Oblique lumbar interbody fusion (OLIF) has gained increasing popularity recently. However, complications resulting from intraoperative retraction of psoas major (PM) sometimes occur. The aim of this study is to evaluate the degree of PM swelling by developing a scoring system called the Psoas Major Swelling Grade (PMSG), and to investigate the correlation between the PMSG and clinical outcomes after OLIF.t‐tests.Patients who underwent L4‐5 OLIF at our hospital from May 2019 to May 2021 were reviewed and all data were recorded. The extent of postoperative PM swelling was determined by calculating the percentage of change in the PM area before and after surgery on MRI and divided into three grades subsequently. Swelling within the range of 0% to 25% was defined as grade I, 25%–50% was grade II, and more than 50% was grade III. All patients were grouped into the new grade system and followed up for at least 1 year, during which the visual analog scale (VAS) and Oswestry disability index (ODI) scores were recorded. Categorical data were analyzed using chi‐square and Fisher's exact tests, while continuous variables were assessed with one‐way ANOVA and paired p = 0.024).  Furthermore, the total complication rate was 43.2% in the PMSG III group, significantly higher than 9.5% and 20.8% in the PMSG I and II groups (p = 0.012). The incidence of thigh paraesthesia was also considerably higher in the PMSG III group at 34.1% (p = 0.015), compared to 9.5% and 8.3% in the PMSG I and II groups. Among the patients, 12.4% exhibited a teardrop‐shaped PM, with the majority (90.9%) belonging to the PMSG III group (p = 0.012). Additionally, the PMSG III group demonstrated a higher estimated blood loss (p = 0.007) and significantly worse clinical scores at the 1‐week follow‐up assessment (p < 0.001).Eighty‐nine consecutive patients were enrolled in this study, with a mean follow‐up duration of 16.9 months. The proportion of female patients in the PMSG I, II, and III groups was 57.1%, 58.3%, and 84.1%, respectively  on MRI  PMSG I: swelling within the range of 0% to 25%;  PMSG II: swelling in the range of 25% to 50%;  PMSG III: swelling more than 50%. Oblique lumbar interbody fusion (OLIF) is a minimally invasive lumbar fusion procedure that has come into focus in recent years.However, to date, there are few clinical methods for radiologic characteristic assessment of the PM.The aim of this study encompassed two primary aspects. Firstly, the study aimed to quantify the extent of PM swelling using the three‐level PMSG classification system. This approach provided surgeons with a more precise and comprehensive classification method for evaluating postoperative swelling. Secondly, the study established a connection between PMSG and the severity of short‐term complications, enabling surgeons to predict patients' prognoses in advance and implement early intervention measures accordingly.This systematic retrospective study was conducted in the First Affiliated Hospital of Guangzhou University of Chinese Medicine between May 2019 and May 2021. One hundred consecutive patients who underwent OLIF surgery were reviewed, 11 of them were lost to follow‐up due to refusal to cooperate, being out of contact, or death, and a total of 89 patients were included finally. Demographic data, perioperative outcomes, imaging parameters, the visual analog scale (VAS) and Oswestry disability index (ODI) scores were recorded. The postoperative MRI scan time point was the second day after surgery. All patients were followed up for at least 1 year. Institutional review board approval was obtained for this study [No. K(2020)148].Inclusion criteria consisted of the following aspects: (i) age >18 years, underwent L4‐5 OLIF surgery; (ii) mild to moderate spinal stenosis at L4‐5 level, I‐II° lumbar spondylolisthesis, discogenic lumbar pain with or without lower limb radicular pain, which could be significantly relieved after bed rest; (iii) failed conservative treatment for more than 3 months.Exclusion criteria consisted of the following aspects: (i) a history of previous abdominal or retroperitoneal surgery; (ii) severe bony hyperplasia of the facet joint; (iii) large disc herniation, rupture of the annulus fibrosus, prolapse of the nucleus pulposus; (iv) lesion occupying the spinal canal; (v) comorbidities of serious medical diseases; (vi) severe osteoporosis, scoliosis deformity, spinal infection, tuberculosis, tumor; (vii) lost to follow‐up.Images of the preoperative and postoperative PM on MRI in the same axial view at L4‐5 level were screenshots captured for the upcoming measurement.The classification principles and bases for PM swelling shared similarities with paraspinal muscle fat infiltration, as both systems were divided into three levels based on percentage values.The patient was placed in the right lateral position under general anesthesia, and the abdominal organs were allowed to dangle naturally under gravity. Cushions were placed under the right thorax and iliac crest, and pillows were placed between the knees. After temporarily fixing the pelvis and knees to stabilize the spine, anteroposterior fluoroscopy was performed to ensure that the spine was not rotated. A 4‐cm‐long incision was made from the left abdominal wall in front of the marker line. The subcutaneous tissue was incised and the external oblique, internal oblique, and transversus abdominis muscles were bluntly separated. The retroperitoneal fat, abdominal organs and vessels were blocked anteriorly and PM was retracted posteriorly by retractors. After reconfirming the correct level under fluoroscopy, the intervertebral space was exposed, the annulus fibrosus was incised, and the nucleus pulposus and endplates were cleared. Next, the contralateral annulus fibrosus was penetrated with a detacher. The size of the cage to be placed was tested with a trial mold. After that, the cage filled with artificial bone was inserted into the intervertebral space and its position was confirmed fluoroscopically. Finally, the incision was rinsed, and the sutures were completed. The patient was then transferred to a prone position for posterior percutaneous screw fixation (PPSF). All procedures were performed by three specially trained spine surgeons.VAS and ODI were used to evaluate clinical efficacy. All scores were recorded at the preoperative, 1‐week postoperative, 3‐months postoperative, 6‐months postoperative, and 12‐months postoperative follow‐ups, respectively. Symptom duration, operation time, estimated blood loss, complications, length of hospital stay, and preoperative PM morphology (teardrop shape or not) were reviewed  statistical software. The chi‐square test and Fisher's exact test were used to compare categorical variables. One‐way ANOVA was used to analyze numerical variables. Paired p = 0.024). No significant difference was observed among the three groups in terms of age, body mass index (BMI), bone mineral density (BMD), symptom duration, and main diagnosis . Twenty‐four cases were enrolled in PMSG II group, including 10 males and 14 females with an average age of 59.08 ± 8.26 years. PMSG III group had 44 cases, including seven males and 37 females, with an average age of 60.70 ± 8.51 years. There was a significant difference between PMSG III and the other two groups in respect to gender (p = 0.007), and there was no significant difference between PMSG I and II groups. The duration of surgery (excluding PPSF) was 39.43 ± 3.46, 38.96 ± 3.43, and 39.14 ± 3.65 min in each group, respectively, with no statistically significant difference. The length of hospital stay was 6.10 ± 1.73, 6.33 ± 1.93, and 6.77 ± 1.57 days in each group, respectively, with no statistically significant difference.PMSG III group showed more estimated blood loss than PMSG I and II groups (p = 0.012), while there was no statistically significant difference among other groups. Two (9.52%) patients in PMSG I group, two (8.33%) in PMSG II group, and 15 (34.09%) in PMSG III group reported thigh pain and numbness or hip flexion weakness after operation immediately. Evidently, PMSG III group showed a much higher incidence of iliopsoas symptoms than the other two groups (p = 0.015). Sympathetic chain injury was reported by one patient in PMSG III and PMSG II group, respectively, with no statistically significant difference. In addition, three (6.82%) and two (8.33%) patients in PMSG III group and PMSG II group had cage subsidence and endplate fracture, with no statistically significant difference. All patients who developed iliopsoas symptoms such as thigh pain and numbness or hip flexion weakness were cured by oral NSAIDs or resolved on their own during follow‐up. Patients with cage subsidence did not develop severe clinical outcomes during follow‐up. No complications such as permanent neurological impairment or ureteral or peritoneal injury were observed throughout the whole follow‐up , five (20.83%), and 19 (43.18%) cases were reported in three groups, respectively. The total complication rate in PMSG III group was significantly higher than PMSG I group  and PMSG I group (p < 0.001), whereas there was no significant difference between the PMSG I and II groups. The postoperative swelling percentage of the PM was also significantly higher in PMSG III group than in the other two groups (p < 0.001), while the percentage between the PMSG II and I groups was also statistically different (p < 0.001). As for the preoperative PM muscles being teardrop‐shaped or not, none of them were found in PMSG I group, while one and 10 cases were found in the PMSG II and III groups, respectively, with a statistically significant difference (p = 0.012)  at the L4‐5 level was 1083.92 ± 269.41, 1046.59 ± 187.40, and 1018.58 ± 226.05 mmp < 0.001), whereas no difference was observed between PMSG I and II groups.Clinical scores were displayed in Table A typical case was shown in Figures This study has evaluated the extent of PM swelling and its association with clinical outcomes and complications following OLIF surgery. Ascertained from MRI scans on the second day after surgery, PMSG enabled surgeons to assess short‐term clinical effectiveness, anticipate short‐term complications, and tailor treatment strategies accordingly. It was particularly crucial for patients classified as PMSG III to consider early initiation of intensified anti‐inflammatory and dehydration measures or physiotherapy as a prophylactic approach. Moreover, the study highlighted the relevance of anatomical gender differences and morphological variations in teardrop shapes to higher PMSG, suggesting that surgeons should exercise increased caution during preoperative evaluations for female patients presenting with PM variants. In summary, as a rapidly obtainable indicator on the second day following surgery, PMSG could effectively predict short‐term clinical outcomes and complications, guiding personalized prophylactic measures and benefiting clinical practice.The practicality of PMSG stemmed from its simplicity, requiring only PM areas before and on the second day after surgery to predict short‐term complications without necessitating additional complex parameter measurements or calculations. Moreover, the learning curve for mastering the measurement method took less than an hour for surgeons, thus offering both simplicity and cost‐effectiveness. The measurement accuracy was ensured using MRI images as the original data source. MRI is one of the most precise and clear imaging techniques available for muscle evaluation, providing accurate and reliable image information based on its underlying imaging principles.p = 0.024). A study conducted by Liu et al. revealed that females were not suitable for OLIF at the L4‐5 level because their physiological anatomy of the abdominal aortic bifurcation and iliac vein confluence was located in front of the L4‐5 disc, which caused high risks of vascular injury.p = 0.007), suggesting that the amount of bleeding was probably an important factor affecting the swelling of PM.We found that the proportion of females was much higher in PMSG III group than in the other two groups (p = 0.015). Thigh pain and numbness or hip flexion weakness were more common and only very few patients had sympathetic chain injury and cage subsidence. Several studies have shown that the lumbar plexus was close to surgical access at L4‐5 level, which meant it was in a particularly dangerous condition during transabdominal surgery.Although OLIF does not cause damage to the posterior muscles, it still requires stretching of the lateral abdominal vessels, nerves, and muscles to obtain an excellent surgical view, resulting in some damage and corresponding postoperative complications, such as vascular injury, sympathetic chain injury, and muscle swelling.p = 0.012). Ng et al. concluded that 10.5% of patients did not have a natural oblique corridor and 20% of patients undergoing OLIF had a structural abnormality of the PM muscles.Different preoperative morphology of PM could lead to different PMSG after surgery. A kind of PM variant known as the teardrop‐shaped PM has been reported, which might affect clinical efficacy.p < 0.001). However, no statistically significant differences were observed between the PMSG I and II groups. Further more, no significant variations were found among the demographics, perioperative results, and imaging parameters between the PMSG I and II groups. Hence, it was deemed reasonable to combine patients from the PMSG I and II groups and redefine the PMSG category. For future studies, a threshold of 50% could be utilized to reclassified PMSG, with PMSG values below 50% falling under the general group and values equal to or exceeding 50% categorized as the overswelling group. This classification could serve as a basis for determining whether additional postoperative anti‐inflammatory and dehydration treatments are necessary.PMSG III group exhibited significantly poorer efficacy outcomes at 1‐week follow–up after the operation, indicating that high PMSG levels might adversely affect short‐term clinical efficacy (The strengths of the study could be highlighted in two primary aspects. First, in terms of postoperative evaluation, this study introduced an innovative PMSG classification system to grade the extent of postoperative PM swelling. This classification not only assisted surgeons in assessing short‐term clinical outcomes following OLIF surgery but also aided in predicting short‐term complications. Second, concerning preoperative evaluation, the study identified risk factors correlated with high PMSG. A more comprehensive preoperative assessment and gentler intraoperative traction were warranted for female patients and those exhibiting teardrop‐shaped PM muscles.However, there were also several limitations of this research. First, this study was retrospective and was subject to some selection and recall bias. Second, the PM swelling was indistinguishable from hematoma or edema when measuring because they were miscellaneous and blurred on MRI. Third, with small sample size and short follow‐up time, longer follow‐up or prospective studies with a larger sample size are needed in the future.Postoperative swelling of the PM affected short‐term clinical outcomes. The higher the PMSG, the more chance of blood loss and higher complication rate of thigh pain or numbness. Women and patients with teardrop‐shaped PM muscles were more likely to develop PM swelling after OLIF.Zefeng Song, Wanyan Chen, and Jingjing Tang contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Zefeng Song, Wanyan Chen, Xingda Chen, Shaohao Lin, Xiaowen Wang, and Peng Zhang. The first draft of the manuscript was written by Wanyan Chen, Zefeng Song, Guangye Zhu, and Zelin Zhou. Xiang Yu, Hui Ren, Jianchao Cui, De Liang, and Xiaobing Jiang commented on previous versions of the manuscript. All authors read and approved the final manuscript.This research received no specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors, and the authors declare that there is no conflict of interest.The authors declare that there is no conflict of interest. All the authors had met the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors, and they are all in agreement with the manuscript.This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the First Affiliated Hospital of Guangzhou University of Chinese Medicine [No. K（2020）148] and the ethics committee agreed to waive informed consent.


Mentha aquatica was nano‐encapsulated in nano‐emulsions coated with chitosan, Lepidium perfoliatum gum (LPG), and complex of chitosan and LPG (CCL) (1:1 ratio). Based on various tests , the LPG coating was the most optimum option for nano‐encapsulation compared to the other coatings. Thus, the LPG‐assisted nano‐encapsulated phenolic extract of M. aquatica was used to improve the oxidative stability of canola oil at three concentrations . The results of peroxide value and anisidine index tests  showed that the nano‐encapsulation improved the antioxidant effect of M. aquatica when compared with free extract in canola oil. In a comparative approach, the best sample was obtained from the LPG‐assisted nano‐encapsulated extract (200 ppm) due to the release of more phenolic compounds. The findings from this study showcase how nano‐encapsulation enhances the efficacy of antioxidants in edible oils.Incorporation of antioxidants, such as phenolic compounds into edible oils has limitations such as rapid release of phenolic compounds, low solubility, low penetration, low accessibility, and rapid degradation by environmental compounds. To solve this problem, the nano‐encapsulation process is offering promising opportunities. In this research, for the first time, the phenolic extract of  Mentha aquatica was used to improve the oxidative stability of canola oil at three concentrations . Peroxide value (PV) and anisidine value (AV) assessments showed that nano‐encapsulation improved M. aquatica extract's antioxidative power. In a comparative approach, the best sample resulted from the LPG‐assisted nano‐encapsulated extract (200 ppm) due to the release of more phenolic compounds.Thus, the LPG‐assisted nano‐encapsulated phenolic extract of  Mentha is an important genus of this family and comprises many medicinal plants and suitable sources of essential oils  improved the antioxidant effect of the extract in soybean oil.Nano‐encapsulated plant extracts can be added to other food ingredients in formulations, making it easier to produce, use, store, or transfer them into food  and chitosan. Ultimately, the efficiency of the nano‐encapsulated extracts was examined on the oxidative stability of canola oil and compared with the efficiency of tert‐butylhydroquinone (TBHQ). Also, pure canola oil without added antioxidants was used as a control.Therefore, considering the mentioned cases and the lack of any research regarding the nano‐encapsulation of 22.1M. aquatica was prepared by Vasteriosh company in Sari City . First, the samples were cleaned manually, then dried in the shade, ground, and turned into powder. The resulting powder was subjected to the extraction process to prepare the phenolic extract. In order to prepare L. perfoliatum gum, 10 kg of seeds were purchased from Tabib Daru Company in Shiraz. With the cooperation of Ghoncheh Sari Oil Compan, refined canola oil without antioxidants was prepared for this research. Merck and Sigma–Aldrich companies obtained the required solvents and chemicals.The 2.2M. aquatica was mixed in 500 mL ethanol/water solvent (1:1). Then the samples were placed in an ultrasonic bath  , according to Jamshidi et al. (L. perfoliatum seeds were dispersed in preheated deionized water (48°C), and the slurry of seed water was mixed continuously during the extraction period (1.5 h) while the temperature was kept constant (48°C) and pH was monitored and adjusted at 8. Finally, the seeds were discarded, and the slurry was dried in an oven (45°C), milled, and sieved by a mesh 18 sifter.i et al.  and Kooci et al. . Briefly2.4L. perfoliatum seed gum in the distilled water and chitosan in the acetic acid solution (1%) and stirring for 30 min at room temperature. The solutions were kept in the refrigerator for 24 h to complete the hydration and disengage the bubbles  was prepared by dissolving 2.5M. aquatica extract in a continuous phase containing 25% span 80 and 68% soybean oil without antioxidants. In the second emulsification phase, the W/O initial emulsion was coated with biopolymers prepared to produce W/O/W double emulsions. As a result, 30% initial W/O emulsion was added to 70% prepared bipolymers and homogenized at 10°C for 5 min at 13,709 g and then at 30,845 g for 8 min. Then, the homogenizer  was used at a pressure of 9500–11,500 psi in 3, 5, and 7 cycles (90 s each) to reduce the particle size and to stabilize the emulsion , and polydispersity Index (PDI) were done by dynamic light scattering (DLS) instrument at 25°C  and half‐life period (t1/2) of encapsulated powders were determined from the slope of the semi‐logarithm plotted of their remaining contents in nano‐capsules versus storage time. The half‐life of polyphenols “t1/2”, which is defined as the time of a reduction of 50% of their initial values in the capsules, was calculated from the slope of the curve and based on the t1/2 = 0.693/k  of the different emulsions  (CCL)). To reduce the droplet size and homogenization, a pressure of 11,000 psi was selected for smaller droplet sizes  caused the greatest reduction in the droplet size of emulsions. Also, Jamshidi et al. . After evaluating their different characteristics, droplet sizes of nano‐encapsulated emulsions with chitosan were reportedly 199 and 233 nm, respectively, and with L. perfoliatum, 146 and 216 nm, respectively. In the current research, however, the droplet size of emulsions was smaller, although with similar coatings. These differences can be explained by the effect of nano‐encapsulated materials, that is, the differences between unsaponifiable matters of the rice bran oil varieties and M. aquatica extract.Dehghan et al.  used nani et al.  used twoL. sativum and S. macrosiphon seeds (1:1). However, several emulsions were made with a single‐layered coating and had a smaller average droplet size than the combined double‐layered coating , ranged from 0.0996 to 0.1198, from 0.1002 to 0.1112, and from 0.072 to 0.091, respectively  with L. perfoliatum nano‐encapsulation were 0.36 and 0.31, respectively. In contrast, the PDI values were 0.44 and 0.32, respectively, when using chitosan , reporting values of −37, 29, and 20 mV, respectively. Tavakoli et al.  was −41.05, 25.97, and −9.2, respectively  for the nano‐encapsulation of P. khinjuk phenolic extract, reporting that the encapsulation efficiency ranged from 59.1% to 63.5%. In contrast to the current study, the research conducted by Hosseinialhashemi et al.  for nano‐encapsulation. In the present research, the size of emulsions correlated with the encapsulation efficiency. Roshanpour et al.  was used in the coating. Estakhr et al. , followed by the CCL‐assisted 23.1%) and chitosan‐assisted encapsulation (25.3%)  and rate constant (k). In the case of samples subjected to chitosan, CCL, and LPG nano‐encapsulation, the rate constants were recorded as 0.014, 0.0129, and 0.0124, respectively. Correspondingly, the half‐life periods for these samples were 49.5, 53.7, and 55.9 days, respectively. It is noteworthy that the rate constant exhibited an inverse correlation with the half‐life period.Table Mentha piperita using chitosan and A. homolocarpum gum, the reported rate constants ranged from 0.011 to 0.0143, while the corresponding half‐life periods fell between 48.5 and 63 days . The free phenolic extract of M. aquatica and TBHQ were observed comparatively.Its effect on the oxidative stability of edible oils should be evaluated to identify and introduce an antioxidant with appropriate potency. Thus, oil is usually subjected to intensified oxidative conditions and various experiments, such as the peroxide and p‐anisidine values over time . However, unlike free extracts, increasing the amount of nano‐encapsulated extract up to 200 ppm alleviated primary oxidation and caused a decrease in hydroperoxide