 kg/day, respectively. During first 8 wk of lactation period, DM intake was greater for the highest versus lowest nutritional plane , with no difference for the diet of grass silage alone. Again, findings such as these may reflect impact of both the quantity and array of nutrients absorbed in gestation as well as the length of periods of dietary differences.Results of some other studies with cattle can be viewed in regard to how the magnitude and nature of differences in gestation diets can impact later feed intake. For example, Holstein cows subjected to a low plane of nutrition during late gestation and the close-up period displayed a tendency or had significantly greater feed intake in early lactation than the cows subjected to a greater plane of nutrition0.75) converse to very similar values between LD with High GS . These numerical differences suggest need for future studies with greater numbers of observations. Research with relatively greater differences in the gestation nutritional plane and(or) diet quality during lactation could be considered as well, but hopefully only with magnitudes relevant to practical production settings. Similarly, as implied above, in the study of Rabelo et al.16 there was not an interaction in feed intake during lactation of different dietary treatments during gestation and lactation.Though the GS × LD interaction was not significant for any DM intake expression, numerically values were greater for High LD than for Moderate LD with Moderate GS  in the latter segment (period 3 versus 4) of the phase for does, which corresponds with a greater decline in milk production of 16% versus 7.6% in this period. Research to identify factors responsible for this difference and to perhaps modify this pattern for higher intake in late lactation could be of interest to support milk production.The pattern of change in DM intake as period advanced is fairly typical of dairy goats as well as dairy cattle, with that in early lactation low relative to later periodsP value for the parity × period interaction in ADG was 0.053. A relatively large amount of tissue mobilized by multiparous animals in the first period is in accordance with greatest milk energy yield at that time, similar to findings in some other studies41. Moreover, the GS treatment × period interaction reflects that High GS allowed for appreciably more tissue mobilization in period 1 than Moderate GS, which is in accordance with pre-birth BW results. It is notable that LD treatment did not impact BW or ADG presumably because of relatively small differences in ingredient and chemical composition and free-choice offering for ad libitum feed intake. Again, this probably relates to the nature of the LD diets being similar to that used in many dairy goat herds rather than having extreme characteristics that could have elicited many significant differences but ones of little practical value.Results for BW and ADG suggest greater tissue mobilization by does versus doelings in early lactation , although the 42. Differences among periods in blood glucose, with a higher level in period 2 versus 3 and 4, were likely due to greater milk lactose yield that is mostly synthesized from blood glucose43. Blood NEFA and BHB concentrations reflect adipose tissue lipolysis due to the energy demand for milk production and metabolism in the liver and peripheral tissues42. Factors responsible for the interaction of GS, LD, and period in blood BHB are unclear, and values did not seem reflective of differences in tissue mobilization or accretion. Blood lactate arises in ruminants from anaerobic glycolysis and absorption from the rumen. The cause(s) of the greater blood lactate concentration in period 2 than 3 and 4, especially for doelings, are also not readily apparent. This in part may relate to the lack of a sample in period 1.Relatively low glucose and high NEFA and BHB concentrations in blood are indicators of negative energy balance15. Conversely, in another study also with Holstein cows, prepartum and postpartum diets varying in starch concentration influenced milk yield and component levels44. However, there were significant effects of period and parity as well as numerous interactions as is common for dairy animals including goats46. For example, milk fat concentration decreased markedly as time advanced to period 3, with relatively greater change for High versus Moderate LD. The protein concentration was greater for doelings versus does, but this was mainly due to a difference only during period 2 probably because of greater milk yield by does in this period.The lack of effect of GS and LD treatments and their interaction on raw milk yield and concentrations and yields of major constituents agrees with other results mentioned earlier, namely in feed intake and BW change. These findings reflect the ability of dairy goats to vary physiological conditions, such as in feed intake and compensatory effects of tissue mobilization or accretion, to maintain high lactation performance with dietary manipulations that can be considered of low to moderate magnitude. Likewise, there were no interactions between prepartum and postpartum diets in milk yield or levels of most constituents for Holstein cows fed diets similar in the concentration of net energy for lactation but differing in fermentability47, with relatively less energy and nutrients diverted for milk production compared with multiparous animals and, relatedly, less tissue mobilization for use in milk synthesis by the former animals. The magnitude of difference in milk energy yield between parities varied markedly with period, being greater in period 1 than in periods 2 and 3, with similar values in period 4. The ratio of milk energy yield to DM intake depicts greatest tissue mobilization in period 1, the least in periods 3 and 4, and an intermediate level in period 2. The lack of a difference in the ratio between doelings and does and a nonsignificant parity × period interaction could involve compensation of tissue mobilization by does and use of energy and nutrients for continued development of nonmaternal tissues by doelings. Lower milk production and a slower rate of decline in milk yield with advancing time for doelings versus does are consistent with other studies on sheep and goats49. The higher lactation persistency and flatter lactation curve are associated with greater rate of mammary gland epithelial cell proliferation, angiogenesis, and survival of primiparous goats, which continues for a relatively longer period of time compared with does50.Period × parity interactions in milk component yields reflect greater magnitudes of change with advancing stage of lactation for does than for doelings. This at least in part should relate to continued growth and development of primiparous animals51. Therefore, physiological stages associated with differences in milk production performance and ruminal microbiota dynamics might have influenced methane production52.The lower RQ in period 2 versus 3 and for does versus doelings were likely due to fat metabolism to support milk yield because fatty acid catabolism results in lower RQ, which is further substantiated by differences in BCS. Greater methane production in period 3 than in period 2 was not expected as feed intake in these periods was similar0.75 for the High LD than for the Moderate LD may be numerically greater DM intake and milk energy yield for High LD, as supported by other reports , with most of the differences attributable to the Moderate GS treatment. In accordance with greater milk production with associated metabolism to synthesize nutrients and DM intake by does versus doelings, HE was higher for does56.Factors responsible for greater HE in both MJ/day and kJ/kg BW0.75 could involve changes in BW corresponding to tissue mobilization early in lactation and accretion later.The difference between LD in HE was not reflected in the ratio of milk energy to DM intake, with in fact a numerically greater value for the High LD. But, based on diet ingredient concentration and a lower level of NDF in the High LD than Moderate LD, the High LD would be expected to be somewhat more digestible than the Moderate LD. Lower HE in MJ/day in period 1 than 3 and 4, with an intermediate value for period 2, probably relates to period differences in milk yield and feed intake. Relatedly, the lack of a significant difference among period main effect means for HE in kJ/kg BW57. Differences in BMI among periods were not substantial, and there was not one BMI for which values for periods 3 and 4 were greater than for periods 1 and 2 as was the case for BCS. Correlations between BCS and all BMI were highly significant, positive, and of low to moderate magnitude. Correlations between BCS and BMI based on Heart were lower than for BMI based on Wither. Findings of Liu et al.20 with yearling Alpine doelings were fairly similar, with highest r between BCS and BMI-WH and BMI-WP (0.35–0.40).The relatively small difference in BCS between periods is somewhat surprising given differences in milk energy yield and ADG, although BCS is a subjective measure as noted before. Nonetheless, lower BCS in the first two periods versus other periods relates to greater milk yields along with low DM intake. The ME requirement during the transition period increases two- to three-fold, resulting in mobilization of energy from fat depot58. The lower correlation between BW and BCS may relate to subjectivity of the BCS measure and greater fat mobilization from internal sites relative to carcass and subcutaneous tissues59. The nonsignificant correlation between ADG and BCS as well as all BMI probably relates to the short 4-wk periods. The negative r between BCS and each DM intake expression could be reflective of animals with high feed intake having relatively high milk energy yield, perhaps with greater tissue mobilization and less accretion. This is in accordance with the negative correlation between BCS and milk energy yield and the ratio of milk energy yield to DM intake.Significant correlation between BW and BMI were expected of courseTwo gestation supplements fed at different rates before and during gestation elicited differences in BW of Alpine doelings and does before kidding but not litter size or kid and litter weights. A greater decline in dam BW from 11 days prior to and the day of birth for High GS than for Moderate GS suggests potential for subsequent progeny effects. Two lactation diets fed in early to mid-lactation had relatively minor effects on milk yield and constituent concentrations, without marked interactions involving GS treatment. Overall, without substantial differences in these nutritional planes in gestation and lactation, the dairy goats displayed a considerable capacity to alter physiological conditions such as feed intake, tissue mobilization and accretion for support of gestation and milk production. Future studies should consider factors such as effects on offspring development and productivity as well as future lactation performance of dams.


