There are no recommended therapeutic agents for acute spinal cord injury (SCI) due to the pathophysiological complexity of the injury.The objective of this study is to investigate the efficacy of various exosomes and potential factors impacting the efficacy of exosomes.We searched the PubMed, EMBASE, Web of Science, Medline, Scopus, and Cochrane Library databases to systematically collect articles comparing the locomotor function of SCI rodents undergoing exosome treatment and untreated SCI rodents. No language was preferred.p < 0.01; 116 mice, 2.46, 95% CI: 1.20–3.72, p < 0.01) compared to those of control rodents. The trial sequential analysis demonstrated the findings of the meta-analysis with the cumulative Z-curve crossing the upper monitoring boundary for the benefit and reaching the adjusted required information size. However, the origin of the exosome, SCI model, and administration method determined the therapeutic effect to some extent.Pooled analysis revealed that the locomotor function recovery of SCI rodents receiving exosomes was greatly improved (583 rats, 3.12, 95% CI: 2.56–3.67, in vivo and in vitro in relation to future trials.Despite the proven therapeutic effects of exosomes on SCI rodents, the results should be interpreted cautiously considering the diversity  Due to Many studies have shown that mesenchymal stem cells (MSCs) are promising cell therapy agents for both humans and animals with SCI, possibly through inhibition of inflammatory cascades ,9,10. AsDespite the unlikelihood of complete recovery, more researchers are acknowledging that exosomes can provide satisfactory improvements in motor function for exosomes. To determine whether exosomes are neuroprotective in rodent models of SCI, a systematic review of the efficacy of exosomes for the treatment of SCI is needed. Thus, we performed a systematic review and meta-analysis of data from studies investigating rodent models of SCI to assess the efficacy of exosomes for acute traumatic SCI.22.1This meta-analysis was limited to published articles on rodents and was performed by searching PubMed, EMBASE, Web of Science, Medline, Scopus, and the Cochrane Library databases (from inception to 2021). The search strategy is as follows: ((exosomes[title/abstract]) OR (extracellular vesicles[title/abstract]) OR (nano-sized vesicles[title/abstract]) OR (micro-vesicles)) AND (SCI[title/abstract]). The reference lists of the included articles were also searched to identify other studies. To perform a comprehensive search, we did not limit the “species”; articles reporting an unexpected “species” were excluded from the study selection process. A detailed database search strategy is provided in Table S1.2.2All studies were stored as bibliographic references in NoteExpress  and selected by two independent researchers (YW and XWL) based on the inclusion criteria. After primary selection, all articles were downloaded, and the articles that did not meet the inclusion criteria were excluded by browsing the specific content. A debate was resolved in consultation with a third investigator (HXY).2.3PICOS principle.The processing of articles followed the P): All studies included laboratory rats and mice subjected to acute SCI. Studies using nonmechanical methods such as radiation, electricity, and biochemical substances were excluded from the analysis.Type of participants (I): Studies that compared exosome administration to PBS, saline, or culture supernatant administration were included regardless of administration frequency, administration mode, and origin of the exosome.Type of intervention (C): Studies with at least two intervention arms, with animals in the control group receiving placebo and animals in the experimental group receiving exosome administration, were included in this analysis.Type of control (O): Studies that evaluated the locomotor function of the hind limbs of rats with the Basso, Beattie & Bresnahan (BBB) scale rather than the Basso Mouse Scale (BMS) and those that evaluated the locomotor function of the hind limbs of mice with the BMS rather than the BBB scale were included.Type of outcome (S): All studies assessing the locomotor function recovery of SCI mice and rats were included.Type of study (2.4Two skilled researchers (YW and XWL) independently extracted data from all articles meeting the inclusion criteria. The following data were extracted from the included studies: author, year, species, weight, the damaged segment of the spinal cord, anesthetic, SCI model, origin of exosomes, dose, administration frequency, and administration mode. When the data were presented as figures rather than tables, GetData Graph Digitizer 2.25 (Fedorov) was used to obtain the data. Based on our observations, the first analysis of mice and rats was usually conducted within 48 h, which may explain why the scores were presented as 0; in such cases, this measurement was not considered the first measurement. The quality of all included studies was evaluated by SYRCLE’s tool.2.5Behavioral improvement was assessed and recorded using the BBB locomotor rating scale for hind limb motor function in rats. The BBB scale, which ranges from 0 (no hind limb movement) to 21 , was used to analyze specific improvements in locomotor function. The BMS, which ranges from 0 (no hind limb movement) to 9 , was also used to assess motor function in mice. The movements of the hip, knee, and ankle joints were recorded when animals were allowed to move freely in an open field for 5 min.2.6p ≤ 0.05 or I2 > 50%); otherwise, a fixed-effect model was used. Publication bias was tested by Egger’s t-test with R software version 3.6.3 and is presented as a funnel plot. Subgroup analyses of different models of SCI, administration modes, and measurement time points were also conducted. Trial sequential analysis (TSA) was conducted by using TSA software.The data from all included studies were summarized and analyzed by using R software version 3.6.3  and meta-package. All results reported in this review are presented as standardized mean differences (SMDs) with 95% CIs for outcomes. A random-effect model was used to analyze the data when heterogeneity was significant  (Table S2) .3.1The article selection process is shown in 3.2As we investigated improvements in the motor function of both rats and mice, data for the two species were collected separately . To collOf the studies on rat models of SCI, one trial used an ischemic model, two trials used a transection model, three trials utilized clip compression, and the remaining trials used Allen’s model or an Infinite Horizon impactor providing a force of 200 kilodynes. Of the studies on mouse models, one used an SCI model of compression, and the rest utilized Allen’s model. Male rats and female mice were the preferred rodent models of SCI. The dose of exosomes applied in these experiments ranged from 10 to 200 μg; however, it was difficult to attain dosing information, and some trials reported only the concentration of exosomes. Exosomes were mainly injected via the tail vein and subarachnoid space within 24 h. The analyzed studies used exosomes that originated from MSCs, including bone marrow MSCs, human umbilical cord MSCs, adipose-derived MSCs, human umbilical vein endothelial cells (HUVECs), and rat pheochromocytoma (PC12) cells, as well as other cell types.3.3n = 583 animals) reporting locomotor recovery in rats at the first measurement. BBB scores reflecting the movement level of the hind limbs of exosome-treated rats were slightly but significantly improved  compared to those of rats in the control group at the first measurement (p < 0.01), which were reported in 29 studies, and the pooled analysis showed a similar outcome  evaluated the effect of exosomes on locomotor function. No remarkable improvements in the mice that received exosome administration compared to mice that received placebo administration were observed at the first measurement  (p < 0.01) (Six of the studies ( < 0.01) . At the  < 0.01) .3.5α) of 0.05 and a type II error risk (β) of 0.1  preset , 7th , 14th , 21st , and 28th  DPI, great improvements in locomotor function were observed in rats. Furthermore, we found that, over time, the difference prominently increased.Most studies continuously measured the BBB scores of rats on the 3rd, 7th, 14th, 21st, and 28th day post injury DPI; . On the p < 0.01), 7th , 14th , 21st , and 28th  DPI. Over time, mice that received exosomes injection exhibited increasingly higher BMS scores than mice that received placebo injection .Four kinds of rat models of SCI  were used, and we conducted subgroup analyses of data from different rat models of SCI. The ischemic model was not subjected to subgroup analysis due to the limited number of articles that used this model (p = 0.04), but no improvements in BBB scores were observed in the compression models  at 3rd DPI; this suggested that rats in compression model trended to recover slower than rats in contusion model. On average, rats in the transection model seemed to get a higher SMD value than rats in contusion and compression models; however, this point should be cautiously concluded owing to the lack of direct evidence  to the 7th DPI ; however, rats receiving intrathecal injection had already got significant locomotory function recovery at the 3rd DPI   .p < 0.01) and PC12 cells  seemed to take effect earlier than exosomes from BMSC  and gene-modified BMSC  , gene-modified BMSC, neuronal stem cell (NSC), and PC12 cells. All exosomes showed satisfying therapeutic effects on SCI. However, exosomes from NSC  . Finally3.8p = 0.907), BBB scores at the last measurement , BMS scores at the first measurement  and BMS scores at the last measurement  were tested by funnel plots and Egger’s linear regression.We evaluated the article quality using SYRCLE’s tool . The res4To ensure reproducibility from the laboratory to the clinic, stringent animal studies should be performed, and the molecular mechanisms involved in neuroprotection should be identified. Herein, we conducted a meta-analysis of all accessible articles to assess the potential clinical translation of exosomes.4.1n = 583; mouse, n = 116) and compared the effects of exosomes with those of placebo. Differences of pooled analysis in the recovery of motor function