formation. However, increasing the concentration of the nano‐encapsulated extract from 200 to 300 ppm decreased the resistance to primary oxidation, and hydroperoxide formation increased. In the 300 ppm nano‐encapsulated extract, phenolic compounds are not released efficiently from the LPG coating. In research by Estakhr et al. , it was revealed that the LPG‐assisted nano‐encapsulated phenolic extract (200 ppm) was the best treatment for preventing oxidation in canola oil. Furthermore, the release of phenolic compounds from LPG‐assisted nano‐encapsulated extracts  was evaluated during 24 days of heated storage (60°C) Figure  reportedr et al.  further r et al. . Howeverr et al. .4M. aquatica extract involved the utilization of chitosan and LPG coatings. Subsequently, the nano‐encapsulated extract underwent a thorough evaluation to assess its antioxidant efficacy. Notably, in this study, the LPG coating proved particularly effective in generating the best nano‐emulsion. Upon subjecting the nano‐encapsulated extract to oxidative stability tests, a significant enhancement in the antioxidant potential of the M. aquatica phenolic extract within canola oil was observed. Remarkably, the most substantial boost in oxidative stability occurred when the M. aquatica extract was nano‐encapsulated with LPG at 200 ppm. This favorable outcome can be attributed to the substantial release of phenolic compounds into the canola oil. In light of these findings, nano‐encapsulating antioxidant compounds stand out as a highly suitable technique for elevating their antioxidant impact within food products—particularly in preserving food quality during storage. As a forward‐looking suggestion, exploring the stability and efficacy of nano‐encapsulated antioxidant compounds under conditions involving intense thermal processes, such as frying, could be a promising avenue for future research inquiries.The process of nano‐encapsulation for the Javad Tavakoli: Investigation ; resources ; supervision ; validation ; visualization ; writing – original draft ; writing – review and editing . Habib Abbasi: Conceptualization ; formal analysis ; funding acquisition ; investigation ; methodology ; writing – original draft . Sara Gashtasebi: Data curation ; formal analysis ; investigation ; methodology ; resources ; validation ; visualization ; writing – original draft . Mohsen Salmanpour: Funding acquisition ; investigation ; methodology ; project administration ; validation ; visualization ; writing – original draft ; writing – review and editing . Amin Mousavi Khaneghah: Funding acquisition ; project administration ; visualization ; writing – original draft ; writing – review and editing .The authors declare no conflicts of interest.None declared.The authors declare their consent to participate in this article.The authors declare their consent to publish this article.


Portulaca oleracea, on lipid profile and C‐reactive protein (CRP) produced contradictory findings. The effect of purslane consumption on lipid profiles and CRP was assessed in this comprehensive review and meta‐analysis. We conducted a thorough literature search in online databases, including PubMed, Scopus, the Cochrane library, and ISI Web of Science to find relevant randomized controlled trials up to June 2023. By incorporating 14 effect sizes from 13 RCTs, we were able to show that purslane consumption significantly decreases serum triglyceride (TG) , total cholesterol (TC) , and CRP  levels in patients compared to the control group. In addition, purslane consumption significantly increases high‐density lipoprotein (HDL‐C)  levels. However, purslane consumption did not affect low‐density lipoprotein (LDL‐C) levels. According to a suggested optimal dosage, purslane consumption is considered to be safe up to 30 g/day. Purslane consumption can significantly improve cardiovascular health by improving lipid profile and inflammation status.Earlier investigations into the impact of purslane,  In this review, we evaluated the effects of purslane supplementation on lipid profiles and CRP. The results of meta‐analysis showed that there was no significant impact of purslane on LDL‐C in terms of total effect size. Each database search did not include any date or language constraints. Additionally, any database search was followed by a thorough manual check of all reference lists from relevant review papers.2.2Study eligibility was checked using the title and abstract of every identified study from the database and manual searches. The current meta‐analysis only considered studies that met the following criteria: (1) were randomized controlled trials (RCTs) or placebo‐controlled trials, (2) included adult participants >18 years old, (3) administered oral purslane alone , (4) had a minimum intervention duration of 2 weeks, and (5) reported the means and standard deviations (SD) of lipid profile serum concentrations and CRP at baseline and after the study or mean change for both the intervention and control groups.2.3Studies lacking a control or placebo group, interventions involving purslane consumption as part of a combination of nutrients, studies utilizing cohort, case–control, and cross‐sectional designs, animal and in vitro studies, literature reviews, and/or summary articles were all excluded from consideration.2.4The two researchers (OA and AD) extracted the data independently using a standardized data collection form. Information such as author's name, year, country of study, age of participants, number and gender, study design, type and dose of purslane, serum TC, TG, LDL‐C, HDL‐C, CRP concentration (before intervention and after intervention), and duration of intervention by researchers were extracted. Finally, all data units of the reported RCTs were unified to compare the average size of the effect.2.5The Cochrane quality assessment technique was utilized in this meta‐analysis to evaluate the risk bias, random sequence generation, and allocation concealment, and the remaining four are related to performance bias, attrition bias, reporting bias, and other causes of bias. All studies were classified based on methodological defects in three domains: “high risk”, “low risk”, or “unclear risk”  from stated and relevant data of RCTs were used to assess the full effect size on outcome measurements of lipid profile and CRP pre‐ to post‐purslane intervention. Weighted mean differences (WMDs) utilizing 95% confidence intervals (CIs) were represented for all variables for assessing effect sizes. The conversion of lipid profiles  and CRP levels reported in mmol/L to mg/dL was done when mean changes were not recorded or when the values were provided in mmol/L but not mg/dL. Standard errors (SE), 95% confidence intervals (CIs), and interquartile ranges (IQRs) were converted to SD , four studies were excluded as they did not provide the necessary information. Finally, 13 studies , Israel (n = 1), and Iran (n = 11). Each study utilized a parallel design and recommended purslane dosages ranging from 0.06 to 10 mg/day. The interventions in the included randomized controlled trials (RCTs) lasted for a duration of 4–16 weeks and were conducted on populations with distinct characteristics. Specifically, eight studies focused on oral purslane consumption in patients with type 2 diabetes, one study targeted hypercholesterolemia patients, one study involved schizophrenic patients, two studies involved patients with metabolic syndrome, and two studies examined individuals diagnosed with non‐alcoholic fatty liver disease. The mean age of the participants ranged from 40 ± 17.52 to 61.17 ± 4.88 years. Among the 13 selected RCTs with a parallel design, only one study had a crossover design. The Cochrane risk of bias assessment tool was used to evaluate the studies, revealing that some studies exhibited a minimal risk of bias in most of the assessed domains (Table Table 3.23.2.1p < .001), combining data from 14 effect sizes extracted from 13 RCTs . To explore potential sources of heterogeneity, we conducted subgroup analyses based on several factors, including sex, trial duration (≤8 vs. >8 weeks), intervention dosage (≥10 vs. <10 g/day), baseline BMI (overweight 25–29.9 vs. obese ≥30 kg/m2), health status (diabetes vs. non‐diabetes), and baseline TG levels (<150 vs. ≥150 mg/dL), using the median values across the included RCTs as cutoffs. The subgroup analyses revealed that purslane consumption significantly reduced serum TG concentrations in studies involving overweight subjects, particularly in females with high TG levels  levels in patients who consumed purslane compared to the control group  . Further subgroup analyses revealed that purslane consumption had a significant impact on serum TC concentrations in diabetic patients , females , when the intervention dose was <10 mg/day , and when the baseline serum TC was below 200 mg/dL   was observed between the intervention group and the control group following purslane consumption . The overall heterogeneity among the studies was found to be significantly high  . Furthermore, when the study duration was >8 weeks , in diabetic patients , and in individuals with a baseline serum LDL‐C level below 130 mg/dL , purslane consumption demonstrated a significant effect  values . However, notable between‐study heterogeneity was observed  . Subgroup analysis revealed significant results when the study duration was <8 weeks , the intervention dose was <10 g/day , the intervention was performed on overweight participants , and the baseline serum HDL‐C was below 40 mg/dL   concentrations. The quantitative meta‐analysis revealed a significant mean effect of purslane consumption on serum HDL‐C concentrations in the intervention group compared to the control group  based on six effect sizes from trials. There was also significant between‐study heterogeneity observed overall  . Similarly, when the intervention was performed on individuals with diabetes, a significant effect on CRP levels was observed  , TC (p = .342), LDL‐C (p = .362), HDL‐C (p = .287), and CRP (p = .218) based on visual inspection of funnel plots and Egger's regression test , total cholesterol (TC) (p = .016), and low‐density lipoprotein cholesterol (LDL‐C) (p = .017)  and LDL‐C (p = .001)  . The observed inhibitory effects of unsaturated fatty acids on NF‐κB in patients could potentially explain the mechanism behind the benefits of omega‐3 fatty acids. Some studies have reported the inhibitory effect of unsaturated fatty acids, including omega‐3, on CRP levels in diabetic patients, although the changes in CRP levels may not have been statistically significant. Nevertheless, the significant reduction of CRP in other studies suggests that there may be a synergistic effect of various compounds present in purslane seeds, working together to provide these beneficial outcomes. It is crucial to note that just four research totaled in our analysis for CRP levels . The various study designs, lengths of interventions, and participant numbers may account for the contradictory outcomes on biomarkers of inflammation.The exact biological mechanism underlying the effects of purslane has not yet been fully elucidated. However, purslane is known to be rich in various nutrients, and it is an excellent source of the antioxidant, vitamins, L‐ norepinephrine, and glutathione in purslane also may play a role in the observed hypocholestrolemic effects Several studies have actually demonstrated that the consumption of purslane can lead to a reduction in oxidized LDL‐cholesterol (OxLDL) levels. It is believed that the antioxidant compounds present in purslane play a crucial role in preventing the formation of lipoperoxides during the process of LDL oxidation. On the other hand, high concentrations of Melatonin, a free radical scavenger, are recently identified in purslane. Melatonin also reduces TC in rats with high cholesterol diet . Nazgol Bahreini: Writing – original draft . Azadeh Dehghani: Writing – review and editing . Yasin Lak: Writing – original draft . Amirhossein Shami: Writing – original draft .The authors declared that there is no conflict of interest.