This study aimed to determine the environmental and health risks of the heavy metal levels in the Danube River in Hungary. The metals, including Fe, Mn, Zn, Cu, Ni, Cr, Pb, and As, were measured in the period from 2013 to 2019. The Spearman correlation and heatmap cluster analysis were utilized to determine the origin of pollution and the factors that control surface water quality. Several indices, such as the heavy metal pollution index (HPI), metal index (MI), hazard quotient oral and dermal (HQ), hazard index oral and dermal (HI), and carcinogenic risk (CR), were conducted to evaluate the potential risks for the environment and human health. The values of the HPI were between the range of 15 < HPI < 30, which indicated moderate pollution; however, the MI results showed high pollution in Dunaföldvár and Hercegszántó cities. The ecological risk (RI < 30) and HI values (< 1) showed low environmental risks and non-carcinogenic impacts of the existing metals, either on adults or children. The mean CR value of oral arsenic was 2.2E−04 and 2.5E−04 during April–September and October–March, respectively, indicating that children were the most vulnerable to arsenic-carcinogenic oral effects. While lead’s CR oral values for children during April–September exceeded the threshold of 1.0E−04, chromium’s oral and dermal CR values for both adults and children were 2.08E−04, 6.11E−04, 1.97E−04, and 5.82E−04 during April–September and October–March, respectively. These results demonstrate the potential carcinogenic risks related to chromium exposure within the two pathways in Hungary and highlight the need for effective measures to mitigate these risks.The online version contains supplementary material available at 10.1007/s10653-023-01769-4. The presence of heavy metals in aquatic environments has raised significant global concerns due to their potential adverse effects on human health , the myriad of organisms inhabiting the water’s bed (benthic fauna), and the lush aquatic flora (macrophytes). This recognition has galvanized scientists to direct their efforts toward both mitigating pollution sources and curtailing the deleterious effects of heavy metals on these aquatic organisms. A central tenet of their endeavors underscores the critical role of consistent monitoring of pollutants within aquatic ecosystems, facilitated through diverse analytical methods  identify potential sources of the heavy metals by employing multivariate statistical techniques such as Spearman correlation analysis and heatmap cluster analysis along with the interpolation IDW technique; (ii) assess the potential non-carcinogenic and carcinogenic human health risks from heavy metals; and (iii) apply the Monte Carlo method to decrease the uncertainty and predict the values of hazard quotients (HQ) for heavy metals.The flowchart of the current research was presented schematically in Fig. The study focused on the water quality of the Danube River in Hungary, specifically in Dunaföldvár, Baja, and Hercegszántó, over a period of seven years, from January 2013 to December 2019. Water samples were collected from seven different monitoring locations along the lower basin of the Danube River, which were located in the south of Hungary between 46° 10′ 54.4548′′ N and 18° 57′ 15.5016′′ E. These sites were identified as “S1, S2, S3” for the right, left, and middle streams of the Danube River in Dunaföldvár city, “S4” represents the left bank of the Danube River in Baja city; and “S5, S6, S7” for the right, left, and middle streams of the Danube River in Hercegszántó city, as illustrated on the map , the average maximum temperature recorded during the period of July–August was 29 °C, and the average minimum temperature was recorded during the period of December–February (− 2.59 °C). The study area experiences heavy rainfall between May and July, with an average annual rainfall of 619 mm. The current study aims to: (i) identify potential sources of heavy metals by employing multivariate statistical techniques such as Spearman correlation analysis and heatmap cluster analysis along with the interpolation IDW technique; (ii) assess the potential non-carcinogenic and carcinogenic human health risks from heavy metals; and (iii) apply the Monte Carlo method to decrease uncertainty and predict the values of Hazard Quotients (HQ) for heavy metals.A total of 280 water samples were collected and placed in plastic bottles that had been pre-washed with acid. The samples were then filtered through a 0.45 mm cellulose nitrate membrane, acidified with diluted nitric acid, and stored in the fridge at − 4 °C before analysis. The concentrations of arsenic, chromium, copper, nickel, and lead were measured using electrothermal atomization atomic absorption spectrometry (ETA-AAS), while iron, manganese, and zinc were measured using flame atomic absorption spectrometry (FAAS). Consequently, Atomic Absorption Spectrometry was employed to analyze 500 mL of each sample. Subsequently, the acidified samples were divided into two 250 mL beakers, and their volume was reduced to 25 mL. An additional step was taken to analyze arsenic (As) samples, which were mixed with 0.5 mL of ascorbic acid, 0.5 mL of potassium iodide, and 3 mL of HCl for a 2-h period before being analyzed. This differed from the procedure for the other heavy metals in the study. Precision was ensured through triplicate analyses for each sample, resulting in relative standard deviations of ≤ 5%.This study used Spearman correlation coefficient analysis (SC) to investigate the correlation between heavy metal concentrations. Heatmap cluster analysis (HCA) was applied to identify the relationships among the eight heavy metals existing in the study area and their potential sources. All data analysis and visualization were carried out using Python, while maps were prepared using QGIS software (version 3.16.4).Qi stands for the sub-index parameter; n is the number of parameters taken for analysis; wi depicts the weight of each parameter, evaluated as 1/Si; Si symbolize the standard value of each parameter; Qi represents the sub-index of the boundary, determined by Eq. The heavy metal pollution Index (HPI) is considered the most effective method for assessing water contamination levels due to the presence of heavy metals (HMs) in water samples , medium (15 ≤ HPI ≤ 30), or high (HPI > 30)  has 6 classes: very clean (MI < 0.3); clean (0.3 < MI < 1); partly affected (1 < MI < 2); moderately affected (2 < MI < 4); heavily affected (4 < MI < 6); and severally affected (MI > 6)  of drinking water considers the cumulative potential impact of heavy metals (HMs) on human health and provides an evaluation of the overall quality of drinking water ; The potential ecological risk index (RI) for heavy metals, as introduced by Hakanson in 1980, is a technique employed to evaluate the potential risk associated with the presence of heavy metals in a specific ecosystem. This index takes into account factors such as the concentrations, types, sensitivity, toxicity, and background levels of the heavy metals, as noted by Xie et al. . While iCave depicts the average concentration of each heavy metal (mg/L); IR stands for the intake rate ; EF