of rats and mice were identified. Subgroup analysis revealed that the differences between exosome- and placebo-treated animals became greater over time. Rats in the compression model trended to recover more slowly than rats in contusion and transection models. Moreover, rats treated by intrathecal injection seemed to recover faster than rats treated by tail vein injection; however, this conclusion needs to be verified by more studies due to the lack of direct comparison. Many previous studies have reported distinct promotion of locomotor function recovery on the 7th DPI, but our findings seem to report earlier recovery on the 3rd day in rats, which is promising. Furthermore, because different rating scales were used, we should be cautious in concluding that rats recover from SCI more quickly than mice; this point should be addressed in future studies.This meta-analysis included 35 articles involving 699 rodents  is a relatively subjective tool, especially while the score is recorded by different performers. We recommend more objective tools, such as the force of the hind limbs, motor-evoked potential (MEP), and sensory-evoked potential (SEP) while evaluating the locomotor function. Additionally, as for the experimental model for SCI, the researchers have not reached a consensus. The establishment of a standardized and globally accepted SCI model should be on the way.As evidenced by our results, the administration method merely impacts the onset time rather than the final therapeutic effect. Thus, the tail vein injection that potentially averts secondary damage to the spinal cord is more recommended.4.2To the best of our knowledge, we are the first to perform a quantitative meta-analysis assessing the curative effect of exosomes on locomotor function recovery. We carefully considered the potential origins of heterogeneity encountered in future trials, such as dose, the timing of administration and administration method, which may contribute to future clinical translation.Limitations of this study should be addressed. We found that most studies reported positive results; hence, we hypothesized that negative results were concealed and unpublished, resulting in potential bias and misleading results. As animal trials differ from randomized clinical trials (RCTs), it is difficult to collect the characteristics of each group in animal trials, and some critical data  were missing from these original articles. Additionally, confusing information was sometimes reported; for example, some studies provided only the volume or concentration of exosomes, and four articles did not report the injured segment of the spinal cord. Owing to the small sample size, we should be cautious to conclude the locomotor function recovery in mice. Finally, the interpretation of observations depends heavily on the individual observer and whether the observer is blinded to the treatment group. Therefore, the efficacious translation of our results should be cautious.4.3Trauma at the lesion site directly leads to apoptosis of neurons , activat4.4Animal studies are important for translation to clinical trials and evaluation of interventions for clinical trials. Identification of phenotypes, which is an important step in drug development and research, is always first performed in animals, and the mechanisms of action are later identified. Despite the large amount of evidence proving that exosomes improve the locomotor function of SCI rats ,22,23,245The present meta-analysis suggested that exosomes improve the locomotor function of rodents with SCI, although the mechanism of action remains investigated.However, the SCI model, administration method, and origin of exosome are potential factors of the therapeutic effect. Our findings should be interpreted with caution considering the disparity between species and provide some insights into future studies rather than definitive clinical recommendations.


Fusarium mycotoxins, and the liver is an important site of mycotoxin metabolism. The objective of the present research was to determine histopathological changes, apoptosis, and proliferation in the liver of gilts fed with Fusarium mycotoxin-contaminated feed for a prolonged time at the end of their pregnancy and until weaning of their piglets. Additionally, the same parameters were evaluated in the liver of their piglets to determine whether Fusarium mycotoxins would affect the offspring. The results revealed increased hepatocellular necrosis and apoptosis as well as sinusoidal leukocytosis with inflammatory infiltrates of hepatic lobules in experimental gilts, but no significant changes were observed in the piglet livers, implying that the utilized concentrations and duration of exposure did not cause detrimental effects on them. Interestingly, the amount of interlobular connective tissue in the liver of experimental gilts was significantly decreased. The obtained results emphasized the need to evaluate Fusarium mycotoxin concentrations in feed because even at low concentrations, they can cause adverse effects, but there is less concern for severe detrimental effects on the offspring.Mycotoxins are toxic secondary metabolites of fungi that frequently contaminate animal feed and human food in different combinations; therefore, it is of great importance to determine the effects of mycotoxin co-contamination. Pigs are one of the most sensitive animal species to Fusarium mycotoxins, namely, deoxynivalenol (5.08 mg/kg), zearalenone (0.09 mg/kg), and fusaric acid (21.6 mg/kg). Their effects on the liver of gilts and their piglets were chosen as the research subject as pigs are one of the most sensitive animal species that are also physiologically very similar to humans. The gilts were fed the experimental diet for 54 ± 1 day, starting late in their pregnancy and continuing until roughly a week after weaning of their piglets. Livers of gilts and their piglets were assessed for different histopathological changes, apoptosis, and proliferation activity of hepatocytes. On histopathology, gilts fed the experimental diet had a statistically significant increase in hepatocellular necrosis and apoptosis (p = 0.0318) as well as sinusoidal leukocytosis with inflammatory infiltrates of hepatic lobules (p = 0.0004). The amount of interlobular connective tissue in the liver of experimental gilts was also significantly decreased (p = 0.0232), implying a disruption in the formation of fibrous connective tissue. Apoptosis of hepatocytes and of cells in hepatic sinusoids, further assessed by the terminal deoxynucleotidyl transferase dUTP nick-end labelling (TUNEL) assay, showed a statistically significant increase . No differences were observed in piglet livers. These results indicated that Fusarium mycotoxins elicited increased apoptosis, necrosis, and inflammation in the liver of gilts, but caused no effects on the liver of piglets at these concentrations.Mycotoxins are common fungal secondary metabolites in both animal feed and human food, representing widespread toxic contaminants that cause various adverse effects. Co-contamination with different mycotoxins is frequent; therefore, this study focused on feed contaminated with  Fusarium, Aspergillus, and Penicillium. Maize is considered the most susceptible crop for mycotoxin contamination and rice the least susceptible one [Mycotoxins are toxic secondary metabolites produced by many filamentous fungi. The most important fungi causing frequent and problematic contamination of human food and animal feed belong to the fungal genera of ible one .Fusarium fungi produce a variety of toxic secondary metabolites, which are not essential to fungal growth but can induce several adverse effects in livestock [Fusarium toxins are fumonisins (FBs), zearalenone (ZEN), and trichothecenes, such as deoxynivalenol (DON), nivalenol (NIV), diacetoxyscirpenol (DAS), and T-2 toxin [Fusarium mycotoxins, there are also several unregulated, so-called emerging mycotoxins, which frequently occur in agricultural products. One of them is fusaric acid (FA), which is found in several types of cereal grain and mixed feeds. This mycotoxin needs to be further investigated in vitro and in vivo because its neurochemical effects and possible synergistic effects with other mycotoxins, especially DON and FBs, may pose a problem to humans and livestock [ivestock . The mos-2 toxin . Both in-2 toxin . ZEN cau-2 toxin ,6. Next ivestock .Fusarium mycotoxins, FBs, ZEN, and trichothecenes, especially DON, are considered highly important in food safety and public health due to their widespread occurrence and toxicity. In people, chronic exposure to mycotoxins, even at low levels, may lead to adverse effects in different organs, such as the liver, kidneys, and immune system [Besides aflatoxins (AFs) and ochratoxins, which are not e system ,9.Due to the frequent presence of several different mycotoxins in grain and animal feed, widespread reports of co-contamination are of great potential significance . A globaFusarium mycotoxins DON, FBs, and ZEN contaminated 55%, 54%, and 36% of feed and feed ingredients, respectively, most samples complied with even the most rigorous European Union regulations or recommendations on the maximal tolerable concentrations of individual mycotoxins [Fusarium mycotoxins, especially at naturally occurring concentrations, as well as concentrations lower than the accepted tolerance concentrations for individual mycotoxins.Concomitantly occurring mycotoxins can have antagonistic, additive, or synergistic effects , but vercotoxins . Currentcotoxins ,16. It iFusarium mycotoxins, especially ZEN and trichothecenes, such as DON and T-2. They are usually fed a cereal-rich diet, which can expose them to higher levels of these mycotoxins. As they are physiologically very similar to humans, they can serve as a good translational animal model, especially due to their similarities in the intestinal tract [Pigs are especially interesting for further research because they are one of the most sensitive animal species for al tract . The effal tract .Fusarium mycotoxin co-contaminated feed has been ongoing for over 30 years, providing insight in various aspects. These studies often emphasized the zootechnical, hematological, biochemical, toxicological, and immunological parameters [Research on the effects of feeding pigs with rameters ,21,22,23rameters ,33,34,35rameters ,37,38.Fusarium mycotoxins are such a common contaminant and clearly have effects on different animal species, it is also of interest whether they have detrimental effects on the offspring. Some studies have analyzed the transfer of single or multiple Fusarium mycotoxins from sows to their offspring, implying that these can cause indirect effects via a decreased feed intake and via direct effects of diaplacentar transfer of ingested mycotoxins to the developing fetuses [Since  fetuses ,31,39,40Fusarium mycotoxin metabolism [The liver is an important site of tabolism . DON’s etabolism ,41,42,43tabolism .The aim of this study was therefore to determine whether feed containing naturally occurring concentrations of DON, ZEN, and FA would elicit histopathological changes, a difference in the number of apoptotic cells, and the proliferation index in the liver of gilts and their suckling piglets.Fusarium mycotoxins, 10 gilts that were fed a control diet, and the offspring of both groups. The gilts were daily fed 3.5 kg of the diet during gestation and 6 kg of the same diet from the day of farrowing until weaning. The gilts from the experimental group consumed significantly less than the control group, but the average bodyweight was not significantly different even at the end of the experiment. At the start of the experiment, the gilts were at 89 ± 2 days of gestation, and they remained in the experiment for a total of 54 ± 1 day. The farrowing in both groups started 24 to 27 days after the start of the experiment and the piglets were weaned at 21 days of age. No antimicrobials were given to either the gilts or their piglets during the experiment.This study was conducted on samples retrieved from the experiment approved by the Veterinary Administration of the Republic of Slovenia and described in detail by Jakovac-Strajn et al. . In summThe experimental diet contained 5.08 mg DON, 0.09 mg ZEN, and 21.6 mg FA per kg of feed. The control diet contained 0.29 mg DON per kg of feed, whereas ZEN (<0.02 mg/kg) and FA (<0.77 mg/kg) were below their detection limits. The concentrations of aflatoxin B1 (<0.2 µg/kg), 15-ADON, NIV, fusarenon-X, DAS, T-2 toxin, HT-2 toxin (<0.05 µg/kg), ochratoxin A, and fumonisins B1, B2, and B3 (<10 µg/kg) were also measured in both diets, but they were all below their detection limits, these being indicated in parentheses.In order to collect organs for further examination, a single 7-day-old suckling piglet was randomly selected from each of the 20 litters and killed by lethal injection of T-61 solution , whereas all the gilts were killed by captive bolt and exsanguination 5 to 8 days after weaning of the remaining piglets in the litters. Afterwards, liver samples were immediately collected, fixed in 10% phosphate buffered formalin and routinely embedded in paraffin blocks. Liver samples from two killed suckling piglets, one from each group, were inappropriate for further processing.Histopathological examination of 4 μm thick tissue sections of formalin-fixed paraffin-embedded (FFPE) liver samples stained with hematoxylin and eosin (H&E) was conducted using light microscopy. Several different histopathological changes were assessed in the liver: irregularity of hepatic cords, fibrosis, sinusoidal leukocytosis with inflammatory infiltrates of hepatic lobules, portal tract inflammatory infiltrates, hepatocytes with vacuolar or granular cytoplasm, hepatocellular necrosis and apoptosis, markedly enlarged hepatocytes , markedly enlarged hepatocellular nuclei (hepatocellular megakaryosis), biliary hyperplasia, dilatation and thickening of blood vessels, and thrombosis of blood or lymphatic vessels.Each assessed histopathological change was graded for its intensity and extent. The intensity of the histopathological changes was assigned one of the following scores: 0—not present, 1—mild, 2—moderate, and 3—severe. The extent of the histopathological changes was assigned one of the following scores: 0—not present, 1—minimal (0 to <5% of the tissue section), 2—mild (5 to <15% of the tissue section), 3—moderate (15 to <40% of the tissue section) and 4—severe (40% or more of the tissue section). The assigned intensity and extent score were then multiplied to obtain the final score for each histopathological change in the tissue section of each liver sample from both the gilts and their piglets.® peroxidase in situ apoptosis detection kit; Chemicon, Temecula, CA, USA) according to the manufacturer’s instructions. Finally, the tissue sections were counterstained with Mayer’s hematoxylin and coverslipped. Tissue sections of porcine kidney incubated with RQ1 RNase-Free DNase  were used as the positive control, and tissue sections of porcine kidney that were only incubated with the label solution  served as the negative control.For the detection of apoptotic cells in 4 μm thick FFPE tissue sections of liver from both the gilts and their piglets, we performed the terminal deoxynucleotidyl transferase dUTP nick-end labelling (TUNEL) assay using a commercial kit , and also noted whether they were apoptotic hepatocytes or apoptotic cells in hepatic sinusoids. For hepatocytes to be considered TUNEL-positive, they had to have a clearly stained nucleus. Similarly, apoptotic cells in hepatic sinusoids had to exhibit moderate to marked nuclear staining.TM Detection System Peroxidase/DAB+, Rabbit/Mouse  was applied according to the manufacturer’s instructions. Finally, the tissue sections were counterstained with Mayer’s hematoxylin and coverslipped. Tissue sections of porcine spleen were used as the positive control, and tissue sections of porcine liver that were not treated with primary antibodies served as the negative control. From one of the experimental gilts, a tissue section of the liver was not acquired due to lack of adequate FFPE tissue.The proliferation activity of hepatocytes was evaluated on 4 μm thick FFPE tissue sections of liver from both the gilts and their piglets using immunohistochemical labelling with the mouse monoclonal antibody raised against human Ki-67 antigen, clone MIB-1 , which was diluted 1:75. The antigen retrieval was performed by microwave treatment at a medium power (550 W) for 15 min in ethylenediamine-tetraacetic acid (EDTA) with a pH of 8.0. The tissue sections were then incubated with primary antibodies for 1 hour at room temperature in a humid chamber. Endogenous peroxidase activity was quenched in the peroxidase-blocking solution Dako REALTM  for 30 min at room temperature. The visualization kit Dako REALTM EnVisionThe proliferation index of hepatocytes was calculated as the rate of Ki-67-positive nuclei in a total of 1000 counted nuclei in the tissue sections of liver under a light microscope.The amount of interlobular connective tissue was measured in 4 μm thick FFPE tissue sections of liver samples only from the gilts. The tissue sections were stained with Goldner’s Masson trichrome stain to clearly depict fibrous connective tissues under a light microscope coupled with a digital camera. Using the software program NIS-Elements Basic Research , five consecutive microphotographs at HPF were made for each tissue section and represented the area of measurement. The microphotographs were then converted into a binary-colored output by marking pixels that belonged to either interlobular connective tissue or parenchyma, thus enabling automated detection of interlobular connective tissue. The amount of interlobular connective tissue was expressed as the area fraction of the corresponding pixels out of the total number of pixels in the area of measurement. When necessary, the automatically detected areas of interlobular connective tissue were corrected manually.p-values. Statistical significance was determined as p < 0.05, and 0.05 ≤ p < 0.1 was marginally significant.For statistical analysis, we used the R statistical software, version 3.6.2  . The obtp = 0.3681). The remaining six histopathological changes also had low final scores with a maximum score of 2, and in one experimental gilt, hepatocytes with vacuolar or granular cytoplasm reached a score of 4 (p = 0.0318) and sinusoidal leukocytosis with inflammatory infiltrates of hepatic lobules (p = 0.0004) were significantly higher in the experimental group compared with the control group (p = 0.4539) showed no statistically significant differences. Additionally, hepatocellular necrosis and apoptosis and sinusoidal leukocytosis with inflammatory infiltrates of hepatic lobules were strongly correlated . The inflammatory infiltrates were composed of different proportions of lymphocytes, plasma cells, neutrophils, eosinophils, and, occasionally, macrophages. Hepatocytes with vacuolar or granular cytoplasm (p = 0.3681), hepatocellular megalocytosis (p = 1.0000), and hepatocellular megakaryosis (p = 1.0000) did not show statistically significant differences between both groups.In gilts, seven assessed histopathological changes were observed on H&E-stained liver sections: fibrosis, sinusoidal leukocytosis with inflammatory infiltrates of hepatic lobules, portal tract inflammatory infiltrates, hepatocytes with vacuolar or granular cytoplasm, hepatocellular necrosis and apoptosis, hepatocellular megalocytosis, and hepatocellular megakaryosis. Overt fibrosis was only observed in the liver of one gilt from the control group, but even this was mild based on its final score of 1 and was not statistically significant in comparison with the experimental group , hepatocellular megalocytosis (p = 1.0000), and hepatocellular megakaryosis (p = 1.0000) showed no statistically significant differences between both groups  and an even more significant difference was observed for the apoptotic cells in hepatic sinusoids (p = 0.0007) (p = 0.0535). The apoptotic cells in hepatic sinusoids were most likely lymphocytes, based on their morphology, but double immunohistochemical labelling was not attempted to further clarify this. There was no statistically significant difference in the proliferation index of hepatocytes between the two groups of gilts (p = 0.6901)  A,B. More 0.6901) .p = 0.1265) and apoptotic cells in hepatic sinusoids (p = 0.8581) between the two groups. No statistically significant