Kidney function is associated with clinical outcomes in patients with cancer.This study aimed to assess the association between kidney function decline and cancer‐related mortality among community‐dwelling elderly individuals.This was a retrospective longitudinal cohort study.The 61,988 participants were from an elderly health examination database in Taipei City from 2005 to 2012.Multivariable logistic regression was used to assess the association between baseline covariates and rapidly deteriorating estimated glomerular filtration rate (eGFR). In addition, Cox proportional hazards model and the Fine–Gray model were used to quantify the effects of covariates on total cancer mortality and six specific cancer mortalities.2, and 18.3% had rapid renal function decline (≥5 mL/min/1.73 m2 per year). Rapid renal function decline was positively related to age, baseline eGFR, proteinuria, hypertension, waist circumferences, high log triglyceride levels, and diabetes mellitus (DM) history. In Cox proportional hazard models, participants with rapid eGFR decline had an increased risk of cancer mortality  compared to those without rapid eGFR decline. In the analysis of site‐specific cancer mortality risk, rapid eGFR decline was associated with six site‐specific cancer mortality, namely gastrointestinal tract, hepatobiliary, lung, prostate, urinary tract, and hematological malignancies.During the follow‐up period, 1482 participants died of cancer. Their baseline average eGFR was 73.8 ± 19.9 mL/min/1.73 mElderly individuals with rapid kidney function decline had higher cancer mortality risks. Serial assessments of dynamic changes in eGFR might provide information relevant for cancer prognosis. This study aimed to assess the association between kidney function decline and cancer‐related mortality among community‐dwelling elderly individuals. In Cox proportional hazard models, participants with rapid eGFR decline had an increased risk of cancer mortality compared to those without rapid eGFR decline. In the analysis of site‐specific cancer mortality risk, rapid eGFR decline was associated with six site‐specific cancer mortality, namely gastrointestinal tract, hepatobiliary, lung, prostate, urinary tract, and hematological malignancies. This is partly because of age‐associated kidney dysfunction and chronic comorbidities, as cancer incidence increases with age. The Renal Insufficiency and Anticancer Medications (IRMA) study in France showed that 52.9% of 4684 patients with cancer had an estimated glomerular filtration rate (eGFR) of <90 mL/min/1.73 m2.While CKD is a well‐established risk factor for all‐cause mortality, there has been growing evidence on the association between sequential changes in kidney function and mortality both above and below the eGFR of 60 mL/min per 1.73 m22.1This community‐based cohort study used data from the Taipei City Elderly Health Examination Database. The study period covered from 2005 to 2012. The Taipei City Government provides free annual elderly health examinations in Taipei City. On average, around 42,000 elderly citizens aged ≥65 years each year can participate in the examinations, which accounts for 13% of the registered elderly population in Taipei City. All qualified participants can receive a health examination once annually. The examination included a standardized medical examination  and questionnaires that addressed a variety of health‐related topics. This database is linked to Taiwan's National Death Registry from 2005 to 2012 by using the participants' identification number and personal information was encrypted by the data managers. Data were stored in the Taipei Geriatric Health Examination Database, and labels were de‐identified before release.2.22) were excluded (visits = 3957). The analysis required at least two time‐point measurements of the eGFR to compute the slope of the change. Therefore, we excluded 35,815 participants  who had only one visit, explanatory variables with missing or abnormal values, and the date of health check‐up later than the date of death. Finally, we included 61,988 participants contributing to 223,231 visits. The endpoint outcome was defined as the deaths from malignant neoplasms registered in the death registry encoded by the ninth or tenth revision (the death year after 2009) of the international classification of diseases (ICD‐9 or ICD‐10).This research was designed as a retrospective longitudinal cohort study based on the elderly health examination database in Taipei City. At the beginning, the database contained 315,045 health check‐up visits from 97,803 participants aged ≥65 years from 2005 to 2012. Each of the participants had different number of health check‐up visits. The selection process is shown in Figure 2.3The participant's baseline comorbidities, clinical conditions, and biochemical parameters were recorded. Trained case managers interviewed the participants using a structured questionnaire to obtain demographic information, lifestyle behaviors , pre‐existing comorbidities (such as diabetes and hypertension), and medications. Anthropometric parameters, including body height, weight, blood pressure, and waist circumference, were measured during the medical checkup. BMI was calculated as body weight (kg) divided by the square of the body height (m). The results of the biochemical tests of the blood samples were used for analysis. Hypertension was defined as systolic blood pressure (SBP) ≥140 mmHg, diastolic blood pressure (DBP) ≥90 mmHg, or the use of antihypertensive medication. Diabetes mellitus (DM) was defined as the use of medications. Biochemical data (white blood cells (WBCs), hemoglobin, albumin, triglyceride (TG), high‐density lipoprotein cholesterol (HDL‐C), creatinine, urine protein, and uric acid levels) were obtained from blood samples collected after midnight fasting. We examined the normality of biochemical values. Among all data distributions, only TG had a high skewness of 2.6. After the log transformation of TG (log TG), the skewness was reduced to 0.27, which is close to the normal distribution, with a skewness of 0.2) = 186 × serum creatinine−1.154 × (age)−0.203 ×  × (1.212 if Black).2), G2 (60–89 mL/min/1.73 m2), G3a (45–59 mL/min/1.73 m2), G3b (30–44 mL/min/1.73 m2), G4 (15–29 mL/min/1.73 m2), and G5 (<15 mL/min/1.73 m2). In this study, we classified eGFR (mL/min/1.73 m2) into four categories: ≥90, 60–89, 45–59, and <45. The number of participants with an eGFR of <45 was rare in the study population. Therefore, we did not classify them into a more detailed group with an eGFR of <45. The absolute annual rate of change in eGFR was calculated by fitting a least‐squares regression line to all measurements for each participant, where the slope of the regression line described the rate of change in eGFR. The rapid decline in kidney function was defined as an eGFR loss of ≥5 mL/min/1.73 m2 per year based on the KDIGO 2012 clinical practice guideline. A urine dipstick test for proteinuria was divided into negative, trace (+/−), 1+, and ≥2 +. We classified urine protein into three groups: “–“as a reference group, “+/−, +” as one group, and ++, +++, ++++ as a second group. Health risk behaviors, including cigarette smoking and alcohol drinking in the past half years, were treated as having or not.We used the MDRD for the eGFR calculation formula. The formula is eGFR , whichever came first. Study participants were censored because of death from causes other than the outcomes of interest, or the end of the study period. Since the dates of death were recorded in year‐month format, we imputed the day of death as the 15th of the month. For participants who died in the same month as the date of the last health check‐up visit, we imputed the day of death as the last day of the month.t‐test for continuous variables and a chi‐squared test or Fisher's exact test for categorical variables as appropriate. Multivariable logistic regression was used to assess the association between baseline covariates and a deteriorated eGFR. The covariates were the same for overall cancer‐related mortality and mortality due to the six specific cancers. We checked for multicollinearity by using the variance inflation factors (VIFs). The VIFs of all the variables in the logistic regression were <5. Cox proportional hazard models were used to quantify the association between renal function deterioration and all‐cancer mortality and six specific cancer mortalities. The elderly population usually has multiple comorbidities and the competing risk of death is high. Thus, we additionally applied Fine and Gray's modelAll analyses were performed with R software version 3.6.1,2.5Participants were enrolled, wherein we obtained signed informed consent and submitted it to the Taipei City Government, to attend the health examinations and record the data for research purposes. The study protocol was approved by the Institutional Review Board (IRB) of Biomedical Science Research, Academia Sinica (IRB no. AS‐IRB‐BM 15043). In this study, we applied anonymous secondary data for analysis, and thus, the requirement for consent was waived by the IRB.33.1p < 0.001). Mean length of follow‐up was 68.0 ± 23.6 months, with 4512 (7.3%) all‐cause deaths and 1482 cancer deaths (2.4%). The percentage of participants with proteinuria (>2+) was 1.9% in those with eGFR ≥90 versus 9.5% in those with eGFR<45.In this study, we report that 4512 elderly individuals had all‐cause deaths, including 1482 who died due to cancer and 3030 who died due to other causes. Table 2, and 382 (25.8%) participants had rapid kidney function deterioration (eGFR declines ≥5 mL/min per 1.73 m2 per year) compared to 17.5% with rapid eGFR decline in the survivor group (p < 0.001). Among non‐cancer deaths, the average eGFR was 68.9 ± 21.5 mL/min/1.73 m2, and 874 (28.8%) participants had rapid kidney function deterioration. The participants