denotes the exposure frequency (adult and child: 350 days/year); ED signifies the exposure duration ; ET represents the exposure time ; Kp is the permeability coefficient (cm/h) given in Table S1. SA depicts the skin area . BW is the body weight ; CF is the unit conversion factor (1 × 10–3 L cm−3); AT indicates the average time for carcinogenic risks   by dividing the chronic daily intake (CDI) by the reference dose (RFD) for both oral and dermal exposure using Eqs. In the final step, the overall potential non-carcinogenic risks were assessed by calculating the hazard index (HI) using Eq. Toxic metals that have a hazard index (HI) or hazard quotient (HQ) of greater than 1 may pose negative impacts on human health, while those with a HI or HQ of less than 1 are considered to have no adverse effects  and the risk value. A higher correlation coefficient signifies a greater contribution to the final health risk, and the sensitivity of each variable was expressed as a percentage  did not exceed the permissible limits established by the EU and WHO, which are 25 µg/L and 50 µg/L, respectively. The slight reduction in chromium concentration during April–September suggests a decrease in activities that contribute to chromium levels in the Danube River due to seasonal effects. This trend is positive for both the environment and public health.Copper is an essential nutrient for the human body  levels observed in surface water could potentially be attributed to various sources, including industrial waste discharge or non-point sources from rainwater runoff. Iron concentrations exceeding 300 µg/L have been reported to cause damage to laundry and plumbing components  model serves as a valuable tool for evaluating the overall pollution level in surface water. This model enables the assessment of heavy metal impacts on water quality and aids in the monitoring and management of potential health risks associated with heavy metal exposure  method was employed alongside the HPI index to assess the level of heavy metal contamination in water, utilizing the upper allowable limit values outlined in the EU-Directive Framework guideline. The average MI values for April–September and October–March were determined to be 4.13 and 3.28, respectively. These values indicate that the water samples exhibited severe contamination during April–September and moderate contamination during October–March. The extent of contamination, relative to the upper limit values set by the EU-Directive Framework guideline, suggests a significant impact and contamination of heavy metals in the water samples. This underscores the need for urgent monitoring and enhancement of water quality in the lower basin of the Danube River in Hungary. Fig. B.p < 0.01, several positive correlations were observed. Specifically, there was a positive correlation between chromium (Cr) and iron (Fe) (r = 0.33), between Cr and manganese (Mn) (r = 0.23), and between Cr and zinc (Zn) (r = 0.37). Similarly, positive correlations were found between Fe and Mn (r = 0.40), Fe and Zn (r = 0.39), as well as between Mn and lead (Pb) (r = 0.32), and between Mn and Zn (r = 0.31). Additionally, at a significance level of p < 0.05, there were positive correlations between arsenic (As) and Fe (r = 0.17), between copper (Cu) and nickel (Ni) (r = 0.19), and between Ni and Pb (r = 0.17). The significant positive correlations between Cr, Fe, Mn, Zn, and Pb at a significance level of p < 0.01 imply a common source for these elements. Conversely, the positive correlations between Ni, Cu, As, and Zn at a significance level of p < 0.05 suggest diverse origins from which these elements may arise  r = 0.3, betweep < 0.01. Specifically, lead (Pb) and chromium (Cr) were positively correlated (r = 0.24), as were Pb and iron (Fe) (r = 0.40), Pb and manganese (Mn) (r = 0.272), and Fe and Mn (r = 0.515). Furthermore, at a significance level of p < 0.05, zinc (Zn) was positively correlated with arsenic (As) (r = 0.19), Mn with Cr (r = 0.199), and Fe with copper (Cu) (r = 0.17). The significant positive correlations between Cr, Fe, Mn, and Pb at a significance level of p < 0.01 during October–March indicate a possible shared source for these elements. On the other hand, the positive correlations between As, Zn, Cu, and Ni at a significance level of p < 0.05 suggest diverse origins for these elements. The heatmap cluster tree is a valuable visualization tool for identifying clusters of variables with similar correlation patterns in a correlation matrix. The results of the heatmap cluster tree analysis in this study were consistent with the findings from the Spearman correlation matrix, which was used to analyze non-normally distributed parameters. The positive correlations between the studied heavy metals, such as Cr, Fe, Mn, Zn, and Pb, observed in the Spearman correlation matrix were also evident in the heatmap cluster tree. Similarly, the diverse origins of heavy metals such as As, Zn, Cu, and Ni identified in the Spearman correlation matrix were also apparent in the heatmap cluster tree. These findings underscore the utility of the heatmap cluster tree as a complementary tool to the correlation analysis matrix, particularly for non-normally distributed data, in revealing correlation patterns among variables. In terms of heavy metal movement, storm runoff can transport heavy metals from various sources  into rivers : This group likely indicates metals that might share similar sources or behaviors in the river. These metals could potentially have a common origin, possibly linked to industrial processes, urban runoff, or agricultural activities. Cluster 2 : The second cluster includes metals that exhibit a different pattern from the first group. This suggests that they might have separate sources or behave differently in the river system. These sources could be related to industrial discharges, traffic pollution, or other anthropogenic activities. Cluster 3 (As): Arsenic (As) forms its own cluster, indicating that it may have distinct sources and behaviors compared to the other metals. Arsenic contamination could be influenced by various factors such as geological sources, agricultural practices, or industrial discharges. Strong Positive Correlations: The correlation values  between Mn and Fe, Mn and Zn, and Mn and Pb indicate moderate to strong positive relationships. This could imply that these metals share common sources or that their behavior in the river is interconnected. For example, the correlation between Mn and Fe might suggest a connection between iron-rich sediments and manganese. Moderate Positive Correlations: The correlations between Cr and Fe (0.33) and Cr and Zn (0.37) suggest moderate positive relationships. Similar to the above point, this could indicate co-occurrence due to shared sources or similar environmental behaviors. Low Correlations: The fact that Ni and As have correlations below 0.1 with all other metals suggests that their presence might be influenced by different factors or sources, and they may not exhibit strong interdependencies with the other metals in the dataset. Industrial Sources: Metals in the same clusters, like Cluster 1 , might suggest industrial inputs as a