difference in the proliferation index of hepatocytes was seen when comparing both groups of piglets (p = 0.1069) (p = 0.006).In piglets, there were no statistically significant differences in the cumulative number of apoptotic hepatocytes ( 0.1069) . Neverthp = 0.0232)  .Fusarium mycotoxins had become much more frequent in the decade between 2003 and 2014, thus highlighting their importance. These mycotoxicoses can manifest as acute diseases with high morbidity and death or as chronic diseases, reduced animal productivity, and decreased resistance to pathogens [Mycotoxin co-contamination of finished pig feed is more common than single mycotoxin contamination , emphasiathogens .Fusarium mycotoxins from roughly the beginning of the last quarter of their pregnancy until a week after the weaning of their piglets . Our experimental diet contained three Fusarium mycotoxins, namely DON (5.08 mg per kg of feed), ZEN (0.09 mg per kg of feed), and FA (21.6 mg per kg of feed). Undertaking this approach, we assumed that the presenting liver pathology of both gilts and their piglets would mimic chronic exposure to mycotoxins in a typical pig production setting.In the present study, gilts were fed a diet containing maize naturally contaminated with A detailed investigation into liver histopathology revealed a statistically significant difference in hepatocellular necrosis and apoptosis as well as sinusoidal leukocytosis with inflammatory infiltrates of hepatic lobules. Additionally, these two histopathological changes were strongly correlated, and they likely represented recruitment of inflammatory cells to sites of hepatocellular necrosis. Since the inflammatory cells were composed of a mixed population of neutrophils, eosinophils, lymphocytes, and, occasionally, macrophages, the observed rise in sinusoidal leukocytes could also be an indicator of a concurrent inflammatory process, knowing that DON is suspected to raise the susceptibility to infection and chronic diseases .In humans and animals, the toxic effects of DON include emesis and anorexia, alteration of intestinal and immune functions, reduced absorption of nutrients, and elevated susceptibility to infection and chronic diseases . As DON Some studies have shown no changes in liver morphology when DON was either the sole potential toxic factor or in combination with another mycotoxin ,40,42,43Interestingly, a statistically significant decrease in interlobular connective tissue was observed in our experimental group of gilts when automated detection was used on slides stained with Goldner’s Masson trichrome stain. Our finding is in contrast with previous studies because in those cases, experimental animals had an increased amount of interlobular connective tissue in the liver ,30,34. ACell culture experiments on porcine hepatocytes have shown that DON causes morphological and functional disorders in hepatocytes. Cell death of hepatocytes occurred in a dose-dependent manner and exhibited morphological changes characteristic of apoptosis. Apoptosis was further confirmed by consistently TUNEL-positive nuclei and increased activity of caspase-3, a key enzyme in apoptotic cell death . Our stuAs DON has also been associated with antiproliferative activity , we asseFusarium mycotoxins clearly have direct and indirect effects on the liver of pigs that are fed contaminated diets, thereby some studies have examined possible placentar transfer from sows to their offspring [Fusarium mycotoxins in the diet fed to the pregnant gilts.ffspring ,31,39,40ffspring  suggesteffspring  also fouffspring . When soffspring . When soFusarium mycotoxins do not have detrimental effects on the liver of offspring.The present study showed that gilts fed a diet contaminated with DON, ZEN, and FA showed significantly increased hepatocellular necrosis and apoptosis as well as sinusoidal leukocytosis with mixed inflammatory infiltrates of hepatic lobules. The number of apoptotic hepatocytes and apoptotic cells in hepatic sinusoids was also significantly higher in the experimental gilts compared with the control gilts. No significant differences were observed in the livers of their piglets, suggesting that the herein utilized concentrations of


Yolk sac tumors (YSTs) of the endometrium and the broad ligament are very rare, with only 29 cases and one case of each other reported before in the English literature. Due to lack of standard guidelines, the treatment strategies of these diseases are controversial. Here, we share two cases of YSTs originating from the endometrium and the broad ligament respectively and review related literature. A 35-year-old woman was diagnosed with endometrial YST in our center and underwent surgery followed by chemotherapy with BEP  regimen for six courses. After follow-up for 21 months, there is still no evidence of relapse. Another 36-year-old woman was admitted to our department with YST of the broad ligament. She was treated with surgery followed by chemotherapy with BEP regimen and was lost to follow-up after completing therapy. The case of endometrial YST we shared was similar to cases reported before, while the case with YST of the broad ligament we shared was the second case reported worldwide. Both of these two cases were treated with surgery combined with chemotherapy with BEP regimen. Yolk sac tumor (YST), also known as endodermal sinus tumor, is a malignant germ cell tumor usually accompanied by elevated serum alpha-fetoprotein (AFP). Most YSTs occurred in the gonads and the midline of the body of young women, young children, and infants . ApproxiThis study was approved by the ethics committee of The Affiliated Cancer Hospital of Nanjing Medical University. Informed consent was obtained from patients for the publication of any potentially identifying information and images included in this article.. The serum AFP was 9,152 ng/ml, while other serum tumor markers including carbohydrate antigen (CA)72-4, CA12-5, CA19-9, CA15-3, neuron specific enolase (NSE), carcinoembryonic antigen (CEA), and β-human chorionic gonadotropin (β-HCG) were 14.39, 29.39, 13.48, and 9.86 U/ml, 16.48 and 0.540 ng/ml and 0.477 mIU/ml, respectively. Based on results of these examinations, the patient was diagnosed with endometrial cancer and scheduled for surgery immediately.A 35-year-old woman was admitted to a local hospital for sudden abnormal uterine bleeding and chronic extended menstrual period in March 2019. Diagnostic curettage was performed at the local hospital, the result of which was endometrial carcinoma not excluding clear cell carcinoma. After consultation with the pathological department of our center, endometrial carcinoma was considered for this patient. Then she was hospitalized in the gynecologic oncology department of our center. Pelvic examination revealed enlarged uterus equal to pregnancy for 2 months without other obvious abnormalities. Computed tomography (CT) scan indicated that the image was similar to that of endometrial cancer with the myometrium invasion, accompanied by a 3-cm mass of uneven density in the right adnexa . According to the FIGO  staging classification published in 2018, the patient belongs to stage IA 7, OCT (octamer-binding transcription factor)3/4, CD30, CD34, estrogen receptor, and progesterone receptor. In addition, endodermal sinusoidal  and hyaloid drop were also observed microscopically stage IA .Two weeks after operation, serum AFP was 231.7 ng/ml. From April 2019 to August 2019, four courses of chemotherapy with BEP  regimen were administered for this patient. During the period of chemotherapy, the serum AFP decreased obviously, and all serum tumor markers had fallen to normal after completing chemotherapy for two cycles. Adverse events of chemotherapy were not serious which included nausea, vomiting, and other chemotherapy related reactions. Follow-up after surgery and chemotherapy including pelvic examination, serum tumor markers, CT scanning, and pelvic ultrasound was also conducted regularly, and the patient was still alive and free of disease for 21 months after surgery.A 36-year-old woman was hospitalized at a local hospital for pelvic mass found by physical examination in November 2017. Exploratory laparotomy was performed at that hospital immediately. Intraoperatively, a free mass at approximately 6 cm × 5 cm × 5 cm in size was observed at the bottom of the right pelvis and adjacent to the uterosacral ligament without any other abnormalities. Due to the examination of frozen sections showing germ cell tumor and consultation with relatives of this patient, pelvic mass resection, biopsy of bilateral ovaries and partial omentum resection were performed. Postoperative pathology reported yolk sac tumor of the pelvic mass, normal biopsy from ovaries and normal tissue of omentum. From December 2017 to June 2018, six courses of chemotherapy with BEP regimen were administrated for her. After five cycles of chemotherapy, serum tumor markers of the patient were all normal, but her alanine aminotransferase (ALT) was elevated nearly to 600 IU/L. She was treated with hepatoprotective therapy for 20 days before completing the sixth cycle chemotherapy. Unfortunately, the serum AFP increased again after sixth cycle of chemotherapy.. Considering relapse of the disease, the patient was hospitalized at our department for a second surgery. During the operation, a dumbbell-shaped, hard, and smooth mass at approximately 3 × 2 × 1.5 cm in size was found at the posterior lobe of right broad ligament and near the uterus. No abnormalities were observed at any other sites of the pelvic and abdominal cavity. After mass resection and right adnexectomy, frozen section was examined and demonstrated yolk sac tumor of broad ligament and normal right adnexa. In consideration of normal adnexa and consultation with her relatives, no other resection was conducted.Due to increase of serum AFP, the patient was admitted to our center in July 2018. Positron emission tomography–computed tomography (PET/CT) demonstrated a round-like mass at the right pelvis accompanied by increased [18F]-fluorodeoxyglucose (FDG) metabolism. CT scan also indicated a 2-cm mass at the right pelvis . Considering diagnosis with yolk sac tumor, four courses of chemotherapy with BEP regimen were administrated