in the non‐cancer group were older and had a higher percentage of participants with a history of diabetes (p < 0.001) and hypertension (p = 0.033) and worse baseline eGFR than those in the cancer‐death group.To elucidate the association between kidney function and survival status, we stratified the groups according to death categories; survivor, cancer death, and non‐cancer death Table . Among t3.22, females had higher risk of rapid decline . However, in the group of eGFR <60 mL/min/1.73 m2, males had higher risk of rapid decline .We found that rapid renal deterioration was associated with metabolic factors and baseline eGFR in the Multivariable logistic regression models Table . Increas3.3Table In addition to total cancer mortality, Figure 4In this longitudinal cohort of the elderly, rapidly declining renal function was associated with an increased risk of cancer mortality independent of metabolic components, baseline eGFR, and proteinuria. This finding remained consistent across subgroups of site‐specific cancers. To the best of our knowledge, this is the first large study that demonstrated the risk of rapidly declining renal function on cancer mortality in an elderly population.2 per year).2 showed that eGFR decline mainly depended on baseline eGFR, with faster decline with higher baseline eGFR values.2, the PREVEND study even found gender was a modifiable variable of predictors for renal function decline.Factors associated with rapid GFR decline in populations with normal renal function have been clinically studied. Disease processes underlying the rate of rapid renal decline and initially involved compartments of kidney  are unknown. In a large cohort of 37,796 primary care patients with preserved kidney function, Koraishy et al. indicated that baseline eGFR, older age, African‐American race, unmarried status, lower neighborhood socioeconomic status, hypertension, type 2 diabetes, and smoking were associated with rapid eGFR decline (>5 mL/min/1.73 m2 per year) increased risk of mortality even though the high average eGFR was 69 mL/min/1.73 m2 at the end.2). Recently, in a Chinese cohort of 37,691 participants aged ≥45 years with preserved kidney function, Guo et al. found that a greater decline in the eGFR over time was associated with the risk of mortality, independent of the initial eGFR.2 per year) is associated with cancer mortality independently of other clinically relevant risk factors.In the past decade, several studies have shown that loss of kidney function even with relatively well‐preserved kidney function at baseline was associated with adverse outcomes, including all‐cause mortality and poor renal outcomes. In 4380 elderly participants, Rifkin et al. found that rapid decline in eGFR ; methodology ; writing – original draft (lead). Yi‐Chi Chu: Formal analysis (lead); visualization (lead). Yen‐Hsu Chen: Conceptualization ; writing – review and editing . Ta‐Chien Chan: Conceptualization ; data curation (lead); funding acquisition (lead); methodology (lead); supervision (lead); writing – review and editing (lead).This research was supported by a grant from the Ministry of Science and Technology, Taiwan (MOST 111‐2121‐M‐001‐002). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.The authors declare that they have no conflict of interest.When participants were enrolled, Department of Health, Taipei City Government obtained signed informed consent from the participants. The study protocol was approved by the Institutional Review Board (IRB) of Biomedical Science Research, Academia Sinica (IRB no. AS‐IRB‐BM 15043). In this study, we applied anonymous secondary data for analysis, and thus, the requirement for consent was waived by the Institutional Review Board (IRB) of Biomedical Science Research, Academia Sinica. This study was performed in accordance with the Declaration of Helsinki and followed by the approved protocol.Not applicable.


Eragrostis tef (Zuccagni) Trotter] is a cereal grain originating in Ethiopia as a staple food for millions of people. Its grain is a gluten-free superfood and got acceptance as a medicinal ingredient. Therefore, it is worthwhile to determine the antioxidative activities and L-ascorbic acid contents of teff grain and its baked food (injera). This study aimed to determine the ascorbic acid contents and antioxidant activities in the aqueous extract of the white and brown teff grains and their injera samples using iodimetric titration and UV-Vis spectrophotometric methods, respectively. The ascorbic acid contents in the white and brown teff ranged from 67.9–112.6 mg/100 g and 69.2–117.2 mg/100 g, respectively, and those in injera of the selected teff samples ranged from 30.5–32.9 mg/100 g and 37.3–43.0 mg/100 g, respectively. The antioxidant activities ranged from 1.26–7.04 μmol AAE/g for the white teff grains, 1.44–6.29 μmol AAE/g for the brown teff grains, 1.81–2.47 μmol AAE/g for white teff injera, and 3.89–4.86 μmol AAE/g for the brown teff injera samples. Findings of the present study have revealed that white teff and brown teff grains and their injera were found to have a higher content of ascorbic acid than commonly consumed grains and vegetables. No significant difference (α = 0.05) has been observed between the two varieties of teff grains with respect to the ascorbic acid content and antioxidant activities. However, there was a statistically significant difference (α = 0.05) in the ascorbic acid content and antioxidant activities between the teff grains and their injera samples. Therefore, this study indicated that teff grains and injera are rich in ascorbic acid content and antioxidant activities as compared to other cereal grains and are very crucial for human nutrition and health.Teff [ Eragrostis tef (Zuccagni) Trotter] is a cereal grain originating in Ethiopia as a staple food to millions of people  × 100 = %R, where CS represents the concentration of the spiked sample extract, C represents the concentration of the unspiked sample extract, and CA represents the concentration of the spiked ascorbic acid. The percent recovery results (98.6–104%) in The precision (% RSD) and accuracy (% recovery) of the titration method for determining ascorbic acid content were assessed. As a result, the method's repeatability was evaluated by calculating the relative standard deviation (RSD) of triplicate measurements, which yielded 1.8–7.6%, indicating that the method is precise. The reproducibility (recovery) test was carried out by adding a known amount of ascorbic acid to injera, white, and brown teff extracts. The spiked solution was analyzed three times to obtain the average recovery (y = −0.0051x + 0.94686) of ascorbic acid standard DPPH scavenging activities determined by its regression coefficient (R2 = 0.9995). The antioxidant capacity of cereal grains can be determined using a variety of assays. The DPPH assay was used in this study to assess the antioxidant activities of the ascorbic acid in white and brown teff grains and their respective injera samples .  Figureμmol AAE/g and 1.44–6.29 μmol AAE/g, respectively. The lowest and highest values of DPPH radical scavenging activities in white teff grain samples were determined for Ada'a district (East Shewa zone) and Goncha Siso Enese district (East Gojjam zone), respectively, while those of brown teff grain samples were determined for Dessie Zuria district (South Wollo zone) and Gomibora district (Hadiya zone). Furthermore, the DPPH scavenging activities of white and brown teff injera were found to be 1.81–2.47 μmol AAE/g and 3.89–4.86 μmol AAE/g, respectively.The antioxidant activity levels in white and brown teff grains were 1.26–7.04 μmol of trolox equivalent antioxidant capacities per g of the sample (μmol TE/g sample) like rice (1.39–10 μmol TE/g) [μmol TE/g) [μmol TE/g), and brown teff (6.54–7.16 μmol TE/g) [μmol TE/g) and brown teff grains (2.14–4.30 µmol TE/g) reported by Kotaskova et al. [α = 0.05) in the mean antioxidant activity content between the white and brown teff grains. The low correlation (r = 0.14937) between ascorbic acid contents and in vitro antioxidant activities  , wheat (ol TE/g) , white tol TE/g) , but thea et al. . One-waytivities  in the tα = 0.05) between the white and brown teff grains and their injera samples . However, the mean concentration of ascorbic acid and antioxidant activities of the selected teff grains and their injera samples differed significantly (α = 0.05). According to this study, teff grains and their corresponding injera have high ascorbic acid content and antioxidant activity. Furthermore, the ascorbic acid content of teff grain and injera was higher than that of commonly consumed grains and vegetables. Were Ilu district of the South Wollo zone had the highest ascorbic acid content in white and brown teff grains. To the best of our knowledge, this is the first study to determine the ascorbic acid content of teff grains and injera. As a result, this finding can serve as a foundation for future research on using teff grains in functional foods.The teff's ascorbic acid content is important for human health and is used as a quality indicator parameter. As a result, the study reported ascorbic acid contents and antioxidant activities in aqueous extracts of white teff grains and brown teff grains and their injera samples. The mean ascorbic acid content and antioxidant activities determined in the white and brown teff grains have shown no significant differences (It is fact that teff grain is typically used in fermented foods. The endogenous and microbial enzymes derived from teff grain flour initiate injera dough fermentation which could be an interesting area of future research. Besides, establishing standards for the quality and quantity of starter culture, fermentation conditions, and other ingredients can let researchers investigate biological activities and prospective applications.