potential source, possibly from industrial discharges or effluents. Urban and Agricultural Sources: Considering the Danube River’s location near urban and agricultural areas, metals like Cu, Pb, and Zn might come from urban runoff, traffic emissions, and agricultural practices. Geological Sources: Elements like As might have geological sources, possibly arising from the natural composition of the soil and rock in the region. These findings could be valuable for understanding pollution sources, planning environmental management strategies, and implementing measures to mitigate heavy metal contamination in the Danube River.The potential ecological hazard index, developed by Hakanson in 1980, is a widely recognized method used for evaluating the extent of heavy metal pollution and its potential impact on both sediment and water environments. This index considers a range of factors, including the concentration of heavy metals, their ecological and toxicological effects, as well as their broader environmental implications. By integrating these factors, the index provides a comprehensive assessment of the ecological risks associated with heavy metal pollution in sediment and water systems. In this study, the potential ecological risk index (RI) for heavy metals was examined, as depicted in Fig. The non-carcinogenic and carcinogenic risk hazard indices (HI) were assessed by calculating the hazard quotients (HQ) for both ingestion and dermal absorption pathways. The outcomes reveal the combined potential health risks for humans resulting from exposure to different heavy metals during both the April–September and October–March time frames for both children and adults.The toxic elements arsenic (As), chromium (Cr), copper (Cu), iron (Fe), manganese (Mn), nickel (Ni), lead (Pb), and zinc (Zn) were evaluated to determine the non-carcinogenic risk in both children and adults Fig. . During Based on HQ oral values, it seems that the human health risks associated with exposure to As, Cr, Cu, Fe, Mn, Ni, Pb and Zn through ingestion are generally higher for child than for adult during April–September period. It is worth noting that though HQ oral values are within the permissible limit under 1, these values are specific to the location and period studied and that the actual human health risks may vary depending on various factors such as exposure duration and frequency, individual susceptibility, and environmental conditions.Nonetheless, during April–September, the HQ dermal values for adults were in the range of 6E−4 to 7E−4, 4.2E−3 to 6.9E−3, 1E−5 to 4E−4, 2E−4 to 7E−4, 6E−3 to 1.07E−2, 1E−4 to 3E−4, 0 to 1E−5, and 1E−5 to 3E−5 for As, Cr, Cu, Fe, Mn, Ni, Pb, and Zn, respectively. Moreover, for children during the same period, the HQ dermal values were in the range of 1.7E−3 to 1.9E−3, 1.25E−2 to 2.03E−2, 1E−4 to 2E−4, 5E−4 to 2E−3, 1.76E−2 to 3.17E−2, 2E−4 to 3E−4, 1E−4 to 2E−4, and 1E−4 to 1E−4 for As, Cr, Cu, Fe, Mn, Ni, Pb, and Zn, respectively  of As, Cr, Cu, Fe, Mn, Ni, Pb, and Zn as well as CR  of As, Cr, and Pb for both adults and children.The results of the Monte Carlo simulation indicated that the predicted HQ values for all heavy metals did not exceed the standard limits (HQ < 1). The estimated exposure levels are unlikely to pose a significant health risk for either adult or child in oral and dermal contact pathways. However, it is essential to note that risk assessments are typically based on conservative assumptions and uncertainties in the available data, therefore, it is essential to continue to monitor exposure levels and update risk assessments as new information becomes available Fig.  and 11.FIn this study, the Monte Carlo method was utilized to simulate carcinogenic risk assessments obtained through the deterministic approach for both oral and dermal exposure pathways in adults and children. The 5th and 95th percentile risk exposures represented the best-case and worst-case scenarios, respectively.The analysis of probabilities Fig. A–D suggeFigures Histograms in Figs. It’s important to highlight that elevated concentrations of heavy metals in surface water can lead to interactive effects on human health that should not be ignored. Therefore, we conducted a sensitivity analysis to identify the most significant parameters contributing to health risks. As depicted in Fig. The primary objective of this research was to investigate the levels of specific metals in the water of the Danube River in Hungary and assess their potential environmental and human health risks. The concentrations of manganese in both the southern (Hercegszántó and Hercegszántó cities) and northern (Dunaföldvár and Dunaföldvár cities) parts of the study area exceeded permissible drinking water limits. Iron concentrations also exceeded acceptable levels at all locations. This consistent increase in iron concentrations could be attributed to industrial activities releasing iron-containing effluents into the river or its tributaries. Conversely, the use of iron-based fertilizers in regional agriculture might contribute to elevated iron levels, while the selective use of manganese-based fertilizers could lead to high concentrations in specific agricultural regions. The study found no ecological risk (RI < 30) in the Danube River, as concentrations of arsenic (As), chromium (Cr), copper (Cu), nickel (Ni), lead (Pb), and zinc (Zn) remained below limit values. According to the Heavy Metal Pollution Index, all water samples collected during both periods indicated moderate pollution levels (15 < HPI < 30). However, the Metal Index revealed that the middle section of the river showed moderate pollution levels (2 < MI < 4), while the north and south parts exhibited higher pollution levels (4 < MI < 6).4−4), and chromium presented a carcinogenic health risk for both adults and children through dermal exposure in both periods (CR > 1 × 10−4). Notably, the data suggested that children were more susceptible to lead-induced cancer compared to adults, as their oral cancer risk (CR) exceeded the threshold value of (CR > 1 × 10−4).In terms of health risk assessment, non-carcinogenic health risk was evaluated using the hazard quotient (HQ) and hazard index (HI) for both oral and dermal exposures. The results indicated no significant risk for both adults and children (HI < 1 and HQ < 1). However, arsenic posed a carcinogenic health risk to children through oral exposure  for oral and dermal exposures in both adults and children, as well as simulating the carcinogenic effects of arsenic (As), chromium (Cr), and lead (Pb), thereby validating deterministic calculations. Sensitivity analysis indicated that metal concentration, intake rate, and exposure frequency were the most influential parameters contributing to the risk of carcinogenicity in the river. Therefore, regular monitoring of heavy metal concentrations in the Danube River is essential to identify any potential increases resulting from human activities. Moreover, proper treatment of wastewater from industrial sectors before discharge into the river is crucial to ensuring compliance with standard limits.Supplementary file1 (DOCX 42 kb)Below is the link to the electronic supplementary material.