for this patient from August 2018 to November 2018. After completing three cycles of chemotherapy, the serum AFP was 15.39 ng/ml. During the period of chemotherapy, adverse events were not serious which included decreased white blood cells and neutrophils. CT and magnetic resonance image (MRI) scan showed thickening of the area of the right adnexa not excluding relapse. She was discharged after four courses of chemotherapy and the follow-up failed later.Postoperatively, pathology report confirmed yolk sac tumor of broad ligament again and normal adnexa. Immunohistochemical staining yielded the following positive results: SALL4 +++, AFP ++, GPC-3 ++, AE1/AE3 +, Ki-67 positivity rate of approximately 70%, patchy positivity for CD117 and VIM+/−. Immunohistochemistry yielded negative results for CK7, CD30, PAX-8, and PLAP Herein, we share a case series of primary YSTs originating from the endometrium and the broad ligament. In order to summarize all reported cases and compare with our cases, we search the related literature using the following combination of MeSH-terms and keywords: “extragonadal”, “yolk sac tumor”, “YST”, “primary”, “endodermal sinus tumor”, “endometrium”, “endometrial”, “broad ligament” in Pubmed, Scopus, and Cochrane Library. Furthermore, references of selected articles were also retrieved to obtain all potentially relevant literature. After review of the English literature, there were only 29 cases of primary endometrial YST including 16 case reports and two case series published before. In addition, extragonadal YST of the broad ligament was reported only once before, which originated from the left broad ligament, so the case we shared was the first case of YST from the right broad ligament in the world . All repPrevious literature reported that YSTs usually occurred in the young population. Among 29 cases of primary endometrial YST, the median age was 59 years (range 24–87 years) which seemed to be in contradiction with the theory of early occurrence of YSTs before. There were 11 cases of endometrial YST from M.D. Anderson Cancer Center, an institution that primarily serves an adult patient population, which possibly contributes to an older median age . The medThe diagnosis of primary YSTs of the endometrium and the broad ligament was still a challenge. On one hand, the literature reported before indicated that symptoms of primary endometrial YST included abnormal vaginal bleeding [82.8% (24/29)], abdominal pain [13.8% (4/29)], abdominal distension [3.4% (1/29)], and abnormal vaginal discharge [3.4% (1/29)]. The patient we reported was admitted to our center due to abnormal vaginal bleeding which was the most common symptom of primary endometrial YST. On the other hand, patients with primary YST usually had an increased level of serum AFP. Among 17 patients with available serum AFP, 88.2% (15/17) of them had an increased value, but only 11.8% (2/17) of them had a normal value. The cases we showed also had an elevated serum AFP, which was a significant symbol for diagnosis of primary YSTs and discrimination from other diseases such as endometrial cancer and undetermined pelvic mass.Due to lack of standard guidelines, the treatment strategies of primary YSTs from the endometrium and the broad ligament are controversial. According to reported cases of primary endometrial YST, surgery combined with chemotherapy was the main strategy for reported cases of primary endometrial YST. Among 26 patients with available surgical information, all of them underwent surgery, and 16 of them were administrated with chemotherapy, yielded a percentage of 100% (26/26) and 94.1% (16/17), except for nine without available information of chemotherapy. For those with detailed surgical information, the proportion of total abdominal hysterectomy, modified hysterectomy, and modified radical hysterectomy was 88.2% 15/17), 5.9% (1/17), and 5.9% (1/17), respectively. There were only three cases that suffered ovarian metastasis, all of whom were diagnosed with stage FIGO IV disease /17, 5.9%. This maAmong 16 patients with available information of chemotherapy, the percentages of BEP regimen, VAC regimen, and other regimens were 56.3% (9/16), 12.5% (2/16), and 31.3% (5/16) individually. In terms of chemotherapy regimen, BEP regimen was the most common regimen. The two cases we shared were also treated with the BEP regimen, but their prognosis was markedly different. The case with endometrial YST was free of disease for 21 months, while the disease from the broad ligament relapsed soon after primary therapy, which indicates that BEP regimen may be not an excellent choice for patients with YST of the broad ligament. Furthermore, radiotherapy was also conducted for 19.2% (5/26) of those who underwent surgery, including 15.4% (4/26) with chemotherapy and 3.8% (1/26) without chemotherapy.Without fertility desire, the case of primary endometrial YST we shared was treated with surgery, including total hysterectomy, bilateral adnexectomy, omental resection, pelvic lymphadenectomy, and paraaortic lymphadenectomy, followed by chemotherapy with BEP regimen, which was the most common strategy for endometrial YST reported before. After follow-up for 21 months, no evidence of disease progression was indicated till now. The outcome of treatment and follow-up differed from each other among all cases published before. As for YST from the broad ligament, the case published before underwent laparotomy, had widespread metastases in the pelvic, and refused to accept chemotherapy and radiotherapy later . The casYSTs originating from the endometrium and the broad ligament are very rare, especially YST from the broad ligament. There are several symptoms of endometrial YST, the most common of which is abnormal vaginal bleeding, usually accompanied by elevated serum AFP. The case of YST from the broad ligament we shared was the second case in the English literature. Due to lack of standard guidelines, the treatment strategies are controversial and needed to be explored.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by The Affiliated Cancer Hospital of Nanjing Medical University. Written informed consent was obtained from the individual for the publication of any potentially identifiable images or data included in this article.XXC and JN were involved in the identification and selection of patient cases. XZC was involved in drafting the manuscript. XZC and QZ were involved in collecting patients’ information, conducting follow-up. XXC, WWG, and JN reviewed and edited the manuscript. QZ, XX, and HYG were involved in the management of patients and reviewed the manuscript. RZ and CC carried out literature review. DWM and YNW carried out the diagnosis of pathological results and reviewed the manuscript. All authors contributed to the article and approved the submitted version.This study was supported by grants from the National Natural Science Foundation of China , Institute level project of Jiangsu Cancer Hospital (No. ZM201804), Beijing Kanghua Foundation for the Development of Traditional Chinese and Western Medicine -Le Fund (KH-2020-LJJ-021), and Jiangsu Province Maternal and Child Health Research Project (F202004).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Although the survival rate of patients diagnosed with multiple myeloma has doubled over the last few decades, due to the introduction of new therapeutic lines and improvement of care, other potential contributors to the therapeutic response/relapse of disease, such as nutrient intake, along with nutrition knowledge, have not been assessed during the course of the disease. The purpose of this research was to assess nutrition knowledge and diet quality in a group of patients with a diagnosis of multiple myeloma. Anthropometric, clinical and biological assessments and skeletal survey evaluations, along with the assessment of nutritional intake and general nutrition knowledge, were performed on 61 patients with a current diagnosis of multiple myeloma. A low carbohydrate diet score was computed, classified in tertiles, and used as a factor in the analysis. Patients in tertiles indicative of high carbohydrate or low carbohydrate intake showed significant alteration of clinical parameters, such as hemoglobin, uric acid, albumin, total proteins, beta-2 microglobulin, percentage of plasmacytes in the bone marrow and D-dimers, compared to patients in the medium carbohydrate intake tertile. Nutrition knowledge was not associated with clinical indicators of disease status, nor with patterns of nutrient intake. Better knowledge of food types and nutritional value of foods, along with personalized nutritional advice, could encourage patients with MM to make healthier decisions that might extend survival. In 2020, the global age-standardized incidence rates for multiple myeloma (MM) were 2.2/100,000 for males and 1.5/100,000 for females, with an age-standardized mortality rate of 1.1/100,000  recognizRecently, the relationship between diet and the risk of MM, as well as the relationship between diet and prognosis of patients with MM, has been tackled in several publications; however, most of the relationships that were studied pertained to pre-diagnosis diet. Protective factors for MM in adulthood included increased intake of fruits (over three servings per week) , increasAlthough the relationship between nutrition knowledge, food choices and food intake is complex, little is known about the level of nutrition knowledge in patients diagnosed with MM and the quality of their diets after diagnosis. Our aim was to assess the nutritional knowledge and quality of diets in a cohort of patients with MM, and prepare an intervention study to increase general and specific nutrition knowledge, including nutrition counseling.From a cohort of 76 patients followed up in the Hematology Department of the Municipal Emergency Hospital, Timisoara, Romania, 61 participants were included in this research . PatientDiagnosis, staging and therapy were established using ESMO clinical practice guidelines . Data wePatients were included only after signing the informed consent. The entire study was conducted according to the principles stated in the Declaration of Helsinki, and was approved by the Ethics Committee of the “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania, with no. 6/2019.2). The nutritional status of the participants was determined using the following BMI thresholds: underweight (BMI below 18.5 kg/m2), normal weight (18.5–24.9 kg/m2), overweight (25–29.9 kg/m2) and obese (over 30 kg/m2). All patients underwent whole-body low-dose computed tomography. All blood samples were collected in the morning. Complete blood count implied the collection of venous blood in a sterile EDTA vacutainer, using fluorescence flow cytometry. Coagulation tests consisted of the following: dosing of fibrinogen through a coagulometric method, and performing quantitative tests to dose D-dimer; analysis of venous blood collected in a vacutainer with sodium citrate, with plasma separation by centrifugation, and processing using a latex method through automatic agglutination with photometric detection. The samples for serum blood urea nitrogen, creatinine, calcium and LDH testing were collected in a sterile vacutainer without anticoagulant, with/without gel separator, by a spectrophotometric technique. Beta-2 microglobulin was assessed using the nephelometric method. The samples underwent analysis via serum protein electrophoresis with immunofixation, serum-free light chain quantification, heavy/light chain quantification, immunoglobulin and total proteins. All patients underwent bone marrow aspiration. Height and weight were measured as per the international guidelines, and were used for the calculation of body mass index /height (m)The diagnosis of chronic kidney disease was established by measuring serum creatinine levels, in order to calculate the glomerular filtration rate, and by measuring the urinary albumin/creatinine ratio, in order to detect proteinuria . OsteopoDietary intake assessment was performed using a validated FFQ, consisting of 53 food items; it investigated food intake during the last 30 days ,15. For A low carbohydrate diet (LCD) score was computed using deciles of the percentage of macronutrients. For carbohydrates, the lowest decile received a score of 10, and the highest decile received a score of one. For fat and protein, the lowest decile received a score of one, and the highest received a score of 10. All individual macronutrient scores were added to obtain the LCD score, which ranged from a possible lowest score of 3 to a highest score of 30, with higher scores indicating higher adherence to a low carbohydrate diet ,19. The A previously validated questionnaire  was usedt-test and ANOVA) were employed for the comparisons of means between the categories. Chi-square or Mann–Whitney or Kruskal–Wallis tests were used to compare the characteristics of participants for categorical data.Statistical analysis was performed using the Statistical Package for Social Sciences . Frequency and percentage were used for the description of categorical data, and mean and standard deviation were used for continuous data. The normality of data was evaluated by the Shapiro–Wilk test. All continuous variables were normally distributed, therefore parametric tests  being overweight and obese, and the remaining 42.6% (26) having a weight within normal limits. In Within the group, 13.1% (8) of participants were in disease stage 1, 21.3% (13) were in disease stage 2 and 65.6% (40) were in disease stage 3. Females represented 57.4%. Mean age was 65.2 +/− 9.5 years, within the age range of 41–84 years. The mean BMI was 26.2 +/− 4.2 kg/mUnadjusted energy , macronutrient intake (g) and total sugar (g), fiber (g) and alcohol (g) by tertiles of energy are presented in In To the best of our knowledge, neither the LCD score nor the nutrition knowledge has been assessed for patients diagnosed with MM. LCD score has been used for several years in relation to the risk of chronic diseases ,19 and mBy tertiles of energy, the energy-adjusted intake of nutrients did not reach statistical significance, meaning that the increase in energy is not due to a particular macronutrient source of energy. A higher LCD score, associated with a diet lower in carbohydrates, was observed in the lowest tertile of energy . ProportSimilar to other populational studies , by tertThen again, high carbohydrate diets are also associated with high morbidity and mortality rates ,34,35. ASeveral hemostatic and thrombotic anomalies have been reported in patients with MM, with D-dimers being the most commonly reported prothrombotic marker . D-dimerPatients with MM suffer diagnostic delays due to the complex nature of the disease and non-specificity of symptoms ,43,44. OThere are several proposed mechanisms to explain the association of anemia with MM, and the most important seems to be inadequate erythropoietin (EPO) production related to inflammatory cytokines  and the Purine-rich foods, high protein intake, alcohol and fructose are known risk factors for increasing the levels of uric acid . FructosTotal nutrition knowledge scores  were lowPatients with MM may gain benefits if they receive nutritional counseling and healthy eating guidance, in order to learn how to sustain a balanced diet, because nutritional needs change during the course of the disease and survivorship . A studyEpigenetic mechanisms via DNA methylation, histone modifications and non-coding RNAs were found to be associated with better evolution and therapeutic response in patients with MM . AlthougA major limitation of our study is the small number of participants since recruitment occurred during the second wave of the COVID-19 pandemic. Secondly, participants were all recruited in a single university clinic, thus the results cannot be generalized. A larger multicentric sample would be necessary to be able to generalize these findings. The participants were volunteers, which might have biased selection toward individuals more interested in food, diet and health and with a genuine interest in these matters, as compared to those who declined participation. Since the current study did not receive external funding, not all participants received metabolic panel analyses. Subsequent studies should plan to overcome this limitation.Stage 3 disease in patients with MM is associated with either a high carbohydrate or low carbohydrate–high saturated fat diet. Other clinical indicators, besides beta-2 microglobulin, which have been related to poor prognosis, are associated in our sample with a high carbohydrate diet. During disease treatment and survivorship, the nutritional needs of MM patients change, thus a better knowledge of foods and nutritional value could encourage them to make healthier decisions that might extend survival.


In 2017, the American College of Cardiology/American Heart Association (ACC/AHA) provided a new guideline for hypertension prevention and management. We aimed to update the prevalence, awareness, control, and determinants of hypertension based on this guideline in Khuzestan province, southwest of Iran, and to estimate the number of people who are eligible for non-pharmacologic and pharmacologic intervention.This population-based cross-sectional study was conducted in Khuzestan, a large province in the southwest of Iran. Comprehensive information about the potential relating factors of hypertension was collected, blood pressure was measured, and anthropometric measurements were obtained. Moreover, the dietary pattern was evaluated in 2830 individuals, using a qualitative food frequency questionnaire.Among 30,506 participants, 30,424 individuals aged 20–65 years were eligible for the study. In comparison with the previous guideline released by the Joint National Committee (JNC8), the prevalence of hypertension in Khuzestan dramatically increased from 15.81 to 42.85% after implementation of the ACC/AHA guideline, which was more dominant in the male population and the 45–54 age group. The sex and age adjustment of the hypertension prevalence was estimated to be 39.40%. The percentage of hypertension awareness, treatment, and control were 45.85%, 35.42%, and 59.63%, which dropped to 22.72%, 26.37%, and 28.94% after implementation of new guideline, respectively.In the ACC/AHA guideline, a higher number of individuals with the pre-hypertension condition were shifted into the hypertension category and the level of awareness, treatment, and control were dramatically decreased, which highlight a great need to expand the public health infrastructure for further managing the substantial increased burden on healthcare system. However, further studies with population over 65 years are required to estimate the eligibility for antihypertensive treatment in this province after implementation of new guideline. Hypertension (HTN) is a major risk factor for non-communicable diseases such as cardiovascular diseases (CVD), stroke, and renal dysfunction. With 1.5 billion hypertensive people and 7.6 million HTN-related death, this disease remains major public health globally . In low-The 6th 5-year National Plan of Economic, Social and Cultural Development of Islamic Republic of Iran 2017–2021) prioritizes the health of the population by expanding health service coverage and increasing financial protection mechanisms . Achievi–2021 priHTN is a multifactorial disease, and several genetic, environmental, and behavioral factors contribute to its manifestation . Low phyKhuzestan is located in the of the southwest of Iran. This province with 4,936,000 population has been exposed to different life-threatening issues such as dust storms, extremely high temperatures, air pollution, and soil contamination . AccordiThis cross-sectional health survey was conducted based on the data of Khuzestan Comprehensive Health Study (KCHS). KCHS is a large population-based cross-section study with the purpose of evaluating the health status of the Iranian adults in Khuzestan. This study was performed in the period of October 2016 to November 2018 and the participants were selected using a multistage random sampling method. In the first stage of cluster sampling, the health centers and health houses within each county were selected randomly . According to the population of each county, a total number of 1079 of clusters, consisting of 780 health centers in urban and 299 health houses in rural areas, were chosen. Afterward, 30 individuals between 20 and 66 years old were selected