Solanum melongena L.) and its wild cousins, comprising 13 clades with 1500 species, have an unprecedented demand across the globe. Cultivated eggplant has a narrow molecular diversity that hinders eggplant breeding advancements. Wild eggplants need resurgent attention to broaden eggplant breeding resources. In this study, we emphasized phenotypic and genotypic discriminations among 13 eggplant species deploying chloroplast–plastid (Kim matK) and nuclear (ITS2) short gene sequences (400–800 bp) at DNA barcode region followed by ITS2 secondary structure predictions. The identification efficiency at the Kim matK region was higher (99–100%) than in the ITS2 region (80–90%). The eggplant species showed 13 unique secondary structures with a central ring with various helical orientations. Principal component analysis (PCoA) provides the descriptor–wise phenotypic clustering, which is essential for trait–specific breeding. Groups I and IV are categorized under scarlet complexes S. aethiopicum, S. trilobatum, and S. melongena (wild and cultivated). Group II represented the gboma clade , and group III includes S. mammosum, and S. torvum with unique fruit shape and size. The present study would be helpful in genetic discrimination, biodiversity conservation, and the safe utilization of wild eggplants.Eggplant or aubergine ( Solanum spp.) are major genera in the family Solanaceae, contributing over 1500 plant species worldwide1. The genus Solanum is subdivided into 13 clades comprising 450 species2. Eggplant or aubergine (Solanum melongena L.) and some of its wild cousins are native to the Indian subcontinent having an unprecedented demand across the globe3. The gboma (Solanum macrocarpon L.) and scarlet eggplant (Solanum aethiopicum L.) of old–world origin are also cultivated as minor vegetable crops all over the world4. Production of eggplant reached over 51 million tonnes from an area of 1.8 million ha worldwide5. India is the second–largest producer of eggplants after China, accounting for global production of 13.4 million tonnes6. Transforming from the ancient world to commercial cultivation, wild relatives of eggplant are often considered the prime source of genetic materials in trait–specific breeding programs. The crop wild relatives (CWR) are hostile species with inherent tolerance towards various abiotic and biotic stresses such as drought, salinity, heavy metals, high temperature, disease, and pest menace. Thus, CWRs became the breeder’s first choice while augmenting breeding strategies for crop improvement7.Eggplant and its wild relatives , maturase K  or Kim matK (3F Kim and 1R Kim), trnH–psbA, and internal transcribed spacer (ITS) are the standard DNA barcodes used in plant species discrimination21. The nuclear ITS region, located at 45S ribosomal RNA (rRNA), subdivided into ITS1 and ITS2 regions, was recommended for species identification in most plant species due to the higher rate of PCR amplification22. Kim matK (3F Kim and 1R Kim), the most promising and well–conserved plastid coding regions in the chloroplast, are the most reliable barcode primers for species identification among land plants23. The Consortium of Barcode of Life 24 suggested a combination of plastid (Matk/Kim matK) and nuclear region (ITS) as a potent barcode tool to examine plant species discrimination20.DNA barcodes targeting several candidate gene regions, such as mitochondrial, plastid, and nucleus, are well adopted in plant species discrimination studiesITS rRNA region is a key ribosomal structure that predicts the function of rRNAs and tRNAs25. Computationally predicted RNA structure represents the native RNA folding status of an organism that sheds light on novel RNA regulatory mechanisms26. RNA secondary structure prediction is an advanced tool for species discrimination as it restricts sequencing error and eliminates pseudogene footprints27.RNA secondary structure predictions at conserved 28 involving a taxonomist. However, DNA barcoding and RNA secondary structure predictions authenticate the species delamination through molecular phylogeny29. Morphological indicators and DNA barcode–based signature molecular events have been used to discriminate species in various plants30.Many researchers across the globe have been working on genetic discrimination and taxonomic identification of wild, underutilized species using morphological indicators, PCR–based biomolecular characterization, and DNA barcode markers. Morphological descriptors discriminate the plant species following phylogeny, which requires in–depth knowledge of plant characteristicsKim matK) and nuclear region (ITS). We have also aimed to predict RNA secondary structures to understand the genetic discriminations among the wild eggplants that substantiates the penological phylogeny at the molecular level. The result of this study would enable accurate identification of wild eggplant relatives for augmenting trait–specific genetic improvement of eggplant.The present study involves the identification of wild eggplant relatives following phenological characterization and molecular documentation using DNA barcode markers at the chloroplast region (P ≤ 0.01) were observed among the 33 out of 40 phenotypic descriptors  and group II  exhibited unique morphotypes compared to other species. Group III includes two cultivated eggplant species of S. melongena (CHB–WEP–12 and CHB–WEP–13) with similar morphological features. Other species such as S. mammosum (CHB–WEP–2), S. aculeatissimum (CHB–WEP–3), S. trilobatum (CHB–WEP–4), S. melongena–wild type (CHB–WEP–5 and CHB–WEP–10), S. torvum (CHB–WEP–6), S. macrocarpon (CHB–WEP–7), S. aethiopicum (CHB–WEP–8 and CHB–WEP–11) are categorized under group with a comparatively narrow phenotypic distance. Group IV was further divided into three subgroups with significant phenotypic variation among S. mammosum (Subgroup 1), S. aculeatissimum, and S. torvum (Subgroup 2), and Subgroup 3 includes S. aethiopicum, S. trilobatum, S. macrocarpon, and two wild types of S. melongena.Figure The phenotypic tree in the heatmap also describes the critical conventional features that predominantly discriminate the eggplant species Fig. . The pheFruit characters such as fruit color at maturity, fruiting pattern, fruit color at harvest, fruit shape, fruit curvature, fruit calyx spine, and flower color in Subgroup1 of Group III signifies less variation among the eggplant species, which may be used for stringent selection of the unique species. On the other hand, fruit glossiness, fruit ápex shape, length of the peduncle, spines intensity, fruit stripes, leaf–spine, and flower numbers in Subgroup 2 showed moderate variation. Subgroup 3  showed a minimum impact on phenotypic discrimination among the eggplant species  and CHB–WEP–6 (S. torvum) differed from other species in terms of plant height, stem girth, plant spread, leaf length and width, fruiting pattern, and fruit and flower color. CHB–WEP–2, CHB–WEP–3, CHB–WEP–4, and CHB–WEP–9 exhibited spiny features in the leaf and stem and discriminated from other species based on the fruit color at maturity and the number of flowers. Two cultivated eggplant species  were categorized in the same group with larger fruit shape, size, curvature, fruit stripes, and calyx spininess. The rest of the five eggplant species plotted in the fourth quadra varied among each other with nine morphological descriptors  [Fig. S. aethiopicum) possesses significant similarities with five species . The wild S. melongena (CHB–WEP–10) resembled five different species  with similar morphological characteristics. The two cultivated species of S. melongena (CHB–WEP–12 and 13) showed the least morphological similarity to other species, indicating their narrow genetic base. There is a need for the incorporation of the wild genetic base to broaden the genetic trait among the cultivated species. The combined understanding of phenotypic phylogeny, principal component analysis, and correlation studies would be helpful in selecting the suitable species for augmenting trait–specific breeding strategies.Pearson’s correlation revealed phenotypic discriminations among the tested species at lue r = 9.763 [Figlue r = 9.763 [FigKim matK, and ITS2 barcode genes with 100% identity. Sequence characteristics of the candidate barcodes have been presented in Supplementary Table Kim matK and 545–850 in ITS2. However, the aligned sequence length was achieved in the range of 463–812 and 295–460 for Kim matK, and ITS2, respectively  and nuclear  regions. Multiple sequence alignments (MSA) using muscle algorithm obtained from the good quality sequences after trimming and filling the barcode gaps indicated a distinct genetic variability among the eggplant wild relatives at the species level. In our study, the identification efficiency at the Kim matK region was higher (99–100%) than that of the ITS2 region (80–90%).Table Kim matK, and ITS2 sequences, respectively. The phylogeny was established using a maximum likelihood tree (MLT) in a K2P model with bootstrap–1000. The MLTs distinctly categorized the 13 eggplant species into four major monophyletic groups. CHB–WEP–13, CHB–WEP–1, and CHB–WEP–2 were consistently categorized under Groups I, II, and III in the phylogeny at the Kim matK, and ITS2 region. CHB–WEP–10, CHB–WEP–11, and CHB–WEP–12 appeared together in one clade (cluster IV). However, ITS2 MLT confirmed the similarities of CHB–WEP–13 with CHB–WEP–4, 5, and 7. The MLT based on Kim matK locus data, CHB–WEP–1, showed similarities with CHB–WEP–3, 7, and 9. Groups I and IV are categorized under scarlet complexes S. aethiopicum, S. trilobatum, and S. melongena (wild and cultivated). Whereas Group II represented the gboma clade . However, the intermediate Group III includes S. mammosum, and S. torvum with unique features in fruit shape and size.Figure ITS2 secondary structures for the 13 eggplant wild relatives , helix II includes six eggplant genotypes. In contrast, helix III (S. torvum) and IV (S. sisymbriifolium) showed unique structures with multi–central rings. Helix V includes wild S. melongena (CHB–WEP–5) that predicted a unique but similar structure as predicted in cultivated S. melongena (CHB–WEP–13), which indicated their near–isogenic nature. The secondary structure prediction is important in the molecular breeding of eggplants interrogating