ERCP is a safe and effective method for managing biliary obstruction in children. A case report illustrates successful removal of a bile duct stone in a 5‐year‐old child using ERCP. Pediatric ERCP is a viable option for treating biliary diseases in well‐equipped centers, alongside other approaches.We describe a 5‐year‐old child with extrahepatic biliary stone who successfully underwent endoscopic retrograde cholangiopancreatography for stone removal. He suffered from persistent colicky abdominal pain accompanied by fever that confirmed biliary stone. ERCP along with other methods, can be considered a safe procedure for managing BD in children. For stones >1 cm, procedures like lithotripsy, shock wave lithotripsy, laser lithotripsy, and stenting are used.This case report presents a CBD stone case with a left‐sided gallbladder treated with ERCP in an otherwise healthy 5‐year‐old male. Left‐sided gallbladder refers to a gallbladder located on the left side of the ligamentum teres. It is a rare anomaly usually related to the absence of segment IV, portal vein anomalies, or biliary system anomalies. Diagnosis of the associated anomalies is essential for managing liver transplantation, liver resection, and complicated hepatolithiasis. Preoperative diagnosis of the left‐sided gallbladder with associated anomalies is required to reduce the risks of operative complications.2A 5‐year‐old male was admitted to Namazi hospital , suffering from a persistent colicky abdominal pain for the last 30 days. Except for his premature birth, he had no history or family history of the following conditions; previous medical problems, taking any medications, past surgeries, abdominal trauma, weight loss, obesity, metabolic syndrome, hemolytic diseases, severe skin itching (Bayler disease), recurrent icterus, anemia, splenectomy, symptoms of chronic liver disease or liver dysfunction, liver disorders , steatorrhea, chronic diarrhea, as well as any underlying causes of gallstone formation. The pain was localized in the epigastric and periumbilical areas exacerbating after consuming dairy and high‐fat foods. The pain was accompanied by fever, vomiting, and constipation. The patient was born with GA = 28 W and a weight of 900 g. His current body weight and height were 16 kg (10–25th percentile) and 112 cm (50–75th percentile), respectively. Vital signs were stable; blood pressure 100/70 mm Hg, heart rate 104 beats/min, respiratory rate 28 breaths/min, and body temperature of 36.5°C. He had hepatomegaly and abdominal tenderness in the epigastric and periumbilical areas in the physical examination.3, respectively. Hemoglobin electrophoresis was normal. Hemolysis was not noted. Blood chemistries were as following: cholesterol 98 mg/dL , total protein 6 mg/dL (6.1–7.9 mg/dL), albumin 4 mg/dL (3.5–5.6 mg/dL), alkaline phosphatase 962 U/L, AST 104 U/L (15–40 U/L), ALT 180 U/L (5–45 U/L), GGT 160 U/L (5–32 U/L), total bilirubin 1.7 mg/dL (<2.0 mg/dL), amylase 44 U/L (16–91 U/L), and lipase 90 mg/dL (4–29 mg/dL)  were started after the patients' admission. The medical care team decided to perform MRCP and ERCP to evaluate and manage the CBD stone. In MRCP evaluation, mild dilation of central intrahepatic bile ducts and CBD (6 mm) was apparent, associated with a dark signal of a 5 mm stone within the pancreatic portion of CBD located at a 15 mm distance to the major papilla. The gallbladder's position was on the left side of the subhepatic area, concurrent with portal vein abnormality. The main portal vein was trifurcated, and ascending portion  of the left portal vein was hypoplastic. Additionally, small teres ligament differentiation of segment IV was suboptimal (Figure Since our center is well‐equipped, ERCP was performed under general anesthesia. During the procedure, dilatation of CBD with a stone in the middle was investigated Figure . After s3CBD stone is a rare condition in children, although it has become more common recently.The left‐sided gallbladder refers to a gallbladder lying on the left side of the falciform ligament.As mentioned before, a left‐sided gallbladder is a rare condition. Nevertheless, it is possible to accurately diagnose a left‐sided gallbladder before surgery and perform laparoscopic cholecystectomy by adjusting the port position. Increased size of the left portal vein and distribution of the left portal vein crossing over to the right side of the liver is the crucial common features of the left‐sided gallbladder. These variations probably have considerable clinical implications in managing hepatic resection, including donor hepatectomy.In recent years, the treatment approaches for managing choledocholithiasis in children have become more specific; however, no gold standard procedure is available yet. The endoscopic approach for managing biliary tract obstruction in medical centers performing ERCP is usually the first choice. Similarly, laparoscopic evaluation of CBD has also proven safe and effective. In the absence of ERCP, laparoscopic investigation can be an appropriate alternative. Laparoscopic cholecystectomy for biliary stone disease in the pediatric population has been well proven as the standard of care, similar to adult patients.To the best of our knowledge, no report on bile duct stone removal by ERCP in children has been published previously in Iran. This case is the first report of a successful pediatric ERCP for treating a bile duct obstruction due to a stone. The CBD stone was endoscopically removed. ERCP, along with other methods, can be considered a safe procedure for pediatric biliary diseases in well‐equipped centers. The patient is still at risk for CBD stone formation because of having an anomaly in the biliary system. Laparoscopic cholecystectomy is necessary in this patient.Ramin Niknam: Conceptualization; data curation; visualization; writing – original draft; writing – review and editing. Seyede Maryam Mahdavi Mortazavi: Conceptualization; investigation; resources; supervision; writing – original draft. Mehdi Ghaderian Jahromi: Project administration; validation; writing – original draft. Marzieh Davoodi: Conceptualization; project administration; supervision; validation; visualization; writing – original draft. Marzieh Soheili: Project administration; resources; writing – original draft; writing – review and editing. Maryam Ataollahi: Conceptualization; data curation; writing – original draft; writing – review and editing. Reza Moshfeghinia: Conceptualization; investigation; project administration; supervision; validation; visualization; writing – original draft; writing – review and editing.Not applicable.All authors declare that this manuscript has no conflict of interest.This research was approved by the ethics committee of shiraz university of medical sciences with IR.SUMS.REC.1401.665 code.sss.Written informed consent was obtained from the patient's mother to publish this case report and any accompanying images. All authors have viewed and agreed to the submission.