within each cluster, using systematic random sampling.The individuals who had been selected in the sampling process and were residents of Khuzestan province for at least 1 year were invited to participate in the study by a trained staff. We excluded individuals with mental, psychological or physical disabilities, or if they were reluctant to participate at any stage of the study. A written informed consent was obtained from all contributors before including them in the study. The sampling frame and study design has been described previously .The SBP and DBP were measured twice with 10-min interval in a seated position using analogue Riester sphygmomanometers. In addition, the participants’ height and weight were measured by Seca 206 body meter measuring tape and Seca 762 mechanical flat scale, respectively.After overnight fasting, 15-ml peripheral blood was collected from each participant and was transferred to a research lab in a 4°C cold boxes within 3 h. After separating the serum, the levels of fasting blood sugar (FBS), total cholesterol, high-density lipoproteins (HDL) cholesterol, and low-density lipoprotein (LDL) cholesterol were measured.The dietary habits were assessed for 2830 randomly selected participants, and the consumption of sodium, total fat, fiber, and carbohydrate was measured per week. Briefly, an 86-item qualitative food frequency questionnaire (FFQ) was designed based on previous studies on major sources of the nutrients of interest in the Iranian diet. To estimate average food consumption frequency in the last year, we used closed-ended responses consisting of 9 categories: never or less than once/month, 1–3/month, 1–2/week, 3–4/week, 5–6/week, 1/day, 2–3/day, or >4/day. The standard portion size was estimated and the micronutrient and macronutrient information were obtained from the United States Department of Agriculture (USDA) database .According to the 2017 ACC/AHA guideline, HTN was defined if the SBP level was ≥130 mmHg and/or the DBP level was ≥80 mmHg and/or the participant takes antihypertensive medication .Awareness was estimated among HTN-identified individuals if they responded positive to the self-reported of physician-diagnosed HTN. Treatment was defined as positive if self-aware individuals answered yes to the questions “Are you currently taking antihypertensive drug?” Moreover, the HTN control was defined among treated individuals with blood pressure <130/80 mmHg based on the 2017 ACC/AHA or <90/140 mmHg based on the JNC8 after taking anti-HTN drugs.Covariates included demographic, economic status, lifestyle, and CVD risk factors. Age groups included <25, 25–34, 35–44, 45–54, 55–64, or 65 years. Marital status consisted of single, married, divorced, or widow. Education was categorized according to the educational system in Iran as either illiterate (<1-year study), elementary school (1–5-year study), guidance school (6–8-year study), high school (9–12-year study), or universities (>12-year study) , and eth2), normal (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2), or obesity (≥30) [Body mass index (BMI) was calculated by dividing weight (in kilograms) to height  and further classified based on the WHO international BMI classification, as either underweight <18.5 kg/m.5 kg/m2,ty (≥30) .The status of smoking, drinking alcohol, and smoking water pipe were documented as either no, current, or former. These variables were recorded as current if the participant answered yes to “do you currently smoke, drink alcohol or smoke water pipe, regardless of the duration or frequency of consumption” OR recorded as former if the participant answered no to the last question but yes to “Did you use to smoke, drink alcohol, or smoke water pipe in the past and had quitted?”Diabetes mellitus (DM) was defined as fasting plasma glucose levels (FBS) > 126 mg/dL, previously diagnosed DM by physician, or current intake of antidiabetic agents . We docuMultiple logistic regression was performed to identify the independent factors associated with prevalence, awareness, treatment, and control of HTN based on 2017 ACC/AHA guideline in the studied population. The final model was adjusted with established risk factors of HTN such as sex, age, BMI, and physical activity. The graphs were presented by GraphPad Prism 7  and the statistical analysis was performed using STATA/SE version 12.0 software . p-value <0.05 was considered as statistically significant.A total number of 30,506 individuals aged 20–65 years participated in this study. We excluded 82 subjects with missing information on SBP or DBP and included 30,424 participants in the final analysis. The mean (±SD) age was 41.71 (±11.89), and 64.26% of the participants were female.According to JNC8 report, the overall prevalence of HTN in the studied population was 15.81%, which considerably increased to 42.85% after adopting the 2017 ACC/AHA guideline , which changed to 39.4% after sex and age adjustment. In the studied population, the mean (±SD) age of hypertensive people was significantly higher than non-hypertensive people (P=0.000) and women were 41% less likely to manifest HTN compared to men . Other independent protective factors were being Bakhtiary, getting married, having higher education level, doing more physical activity, and smoking, whereas being Arab, having high WHR and BMI, drinking alcohol, and having a family history of HTN were positively associated with prevalence of HTN (Table 2) and WHR (≥0.85), a family history of HTN, history of DM, and CVD are more likely to be aware of HTN. Receiving HTN treatment was more prevalent in Lor people, those with history of DLP, and higher educated subjects (≥9 years). Individuals with history of CVD had 58% higher HTN control level after taking the HTN medication comparing to those with no CVD history (Table Older people (≥35 years old), females, not single individuals, and those with high level of BMI >25 kg/m5 kg/m2 aAlthough Arab people are 18% more likely to develop HTN comparing to Fars , they were 76% less likely to receive HTN treatment  and 71% less likely to have controlled HTN after receiving the anti-HTN drug . Awareness was more prevalent in overweight, obese, and those with WHR>0.85. However, control of the treatment was 51% less prevalent in obese people .People with higher socioeconomic status had lower prevalence of HTN; however, there was no significant association between socioeconomic status and awareness, treatment, and control of the HTN Table . MoreoveIn the nutrient assessment, we found no significant differences in the dietary habits of hypertensive and nonhypertensive group. In the sex stratification analysis, high fat intake was two-times more prevalent in hypertensive male population. In addition, a lower intake of salt and carbohydrate was observed in age group of 20–29 with HTN (data not shown).After implementation of the 2017 ACC/AHA guideline, the prevalence of HTN in the Khuzestan province increased from 15.81 to 42.85% and the level of awareness (from 45.85 to 22.72%), treatment (from 35.42 to 26.37%), and control (from 59.63 to 28.94%) dramatically dropped. Since Khuzestan had the lowest level of healthcare development, and highest inequality of health services utilization in the country, a great need to expand the public health infrastructure for progressing towards the goals of UHC of HTN in this province is required.In order to reduce the major adverse of CVD events, ACC/AHA has recommended a lower threshold of SBP and DBS (130/80 mm Hg) for diagnosis of HTN compared to what had been suggested earlier (140/90 mm Hg); however, there are debates about the proposed HTN cut-off and CVD benefit. Some studies reported reducing the SBP to 120 mm Hg level significantly decreased the risk of CVD , and a sThe increased prevalence of HTN was observed in all age group of Khuzestan population: lowest in under 25 years of age (from 3.36 to 24.44%) and highest in 45–54 years old individuals (from 22.28 to 52.73%). Although Khuzestan has critical health issues, the overall prevalence of HTN in this province is lower than the estimated HTN prevalence in Iran [According to the JNC8 report, we found that 45.85% of the hypertensive participants in Khuzestan province were aware of HTN, which is lower than the overall awareness estimates in the country  Fig. 1aa1a. KhuzMoreover, the HTN treatment strategy has been revised in the 2017 ACC/AHA guideline and those with SBP 130–139 or DBP of 80–89 were also recommended to received anti-HTN treatment if they are +65 years older, or the clinical CVD or 10-year atherosclerotic cardiovascular disease risk is 10% or greater [However, in Khuzestan province, the effect of new guideline would be more noticeable. For example, based on JNC8 report, an average of 81.4% of self-aware individuals between 55 and 64 years old received HTN treatment at the national level [Among treated individuals, 59.63% had blood pressure <130/80 mmHg. Under ACC/AHA guideline, the blood pressure <130/80 mm Hg was considered as the target cut-off; therefore, the control rate dropped to 28.94%, which highlight a great need to expand the public health infrastructure for further managing the substantial increase in the public health burden of HTN. Although the treatment rate in Khuzestan was much lower than mean percentage of the country, the controlled level was higher in this province  of sodium, equivalent to 5 g/d of salt) . Based oOur study has certain limitations. This is a cross-sectional based study, and a causal relationship cannot be inferred. Moreover, based on the HTN 2017 ACC/AHA, those with SBP 130–139 or DBP of 80–89 were also recommended to receive anti-hypertension treatment if they are +65 years older. However, our study was limited to people aged 65 and younger, and further study covering all range group is required to estimate the real impact of treatment after implementation of new guideline.In the ACC/AHA guideline, a higher number of individuals with the pre-hypertension condition had been shifted into the hypertension category, and the level of awareness, treatment, and control was dramatically fallen, which highlight a great need to expand the public health infrastructure for further managing the substantial increase in the public health burden of hypertension.