wild relatives. The unique genetic sequences at the conserved nuclear region would also help to develop species–specific primers for the identification of wild eggplants at a faster pace.We have predicted ves Fig. . The stu31. In the present study, thirteen diverse eggplant species were phenotypically discriminated using the forty morphological descriptors illustrating a close relationship among the eggplant wild relatives. Among all the significant heritable descriptors, plant height, stem features, leaf characters, and fruit characters  could be considered reliable traits to distinguish eggplant diversity phenotypically32. Leaf structural descriptors, such as the spiny features in wild eggplants, served as a potential basis for morphological discrimination among the wild and cultivated ones. The species closer to the wild eggplants support the assumption of interspecific hybrids revealing the general observation of allelic uniformity13. Overlapping phenotypic features in the same genus Solanum correlates with the genetic interrelationship among the wild and cultivated eggplant gene pool. Following the hypothesis of the gene pool notion, Howard et al.32 suggested that although the wild progenitors and the cultivars possess some morphological similarities, they might differ at the genotypic/species level, which needs to be confirmed at the molecular level.Phenotyping using morphological descriptors is crucial for the preliminary identification and selection of genotypes for breeding and crop improvementS. torvum and S. mammosum are often used as a primary gene pool for interspecific hybridization against biotic and abiotic stress33. Similarly, introgression of Solanum incanum and Solanum lichtensteinii are accomplished for broadening eggplant genetic diversity13. In our study, PCoA suggests considering S. wrightii, S. torvum, and S. macrocarpon for trait–specific breeding for plant height, plant spread, stem girth, and fruiting pattern. S. sisymbriifolium, S. mammosum, S. trilobatum, and S. aculeatissimum are grouped under the leaf and stem spininess may be selected for breeding for spiny characters. S. melongena, and S. aethiopicum could be selected for breeding for better fruit characteristics. The morphological clustering in our study would help select suitable species for improving introgression breeding strategies to develop stress–tolerant eggplant species. The detailed analysis of morphological characters represents a powerful technique for analyzing the phenomic relationship among wild and cultivated eggplant species34. However, DNA–based molecular tools may be considered for species identification and gene bank conservation35.In the eggplant improvement program, Kim matK, and ITS) to accurately discriminate the species of the thirteen eggplant wild relatives at the molecular level. Specific candidate barcode markers such as Kim matK (chloroplast–plastid region) and ITS (nuclear region) were often deployed for species identification in many plants32. Consequently, molecular barcoding approaches can provide a tool to identify novel eggplant species–specifically. Using the advancement of DNA barcode, ITS and Kim matK barcode loci efficiently discriminate Solanaceae family at species level36. The genotypes with significant barcode gaps may be considered for inter- or intraspecific eggplant breeding strategies. The genetic information at a particular barcode location is suitable for enhancing eggplant breeding techniques. The genotypes with fewer DNA barcode sequence gaps could be chosen for breeding eggplants with specific traits.Various molecular markers are often used for the genetic characterization of plant species to identify quantitative and qualitative trait–specific loci. However, the accurate identification of a species is practically complicated using taxonomic or molecular characterization. In the present study, we have efficiently used the DNA barcode markers  using S. wrightii) and CHB–WEP–6 (S. torvum) exhibited unique plant characteristics such as plant height, stem girth, plant spread, and fruiting pattern. CHB–WEP–2 (S. mammosum), CHB–WEP–3 (S. aculeatissimum), CHB–WEP–4 (S. trilobatum), and CHB–WEP–9 (S. sisymbriifolium) exhibited spiny features, which could be considered for the trait–specific approaches with the cultivated Solanum melongena  possessed better fruit shape, size, and curvature, and fruit stripes. The chloroplast–plastid gene Kim matK provided better species discrimination over the nuclear ITS2. The species discrimination was more prominent at DNA barcode regions, confirming the genotypic variations among the wild eggplant species. Kim matK could be used for the identification of new species or discrimination among large genetic populations. ITS2 secondary structure predictions depict the unique genetic configuration at the conserved 5.8S nuclear region. Most species represented a central ring with various helical orientations regarding loop number, position, size, and angle from the spiral. This study shows the potential of DNA barcoding in discriminating eggplant wild relatives. Understanding the phenology and molecular phylogeny would be helpful for the selection of CWR for breeding strategies of eggplants.CHB–WEP–1 , Indian Council of Agricultural Research–Indian Institute of Horticultural Research (ICAR–IIHR), Bhubaneswar, India, with due approval of the competent authority following institutional guidelines and legislation, were used as the source materials for the present study. The station is located at a latitude of 20° 15′ N, a longitude of 85° 52′ E, and an altitude of 35 m above mean sea level.Seeds of eggplant and its wild relatives were sown in pot trays containing cocopeat for germination under a naturally ventilated poly house . Six weeks old seedlings were transplanted to the polyethene pots (30 × 30 × 30 cm) containing garden soil, sand, and farm yard manure (1:1:1) in the polyhouse. The plants were maintained as per the recommended package of practice for eggplant. The experiment was designed with 13 genotypes and five replications in a completely randomized design (CRD). The leaf voucher specimens . Principal component analysis (PCoA), and heat map were illustrated using GraphPad Prism 9 . The 13 eggplant species were characterized using 40 morphological descriptors at the whole plant level  guidelines for eggplant as recommended by the protection of plant variety and farmers’ rights authority (PPV&FRA)–1 was used for PCR amplification with different barcode primers24.Total genomic DNA (gDNA) was isolated from the fresh juvenile leaf tissues of the 13 wild and cultivated eggplants using GCC–WLN plant gDNA extraction kit  by following manufacturer’s protocol. The isolated gDNAs were quantified using a nanodrop spectrophotometer  and checked on 0.8% agarose gel electrophoresis . Total gDNA concentration adjusted to 50 ng µLKim matK) and nuclear gene (ITS2) were synthesized at M/S Bioserve Biotechnologies India Pvt. Ltd., Hyderabad, India. The details of the barcode primer sequences (5’ to 3’) are, Kim matK  and ITS2 . For each chloroplast and nuclear marker, PCR amplification was performed in a volume of 25 µL, containing 50 ng of gDNA (1 µL) as a template, 12.5 µL 2 × PCR master mix , primers , and 9.5 µL Milli–Q water. All PCR amplifications were performed in the thermal cycler  following denaturation of 5 min at 95 °C, 40 cycles of 1 min at 95 °C, 1 min at 55 °C of annealing, 1 min at 72 °C and a final extension of 10 min at 72 °C. The PCR products were purified using a PCR Purification Kit  following the manufacturer’s instructions. The PCR–purified fragments were visualized in 1.5% agarose TAE gels, and the gel images were taken in the E–Box gel documentation system .DNA barcode primers for the chloroplast–plastid genome (http://blast.ncbi.nlm.nih.gov) to identify the highest similarity of the eggplant accessions within the GenBank database41. Before submission of the sequences in NCBI, the analyzed forward and reverse sequences (Kim matK and ITS) were edited, trimmed, and contig formation was done using SnapGene v 5.3 (https://www.snapgene.com/). The nucleotides were BLAST, and the selection of the species was made based on the maximum similarity score, per cent identity (above 80%) and lowest E value after significant sequence alignment. The barcode gaps were manually edited in a pairwise alignment view using BLAST42. To obtain their respective accession numbers, the acquired Kim matK and ITS barcode sequences of each eggplant genotype were submitted to the BlankIt submission portal (https://submit.ncbi.nlm.nih.gov/subs/genbank/) and Genbank (https://submit.ncbi.nlm.nih.gov/) submission portal, respectively43. Around ten closest matches of the sequences were aligned with the query sequences by using Cluster Omega, and the resulting alignments were used to construct the phylogenetic tree by the neighbor–joining method. Multiple sequence alignment was run with all obtained sequences in the “muscle algorithm” using the neighbor–joining cluster method in MEGA11 software 44. Two Neighbor–Joining trees were constructed by selecting phylogeny reconstruction with 1000 “Bootstrap phylogeny” test method and “kimura–2–parameter” substitution model (d–transitions) in MEGA software45. Phylogenetic relationships and evolutionary distance were studied using the minimum evolution method of Kim matK, and ITS2 sequences. The maximum likelihood tree was estimated using MEGAX software considering the transitional and transversional nucleotide substitution. DNA barcodes were generated using Bio–Rad DNA barcode generator (http://biorad-ads.com/DNABarcodeWeb).The purified PCR products were sequenced using Sanger sequencing  at M/S Bioserve Biotechnologies India Pvt. Ltd., Hyderabad, and the sequences were viewed in FinchTV v1.4.0. Phylogenetic analysis of the 13 eggplants was carried out by the homology search of the obtained sequences using NCBI Basic Local Alignment Search Tool .RNA secondary structure represents the list of nucleotide bases paired by hydrogen bonding within its nucleotide sequence, and these base pairs form the scaffold driving the folding of RNA two– and three–dimensional structures. The knowledge of the RNA secondary structure is essential for modelling RNA structures and understanding their functional mechanismSupplementary Tables.