Twin–twin transfusion syndrome (TTTS) is characterized by unequal hemodynamics between the twins. We aimed to assess preoperatively the difference in umbilical vein flow (UVF) between the recipient and donor monochorionic diamniotic twins and evaluate the change in UVF following laser surgery in both twins.Z‐score by a calculator created using gestational age as an independent variable. Z‐score values were converted into centiles, which were evaluated statistically. Median differences in UVF/kg centile values were adjusted for TTTS stage and presence of arterioarterial anastomoses.This was a retrospective cohort study of differences in UVF that occurred following laser surgical treatment of TTTS. Sonographic assessment of the umbilical vein before and 24 h after fetoscopic laser surgery for TTTS was performed. Umbilical vein diameter and time‐averaged maximum velocity were measured, and UVF per kg (UVF/kg) was converted into a vs donor twin was 17.9% (−17.1% to 57.6%), P < 0.0001. The adjusted median difference in UVF/kg centile between the postoperative vs preoperative period among recipients was 2.2% (−10.8% to 13.8%), P < 0.0001, while the adjusted median difference among donors was 27.3% (8.2%–34.6%), P < 0.0001.The study population consisted of 363 TTTS patients. The adjusted preoperative median difference in UVF/kg centile between the recipient The preoperative difference in UVF between the recipient and donor twins confirms the pathophysiology of TTTS. Postoperatively, the substantial increase in UVF of the donor twin and the relatively small increase in UVF of the recipient twin confirm that ablation of the vascular communications resulted in rapid improvement in perfusion of the donor twin. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. What are the novel findings of this work?Z‐score calculator, which uses gestational age as an independent variable, to evaluate changes in umbilical vein flow (UVF) following treatment. We demonstrated a significant difference in the UVF between recipient and donor twins, confirming unequal intertwin blood flow as the cause of TTTS. We also observed a significant postoperative increase in UVF of the donor twin, confirming fetoscopic laser surgery as an effective treatment on a pathophysiological level.In this large study on monochorionic diamniotic twin pregnancies treated with laser surgery for twin–twin transfusion syndrome (TTTS), we employed a newly designed What are the clinical implications of this work?This study sheds light on the preoperative difference in UVF per kg between recipient and donor twins in TTTS. This paves the way for future studies to evaluate the role of this difference in UVF per kg in predicting TTTS, as a prediagnostic step or an estimate of severity.Twin–twin transfusion syndrome (TTTS) occurs in approximately 10% of monochorionic diamniotic (MCDA) pregnancies, and carries a significant risk of perinatal morbidity and mortality if left untreatedAlthough different management options for TTTS have been described, fetoscopic laser ablation of communicating vessels remains the first‐line treatment for Quintero Stage‐II, ‐III and ‐IV TTTSZ‐score calculator that converts Z‐scores to centiles as a clinical tool to measure changes in UVF before and after laser surgeryGiven that the umbilical vein (UV) is the only conduit of blood from the placenta to the fetus, assessment of its pre‐ and postoperative flow may help understand the pathophysiology of TTTS. Previous studies have demonstrated a significantly higher UV flow (UVF) of recipients compared with donors in TTTSThe aims of this study were (1) to describe the difference in UVF between the recipient and donor in MCDA twin pregnancies complicated by TTTS prior to laser surgery and (2) to evaluate the change in UVF following laser surgery in both twins.Z‐score calculator was computed . Incomplete laser surgery was defined as inability to perform laser photocoagulation of all intertwin vascular anastomoses. Reasons for incomplete surgery may include poor visualization of vascular anastomoses secondary to discolored amniotic fluid (e.g. due to pre‐existing subchorionic hematoma or bleeding from uterine trocar insertion), challenging placental location and maternal or fetal instability precluding ability to complete surgery. Each patient underwent a detailed preoperative ultrasound examination, which included evaluation of cervical length, amniotic fluid volume, fetal morphology, biometry, estimated fetal weight (EFW) and Doppler flow of the umbilical artery, UV and ductus venosus. The preoperative ultrasound examination was performed 1 day prior to surgery, and the postoperative scan was conducted on postoperative day 1. EFW was not remeasured postoperatively.This was a retrospective cohort study of changes in UVF following laser surgical treatment of MCDA twin pregnancies complicated by TTTS. The study population consisted of all patients diagnosed with TTTS, including Stage‐I TTTS patients, who underwent fetoscopic selective laser photocoagulation of communicating vessels (laser surgery) between 18 and 26 gestational weeks at our center  from February 2010 to May 2020. Laser surgery was offered routinely to patients with symptomatic or unstable Stage‐I TTTS (e.g. patients with symptomatic polyhydramnios or short cervix). Stable patients were counseled regarding the lack of consensus with respect to optimal first‐line management of stable Stage‐I TTTS, as detailed in a recent articleUV parameters were measured from the free loop of the UV at or near the abdominal wall insertion site. Color Doppler was activated to visualize flow and measure the time‐averaged maximum velocity (TAMX). The same section of the sampled UV, adequately zoomed, was used to measure the UV diameter (UVD) from the anterior inner to the posterior inner wall perpendicular to the beam of ultrasound Figure . All ang2) and TAMX (cm/s) as follows: UVF = 3.14 × (UVD/2)2 × 0.5 × 60 × TAMX. UVF/kg was derived by dividing the UVF by the EFW in kg. UVF/kg Z‐scores and the corresponding centiles (UVF/kg centiles) were calculated using a Z‐score calculator with a range of 18–26 gestational weeks, created using GA as an independent variable in a population of normal singleton fetusesAssuming parabolic flow in a straight lumen, UVF (mL/min) was calculated based on the cross‐sectional area . This difference was also calculated for the postoperative period for completeness. For Analysis 2, the difference between preoperative and postoperative measurements was calculated separately for donors and recipients (postoperative minus preoperative). These differences were tested and found to vary with Quintero stage and presence of arterioarterial (AA) anastomoses on bivariate analyses Tables ; they din (%) or median (range). Analysis was performed using SAS statistical software . The study was approved by the University of Southern California Health Sciences Campus institutional review board .Data are presented as Of 633 patients diagnosed with TTTS and treated with laser surgery during the study period, 270 were excluded, resulting in 363 patients included in the final study population  vs 8.2% ) mL/min/kg and 79.9  mL/min/kg, respectively, with a median difference between the recipient and donor of 20.12  mL/min/kg, R2, 0.1424, P < 0.0001) (data not shown). When adjusted for Quintero stage and presence of AA anastomoses, the preoperative median difference in UVF/kg centiles between the recipient and donor was 17.9% , P < 0.0001.Bivariate analysis demonstrated an association of the preoperative differences in UVF/kg centiles with Quintero stage Table  and presP = 0.1334. The median postoperative UVF/kg centile of the recipient and donor twins was 40.5%  and 54.1% , respectively, with a median difference between the recipient and donor of −5.2% , P = 0.0021. When adjusted for Quintero stage and presence of AA anastomoses, the postoperative median difference in UVF/kg centiles between the recipient and donor was −7.2% , P < 0.0001.The median postoperative UVF/kg of the recipient and donor was 109.8  and 110.1  mL/min/kg, respectively, with a median difference between the recipient and donor of −5.26  mL/min/kg, P = 0.0848 and 31.6  mL/min/kg, P < 0.0001, respectively. The median UVF/kg centile of the recipient twin increased from 31.6%  to 40.5%   to 54.1%  , R2 value was 0.0290 (P = 0.0057) for recipients and 0.0230 (P = 0.0150) for donors (data not shown). When adjusted for Quintero stage and presence of AA anastomoses, the median difference in recipient UVF/kg centile between the postoperative and preoperative period was 2.2% , P < 0.0001. When adjusted for Quintero stage and presence of AA anastomoses, the median difference in donor UVF/kg centile between the postoperative and preoperative period was 27.3% , P < 0.0001.The median difference in UVF/kg centiles between the postoperative and preoperative period for both recipients and donors was associated with Quintero stage Table  and presThe pathophysiology of TTTS is attributed to imbalance in blood flow between monochorionic twins, which occurs due to shunting of blood through vascular communications in the common placenta. The UV is the only conduit of blood from the placenta to the fetus; therefore, any fetoplacental hemodynamic changes are reflected by its flow parameters. In TTTS, the discrepancy in UVF between the recipient and donor twins reflects the unidirectional net flow of blood from one twin to the other. The findings of this study are consistent with this theory, as recipient twins had a significantly higher UVF/kg centile compared with donors prior to laser surgery for TTTS. At the assessment 24 h after corrective laser surgery, the UVF/kg centile of recipient twins remained relatively stable, while the UVF/kg centile of donor twins increased significantly. These findings suggest rapid correction of blood‐flow imbalance following laser surgery.et al.n = 32) and Ishii et al.n = 41) directly measured time‐averaged mean velocity, also referred to as intensity‐weighted mean velocity2) × 60. In contrast, we measured TAMX to derive the time‐averaged mean velocity (TAMX × 0.5), assuming parabolic flow, and calculated UVF (mL/min) as follows: TAMX (cm/s) × 0.5 × mean cross‐sectional area (cm2) × 60. Figueras et al.Gratacós et al.et al.vs 151 mL/min/kg, P < 0.0001vs 173.2 mL/min/kg, P < 0.0001et al.P < 0.0001) 1 day after surgery, while recipients had a non‐significant postoperative increase in median UVF/kg (260–283 mL/min/kg). Likewise, Ishii et al.P < 0.0001) and a non‐significant change in recipients , which is concordant with our findings.Although our UVF/kg values are not directly comparable to those reported by Gratacós Placental territory discordance is thought to be the cause of sFGR in monochorionic pregnancyvs 0.2%, P < 0.0001)  Table . In otheZ‐score calculator, which converted Z‐scores to their corresponding centiles and accounted for both GA and EFWThis study has several strengths. The parameter we used to compare differences in UVF (UVF/kg centile) was derived from a et al.Z‐score calculator presented a potential limitation because it was derived using a singleton‐fetus population and was applied to our twin‐fetus population. Despite the abovementioned limitations, our findings are not only concordant with prior published studies, but are also physiologically plausible.The limitations of this study include potential variability in data accuracy given the operator‐dependent nature of sonographic measurements. Different sonographers took measurements of UV parameters over a period of 10 years, and while the measurement technique was the same, operator‐dependent variability is inevitable. An additional limitation of this study is that all ultrasound UV parameters were acquired from the free‐loop portion of the UV. While this technique is in line with that utilized by Ishii The preoperative difference in UVF between the recipient and donor twins confirmed that unbalanced intertwin blood exchange is a characteristic of TTTS. Postoperative measures that demonstrated an increased overall median UVF in donors and overall unchanged median UVF in recipients confirmed that the ablation of vascular communications resulted in rapid improvement of perfusion in donor twins and a relatively stable perfusion of recipient twins. Future studies exploring the effect of AA anastomoses and sequential surgical technique on UVF parameters may offer a better understanding of pre‐ and postoperative hemodynamic fluctuations in TTTS. The performance of the preoperative difference in UVF/kg between the recipient and donor twins in predicting TTTS, as a prediagnostic step or estimate of severity, should be investigated further to assess its potential clinical utility.


Clinical evidence of immune checkpoint inhibitors combined with antiangiogenic drugs in patients with advanced non‐small cell lung cancer (NSCLC) was limited. Recombinant human endostatin (rh‐endostatin), an antiangiogenic drug, and camrelizumab, an anti‐PD‐1 antibody, have been approved for the treatment of advanced NSCLC in China. This study aimed to investigate the efficacy and safety of rh‐endostatin plus camrelizumab and chemotherapy in the treatment of advanced NSCLC.Eligible patients were enrolled and received camrelizumab  every 3 weeks and continuous intravenous infusion of rh‐endostatin  and cisplatin combined with pemetrexed (for adenocarcinoma) or paclitaxel (for NSCLC other than adenocarcinoma) every 3 weeks. Primary endpoint was progression‐free survival (PFS). Secondary endpoints were objective response rate (ORR), disease control rate (DCR), overall survival (OS), and safety profiles.Overall, 27 patients were included, and 25 patients were eligible for efficacy evaluation. For these 25 patients, ORR was 48.15% (13/27) and DCR was 85.19% (23/27). With a median follow‐up of 10.37 months, the median PFS was 8.9 (95% CI: 4.23–13.57) months. Median OS was not reached. Overall, 96.3% of patients experienced at least one treatment‐related adverse event, and grade 3 TRAEs occurred in 9 (33.3%) patients. No unexpected AEs were observed.Rh‐endostatin plus camrelizumab and chemotherapy showed favorable efficacy and safety profile in patients with advanced NSCLC, representing a promising treatment regimen for these patients. Rh‐endostatin combined with camrelizumab plus chemotherapy treating advanced NSCLC showed ORR of 48.15% and DCR of 85.19%, with a median PFS of 8.9 months. The safety profile was comparable with former studies, representing Rh‐endostatin combined with camrelizumab and chemotherapy as a promising treatment regimen in advanced‐stage NSCLC patients. Rh‐endostatin has been recommended as a treatment option for locally advanced and advanced NSCLC and rh‐endostatin combined with chemotherapy for the first‐line treatment of advanced‐stage NSCLC patients without targetable genetic aberrations in Chinese NSCLC treatment guidelines.The improvement of the delivery route of antitumor drugs could reduce the toxicities of drugs and prolong the circulation cycle of drugs in vivo. Given as a continuous intravenous infusion, rh‐endostatin could accumulate to a steady state concentration, and minimize fluctuations in drug concentrations. This could improve the efficacy of rh‐endostatin and patient's compliance.Currently, few studies reported the treatment for advanced NSCLC with rh‐endostatin plus camrelizumab. Considering these promising data of the potential therapeutic benefits of rh‐endostatin plus camrelizumab, we retrospectively reviewed the efficacy and safety of rh‐endostatin combined with camrelizumab in patients with advanced‐stage NSCLC in a first‐line setting. This study aimed to provide alternative treatment strategies for these patients.22.1We retrospectively reviewed the clinical data of patients with advanced‐stage (unresectable stage IIIB and IV) NSCLC confirmed by histopathology and treated with rh‐endostatin combined with