Clinical decision‐making for patients with myelodysplastic syndromes (MDS) is challenging, and both disease and treatment effects heavily impact health‐related quality of life (HRQoL) of these patients. Therefore, disease‐specific HRQoL measures can be critical to harness the patient voice in MDS research.We report a prospective international validation study of the Quality of Life in Myelodysplasia Scale (QUALMS) with a main focus on providing information on the psychometric characteristics of its three subscales: physical burden (QUALMS‐P), emotional burden (QUALMS‐E), and benefit finding (QUALMS‐BF). The analysis is based on patients enrolled from three European countries and Israel, participating to the MDS‐RIGHT Project. The scale structure and psychometric properties of the QUALMS were assessed.Overall, 270 patients with a median age of 74 years were analyzed and the majority of them (60.3%) had a low MDS‐Comorbidity Index score. Results of the confirmatory factor analysis supported the underlying scale structure of the QUALMS, which, in addition to a total score, includes three subscales: QUALMS‐P, QUALMS‐E, and the QUALMS‐BF. The QUALMS‐P exhibited the highest Cronbach's alpha coefficients. Discriminant validity analysis indicated good results with the QUALMS‐P and QUALMS‐E distinguishing between patients with different performance status, comorbidity, anemia, and transfusion dependency status. No floor and ceiling effects were observed. Responsiveness to change analysis supported the validity of the measure. Patients with a hemoglobin (Hb) level of <11 g/dL at study entry, who subsequently showed an improvement in their Hb levels, also reported a mean score change of 9 and 8 points  in the expected direction of the QUALMS‐E and QUALMS‐P, respectively.Our study provides additional validation data on the QUALMS from the international MDS‐RIGHT Project. The use of this disease‐specific HRQoL measure may contribute to raise quality standards of patient‐centered outcomes research in MDS. The QUALMS is a Patient‐Reported Outcome measure to assess health‐related quality of life in patients with myelodysplastic syndromes. This study, conducted across three European countries and Israel, supports the validity of the QUALMS and provides novel information on the psychometric performance of its three subscales . The EUMDS Registry (NCT 00600860) is a prospective, multicenter, non‐interventional study in patients with MDS from 16 European countries and Israel, which started in 2008.The current study is part of the European Horizon 2020 MDS‐RIGHT Project “Providing the right care to the right patient with MyeloDysplastic Syndrome at the right time” . Depending on the variable type, the Wilcoxon–Mann–Whitney test or the Fisher exact test were used to examine possible differences in socio‐demographic and clinical characteristics between patients with and without a completed QUALMS at study entry.Descriptive statistics  were investigated for the three QUALMS subscales and the QUALMS Total . The presence of floor and ceiling effects at the scale level was also examined as this may negatively impact on sensitivity and responsiveness.The internal consistency of the QUALMS scales was estimated using Cronbach's alpha,Concurrent validity was assessed by performing Spearman's rank correlation analyses between the scales of the QUALMS and the EQ‐5D‐3L. We hypothesized that patients with higher scores on all scales of the QUALMS also had better outcomes  in the five dimensions of the EQ‐5D‐3L  and a higher score  in EQ‐VAS.Known‐group comparisons were carried out to evaluate the discriminant validity of the QUALMS, using the Wilcoxon‐Mann–Whitney test to assess differences between patient subgroups. We compared the QUALMS scores in the following patient subgroups: MDS‐Comorbidity Index (CI)Responsiveness to change of the QUALMS scales was assessed by examining differences between baseline and follow‐up data for patients who reported an improvement in Hb levels (≥1.5 g/dL) from baseline (only for patients with a baseline Hb level < 11 g/dL).33.1N = 61], Israel [N = 67], the Netherlands [N = 37], the United Kingdom [N = 105]). No statistically significant differences were observed in key sociodemographic and clinical factors, including age, sex, comorbidity, IPSS risk category, and having previously received RBC transfusions, between those who did not complete the QUALMS (N = 38) and those who did, considered in current analysis (N = 270) (data not shown).As of August 2020, the QUALMS was completed by 270 (87.6%) out of 308 MDS patients, who agreed to participate in the study from 17 centers across four countries , the majority of patients were male (67.4%) and had a low MDS‐CI score (60.3%). Further details are provided in Table 3.2Table n = 146, 55%), 12 , 18 , and 24 months . The QUALMS‐P scale exhibited the highest coefficients across all timepoints, ranging from 0.88 to 0.93.Figure r = 0.92, p < 0.001) and the QUALMS‐E  were found. A weak negative correlation was observed between the QUALMS Total and the QUALMS‐BF .Results of the CFA showed support for the underlying scale structure of the QUALMS. All items of the QUALMS‐E exceeded the threshold of 0.40 (range = 0.56–0.73), while one item of the QUALMS‐P (range = 0.30–0.90) and one item of the QUALMS‐BF (range = 0.32–0.75) remained below the threshold of 0.40. Further, the fit indices CFI (0.93), TLI (0.93), and RMSEA (0.07) indicated acceptable model fit. In addition, strong positive Spearman correlation coefficients between the QUALMS Total and the QUALMS‐P  and a moderate positive correlation with the EQ VAS . The directions of these correlations were consistent with the conceptual assumption. The QUALMS‐BF, however, did not show a statistically significant correlation with any of the EQ‐5D‐3L scales and the EQ VAS .As displayed in Table 3.4p = 0.006), QUALMS‐E (p = 0.014), and the QUALMS Total (p = 0.006) than patients with an intermediate or high MDS‐CI score. Compared to patients with a lower Karnofsky performance status (< 90), patients with a higher Karnofsky performance status (≥ 90) demonstrated significantly better scores for QUALMS‐P (p < 0.001), QUALMS‐E (p = 0.001), and the QUALMS Total (p < 0.001). Anemic patients, compared to non‐anemic patients, reported significantly worse scores for QUALMS‐P (p < 0.001), QUALMS‐E (p = 0.010), and the QUALMS Total (p = 0.001). Mean and (SD) of Hb levels were 9.5 g/dL (1.8) and 13.7 g/dL (1.1), for anemic and non‐anemic patients, respectively. Transfusion‐dependent patients, compared to those who were not, reported significantly worse scores for QUALMS‐P (p < 0.001), QUALMS‐E (p = 0.002), and the QUALMS Total (p < 0.001). However, mean scores of the QUALMS‐BF did not go in the expected direction by performance status score, anemia or transfusion dependency.Results of the known‐group comparisons are shown in Table Responsiveness to change analysis indicated that patients with a Hb level of <11 g/dL at study entry, who subsequently showed an improvement in their Hb level (≥1.5 g/dL), also reported mean score changes (Δ) in the expected direction for the QUALMS Total (Δ = 9), and the subscales: QUALMS‐E (Δ = 9), QUALMS‐P (Δ = 8), QUALMS‐BF (Δ = 1) Figure .4Our data provide novel information on the validity of the QUALMS which broadly support its use in patients with MDS. Factor analysis confirmed the hypothesized structure of the measure and fit indices were high; also, no floor and ceiling effects were observed. Compared to previous validation steps of the QUALMS,In particular, our data indicate the high performance of the QUALMS‐P, which captures specific physical health related aspects as well as fatigue and other key symptoms. Indeed, our discriminant validity analysis indicated large mean score differences (in the expected direction) among different clinical conditions highly relevant for the MDS population, including anemia and RBC transfusions. Also, reliability of the QUALMS‐P was good as indicated by a Cronbach's α of ≥0.90 across 4 of out 5 consecutive assessments. This is an important finding as physical function is a key PRO domain frequently associated with survival outcomes in cancer patients,Inspection of the psychometric performance of the QUALMS‐E was also in the expected direction and overall good, similarly to what was observed in the initial validation steps.While valuable advances have been made in recent years in MDS research, these have been mainly confined to biological and clinical research. The wealth of information currently available on the biology of the disease and of its clinical evolution, stands in sharp contrast with the scarcity of robust HRQoL data, for example, with regard to the patient‐relevant impact of different MDS therapies. While several reasons may account for the lack of more substantial efforts in HRQoL research in MDS, one reason is possibly the paucity of internationally validated disease‐specific PRO measures.A recent systematic review on the most frequently used PRO measures in MDS research,The QUALMS is already used in a large US‐based registryImplementation of the QUALMS, or of some of its scales, may possibly be considered in routine clinical practice to help clinicians better understand burden of disease and therapy from each individual patient's unique viewpoint. There is convincing evidence that regular PRO monitoring in clinical practice may have a number of valuable clinical implications.Our study has limitations. Responsiveness to change analysis was limited to the evaluation of improvement in Hb levels. Therefore, it will be important to obtain in future studies further information on the performance of the QUALMS across various MDS therapies, including data on QUALMS scores changes in patients who become transfusion independent. Also, further work is needed to identify scale‐specific thresholds for determining clinical significance of results beyond the one that is suggested above for the QUALMS‐P scale. A strength of this study is the involvement of several centers across different countries, which lends further credit to generalizability of our findings.In conclusion, our results support the validity of the QUALMS and provides novel information on the psychometric performance of its three subscales. This questionnaire may help clinicians to harness the patients voice both in clinical research and practice.Fabio Efficace: Conceptualization (lead); investigation ; methodology ; supervision (lead); writing – original draft (lead); writing – review and editing . Karin Anne Koinig: Conceptualization ; investigation ; methodology ; writing – original draft ; writing – review and editing . Francesco Cottone: Conceptualization ; formal analysis ; investigation ; methodology ; writing – original draft ; writing – review and editing . David Bowen: Investigation ; methodology ; writing – review and editing . Moshe Mittelman: Investigation ; methodology ; writing – review and editing . Kathrin Sommer: Conceptualization ; formal analysis ; investigation ; methodology ; writing – review and editing . Saskia Langemeijer: Investigation ; methodology ; writing – review and editing . Dominic Culligan: Investigation ; methodology ; writing – review and editing . Kalman Filanovsky: Investigation ; methodology ; writing – review and editing . Michael Storck: Investigation ; methodology ; writing – review and editing . Alexandra Smith: Investigation ; methodology ; writing – review and editing . Corine van Marrewijk: Investigation ; methodology ; writing – review and editing . Martin Dugas: Investigation ; methodology ; writing – review and editing . Igor Stojkov: Investigation ; methodology ; writing – review and editing . Uwe Siebert: Investigation ; methodology ; writing – review and editing . Theo De Witte: Investigation ; methodology ; writing – review and editing . Reinhard Stauder: Conceptualization (lead); investigation ; methodology ; supervision (lead); writing – original draft ; writing – review and editing .www.senioren‐krebshilfe.at . The EUMDS Registry is supported by educational grants from Novartis Pharmacy B.V. Oncology Europe, Amgen Limited, Celgene International, Janssen Pharmaceutica, and Takeda Pharmaceuticals International.This work is part of the MDS‐RIGHT activities, which has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement No 634789—“Providing the right care to the right patient with MyeloDysplastic Syndrome at the right time.” This study was supported by Senioren‐Krebshilfe, Fabio Efficace: personal fees from Amgen, Abbvie, Janssen, and Novartis. Research support (to Institution) from Abbvie, Amgen, Novartis, all unrelated to this work. Corine van Marrewijk: project manager of the EUMDS Registry, is funded from the EUMDS  and MDS‐RIGHT (grant from EU's Horizon 2020 programme) project budgets. Moshe Mittelman: research grant: Janssen, Roche, Novartis, Medison/Amgen, Celgene/BMS, Abbvie, Gilead. Clinical trials sponsored by: Novartis, Takeda, Fibrogen, Celgene/BMS, Geron. Advisory board: Onconova, Novartis, Takeda, Silence, Astellas. Consulting fees: MDS HUB. Speakers' bureau: Celgene/BMS, Novartis, Media Digital. Reinhard Stauder: Celgene, BMS, Novartis (Advisory board); Celgene/BMS, Novartis (Honoraria); Celgene and BMS (Research funding), all unrelated to this work. Theo de Witte: Research Funding: Amgen, Celgene, Janssen, Novartis, Takeda.The EUMDS Registry was approved by the ethics committees of all participating centers and was performed in accordance with the Declaration of Helsinki. Written informed consent was obtained from all patients.Table S1Click here for additional data file.