camrelizumab from December 2019 to August 2021 in four medical centers. All included patients should have received rh‐endostatin combined with camrelizumab and chemotherapy. All procedures performed in this study involving human participants have followed the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved by the Hunan Cancer Hospital ethics committee (no. 202256). As this was a retrospective study, the individual informed consent was waived.2.2Male or female patients ranging from 18 to 75 years were eligible to include in this study. The inclusion criteria included: (1) patients with unresectable stage IIIB or IV pathologically confirmed NSCLC according to the classification of IASLC Thoracic Oncology, 1st Edition2.32/day) on day 1 and pemetrexed (500 mg/m2/day) on day 1. For patients with NSCLC other than adenocarcinoma, their chemotherapy regimens consisted of DDP (75 mg/m2/day) on day 1 plus paclitaxel (135 mg/m2/day) on day 1. All treatments were given intravenously every 3 weeks as one cycle. Symptomatic treatment or best supportive treatment was allowed according to the clinician's judgment. Computed tomography (CT) scan was conducted every two cycles to monitor the changes in lesions. Patients who experienced a tumor response or achieved stable disease (SD) after four cycles of treatment would be suggested to receive maintenance therapy of rh‐endostatin combined with camrelizumab until unacceptable adverse events (AEs) or disease progression.All included patients should have received at least two cycles of rh‐endostatin  combined with camrelizumab  plus chemotherapy. According to the dosage applied by previous studies, the continuous intravenous infusion of rh‐endostatin (70 mg/day) was administrated consecutively from day 1 to day 3 and camrelizumab (200 mg fixed dose) was administrated on day 1.2.4Baseline assessment included gender, age, physical examination, treatment lines, and histology in this study. AEs were followed‐up and documented during treatment every week. Response evaluations were performed every two treatment cycles evaluation standard. In this study, treatment response was evaluated according to the Response Evaluation Criteria in Solid Tumors .2.5The primary endpoint was progression‐free survival (PFS), which was defined as the interval from admission to disease progression or death. The secondary endpoint includes overall survival , ORR, DCR, and AEs, which was recorded according to National Cancer Institute Common Toxicity Criteria of Adverse Events (NCI‐CTCAE) Version 3.0.2.6p < 0.05 was considered statistically significant.Statistical analyses were conducted using SPSS software  and R studio . The visualization of the analysis results was conducted with GraphPad Prism . The categorical data were described as frequency or percentage (%), and the chi‐square test or Fisher's exact probability method was used for comparisons between groups. The median follow‐up period, PFS, and OS were analyzed by the Kaplan–Meier method. Clopper–Pearson method was used to calculate the 95% CI of ORR or DCR. 33.1A total of 27 eligible patients were included in safety analysis and 25 patients were included in the efficacy analysis Figure . The bas3.2The data cutoff date for final analysis was September 7th, 2022, with a median follow‐up of 14.41 (95% CI: 11.52–17.30) months. Of 25 patients in response evaluation, 12 (48.0%) patients achieved PR while 10 (40.0%) patients achieved SD, resulting in an ORR of 48.0% and DCR of 88.0%. For the whole cohort, the median PFS was 7.57 months (95% CI: 5.80–NR), and the median OS was not reached . In addition, DCR was 75.0 (95% CI 42.8–94.5) % and 100 (95% CI 75.3–100)% in those who received <4 cycles and those who received ≥4 cycles (p = 0.007), respectively (Table p = 0.06)   tumor proportion score (TPS). No significant differences were found between the different subgroups of age, sex, ECOG PS, or TPS in PFS and OS Figure . In the  95% CI 4.8–94.5 %) Figure , while n) Figure . For pat3.3The adverse events (AEs) are outlined in Table 4In this retrospective multicenter study, we evaluated the efficacy and safety of the combination of rh‐endostatin with camrelizumab plus chemotherapy in patients with advanced‐stage NSCLC. Our exploratory study demonstrated that rh‐endostatin plus camrelizumab as a combined regimen resulted in a promising efficacy in improving survival outcomes and therapeutic outcomes. To the best of our knowledge, this was the first verification of the clinical outcomes and values of rh‐endostatin combined with camrelizumab plus chemotherapy in advanced‐stage NSCLC patients.In recent years, anti‐PD‐1/PD‐L1 antibodies have shown efficacy for advanced NSCLC patients in previous clinical trials and anti‐PD‐1/PD‐L1 therapy has been recommended as a standard treatment for advanced‐stage NSCLC.Several preclinical results suggested that anti‐angiogenesis agents could enhance the antitumor effects of ICIs by both normalizing tumor vessels and improving the tumor immune microenvironment.In our study, the efficacy and survival results of rh‐endostatin with camrelizumab plus chemotherapy were satisfactory. The combination of rh‐endostatin plus camrelizumab and chemotherapy in our study achieved an ORR of 48.0% and a DCR of 88.0%. The median PFS in our study was 7.57 (95% CI: 5.80–NR) months, with median OS not reached. Previous studies have explored the efficacy and safety combination regimens of camrelizumab and other treatments, including camrelizumab and anti‐angiogenesis agents. In the CameL study, results showed that for non‐squamous NSCLC, camrelizumab plus chemotherapy achieved the median PFS for 11.3 (95% CI 9.6–15.4) months with a DCR achieving 87.8% (95% CI 82.5–92.0%).Safety profile in our study was satisfying and compared to former clinical trials of camrelizumab, there were no unexpected safety events appeared in our study. Especially, RCCEP is the most symbolic adverse event related to camrelizumab. In previous multicenter prospective studies of camrelizumab, the incidence rate of RCCEP ranges from 66.8% to 79.9%.There were some limitations of our study. First, the sample size of this study was small, which indicated that the results of our study should be interpreted with caution. Furthermore, enrolled NSCLC patients were with pathological heterogeneity, which might result in some uncertainty of the therapeutic effects. Therefore, larger sample sizes, multicenter, randomized, and controlled clinical trials are warranted to provide further validation for the use of rh‐endostatin and camrelizumab treating advanced NSCLC, as well as to confirm its long‐term efficacy and toxicity.5In summary, our study revealed that rh‐endostatin plus camrelizumab and chemotherapy has promising efficacy and safety profile in the first‐line treatment of advanced‐stage NSCLC, which indicated that this regimen could be a potential treatment option for advanced‐stage NSCLC patients. Further randomized controlled study is warranted to investigate the therapeutic outcomes of the rh‐endostatin combined with camrelizumab for advanced NSCLC.Xingxiang Pu: Data curation ; formal analysis ; investigation ; methodology ; validation ; visualization ; writing – original draft ; writing – review and editing . Qianzhi Wang: Data curation ; formal analysis ; investigation ; methodology ; validation ; visualization ; writing – original draft ; writing – review and editing . Liyu Liu: Data curation . Bolin Chen: Data curation . Kang Li: Data curation . Yu Zhou: Software ; visualization ; writing – original draft (supporting). Zengmei Sheng: Data curation . Ping Liu: Data curation . Yucheng Tang: Data curation . Li Xu: Data curation . Jia Li: Data curation . Yi Kong: Data curation . Fang Xu: Data curation . Yan Xu: Data curation . Lin Wu: Conceptualization ; data curation ; methodology ; project administration ; resources ; supervision ; writing – review and editing .The authors declare that they have no competing interests to disclose.