Overall, BREEDPLAN EBV did predict progeny performance of the beef-cross-dairy cattle from this study. Gestation length and birthweight increased with increasing sire EBV . Age at weaning decreased with increasing sire EBV for liveweight at 200days  but sire EBV for liveweight at 200days had no effect on the liveweight of the progeny at 200days for either breed (p>0.05). Liveweight increased with sire EBV for liveweight at 400, 600, and 800days, by a similar amount for both breeds . The relationships were more inconsistent for carcass traits. For Hereford, carcass weight and eye muscle area increased with increasing sire EBV . For Angus, marble score increased by 0.10 with 1% extra in sire EBV for intramuscular fat (p<0.05). Rib fat depth tended to increase with sire EBV for both breeds (p<0.1). EBV derived from beef-breed data work in dairy-beef systems but maybe slightly less than the expected 0.5units of performance per unit of EBV. New Zealand farmers should consider BREEDPLAN EBV when selecting sires to mate dairy cows or when buying beef-cross-dairy calves for beef production, to ensure the resulting calves are born safely and on time and then grow well to produce carcasses of suitable meat and fat composition.On average, half of the animal’s estimated breeding value (EBV) is passed on to their progeny. However, it is not known how the performance of beef-cross-dairy cattle relates to the EBV of their beef sire. Such information is required to determine the genetic potential of beef sires selected based on existing EBV to be used on dairy cows in New Zealand. This study evaluated the relationship between the EBV of 30 Angus and 34 Hereford sires and the performance of their progeny for birth, growth, and carcass traits,  The EBVThe value of using EBV generated from data collected in purebred nucleus herds for selecting sires for use in a beef-on-dairy crossbreeding scheme is less clear. Genetically superior animals are expected to perform better than inferior counterparts, particularly for weight, fat, and carcass traits . HoweverThere are important differences between the beef and dairy-beef systems in New Zealand, particularly around rearing, weaning, and finishing age. In a beef cow-calf system, calves are reared on their dams until weaning at a set date, around 5–7months of age [150–210days and 180–240kg liveweight ]. In conAround 66% of the cattle slaughtered for beef production in New Zealand originate from dairy farms , and thePrevious studies in New Zealand  have demvia progeny testing of beef-cross-dairy offspring born to dairy cows and grown on hill country pasture for beef production.The hypothesis of this study was that the performance of beef-cross-dairy offspring is predicted by their sire’s EBV. Therefore, this study aimed to evaluate the relationship between Angus and Hereford sires’ EBV and the performance of their progeny for birth traits (gestation length and birthweight), growth at different ages , and carcass traits , The animals reported here are a subset of animals for which growth and carcass traits were previously reported . The aniThe Angus and Hereford sires used in this experiment were selected from those nominated for progeny testing by cattle breeders in New Zealand. Sires were selected on the basis of their EBV prior to each mating. The EBV are generated by BREEDPLAN for Angus and Hereford bulls within breed, as part of the trans-Tasman Angus or Hereford genetic evaluations. The EBV for each sire were obtained from the online databases of the New Zealand Angus and Hereford breed associationsWithin each breed, a spread of birthweight, gestation length, and liveweight at 600days of age (600d) EBV was achieved, except that birthweight EBV was restricted to the lightest 50% of the breed at the time of selection to prevent potential calving difficulty. When similar sires were available, those with superior EBV for intramuscular fat (IMF) and eye muscle area (EMA) were selected. There were a total of 31 Angus and 34 Hereford bulls used over 2 breeding seasons. Mean and range of EBV for birth, liveweight, carcass, and meat traits by breed of sire are presented in Lactating, mixed-aged cows (over 2years old and multiparous) were individually inseminated with semen from the selected sires. Cows were predominantly Holstein-Friesian or Holstein-Friesian-cross-Jersey crossbred. Semen was rotationally allocated to mating days and randomly allocated to cows in estrus on each mating day, to achieve random mating with semen from all sires distributed throughout the mating period. Cows were bred for 63days in 2015 and 54days in 2016.n=512) and 2017 (n=463) were included in the study. Mean birth date was August 6, 2016, (SD 18days) and August 8, 2017 (SD 16days). Calves born in the previous 24h were collected daily at approximately 10am and brought to the calf rearing shed.Angus-sired and Hereford-sired singleton calves born to mixed-aged dairy cows in spring 2016 (n=119) were sent to a commercial calf rearer  at a minimum of 7days old. These calves were reared on an allowance of 3L of milk/head twice a day for the first 3weeks and then 4L of milk/head/day until weaning. Calves were fed colostrum or whole milk for 6weeks and a 50:50 mixture of stored colostrum and milk powder  for the remainder of the time until weaning. All calves were offered ad libitum meal [16% Crude Protein (CP)] and had no access to pasture during the pre-weaning period. These calves were weighed weekly and weaned at a minimum of 75kg liveweight, before returning to the farm of birth at around 100kg.In 2016, early-born calves  was offered The resulting mean weaning liveweight of all calves in this study was 93.0kg (SD 7.0). Once weaned, calves were moved from the dairy farm to the adjacent sheep and beef hill country farm. Male calves were castrated before 4months of age.At 4months of age (December of 2016 and 2017), at a mean age of 128.7days (SD 16.8), and a mean liveweight of 123.3kg (SD 15.5), calves were allocated into 6 grazing herds based on liveweight  and sex (heifer and steer) and balanced for sire so that, where possible, all sires were represented in each grazing herd within a year. In total, there were 12 grazing herds (2years×2 sexes×3 liveweight groups) and animals remained in those herds throughout the experiment until slaughter. All cattle were grazed on summer-dry hill country pasture under commercial conditions . Any aniEach grazing herd was slaughtered as a complete group on the same day, when the mean liveweight reached the slaughter target liveweight of 500kg for heifers and 600kg for steers . HeifersBirth traits were recorded for all calves, whether alive or dead at the time of collection. Parentage was assigned using DNA parentage assignment . Gestation length (days) was calculated as the difference between insemination date and birth date. Insemination date was the date on which the DNA-assigned dam was inseminated using semen from the DNA-assigned sire. Date of birth was recorded as the date which the calf was brought into the calf rearing shed.Birthweight was recorded on arrival to the calf rearing shed, prior to being fed, using a weigh crate .Prior to weaning, calves were weighed every 1–3weeks as they approached weaning weight, and on each occasion, calves over 85kg were weaned . Date and liveweight at weaning were recorded for each calf. Age at weaning was calculated as the difference between birth and weaning dates.After weaning, calves were weighed on the farm using a weigh crate at a minimum of 2-monthly intervals, as described in M. longissimus thoracis) for in-chiller assessment of rib fat thickness (mm), eye muscle area (EMA in cm2), and marbling score. Marbling was scored on a scale from 0 (nil) to 9 (abundant) according to the AUS-MEAT/MSA reference standards .n=8, with 101 to 149 animals in each group) was defined as the group of animals born in the same year , of the same sex  that were progeny of sires of the same breed .The models for birth traits (gestation length and birthweight) included the fixed effect of sire within breed and the random effect of contemporary group. Contemporary group  was defined as the group of animals born in the same year , of the same sex  that were progeny of sires of the same breed  and were reared at the same location . Weaning weight was fitted as a covariate for weaning age.The model for weaning age included the fixed effect of sire within breed and the random effect of contemporary group. Contemporary group  was defined as the group of animals grazing in the same herd , that were progeny of sires of the same breed .The models for liveweight  included the fixed effect of sire within breed and the random effect of contemporary group. Contemporary group  was the same as that for liveweight. Age deviation at slaughter (within contemporary group) was fitted as a covariate for carcass weight. Carcass weight was fitted as a covariate for EMA, rib fat depth, and marble score.The models for carcass traits  included the fixed effect of sire within breed and the random effect of contemporary group. Contemporary group .Gestation length increased by 0.37 or 0.62days for a 1-day increase in sire EBV for Angus and Hereford sires, respectively p<0.05, . Birthwep<0.05, p>0.05). Liveweight increased with EBV at 400d, 600d, and 800d, by a similar amount for both breeds (p<0.05).Age at weaning decreased by 0.17 or 0.21days per 1kg extra in sire EBV for liveweight at 200d for Angus and Hereford, respectively p<0.05, . Howeverp<0.05, 2 with 1cm2 extra in sire EBV (p<0.05), and rib fat depth tended to increase with sire EBV (p<0.1), but there was no relationship between marble score and sire EBV for IMF (p>0.05). For Angus, marble score increased by 0.10 with 1% extra in sire EBV for IMF , and there was no relationship between EMA and sire EBV (p>0.05).For Hereford, carcass weight increased by 0.27kg per 1kg extra in sire EBV p<0.05, , EMA inc p<0.05, , while c2=57 and 40%, respectively), because there was a greater spread and more sires in the top 5% of the breed. The good match between EBV and actual performance indicates that these are likely to be the same trait being assessed in both purebred Angus or Hereford cattle and beef-cross-dairy cattle. Gestation length records are readily obtained in dairy herds through the widespread use of artificial breeding in New Zealand . Low-quBy 400d, liveweight of calves was again reflective of their sire’s EBV, although the regression coefficient was less than the 0.41 and 0.45 reported for 400d and 600d weight in the New Zealand Beef Progeny Test mentioned earlier . When co2 value was low for both breeds, but this result was generally consistent with the result from the Beef Progeny Test previously mentioned , but not for the Hereford sires. Angus sires used in the experiment had a wider range of EBV for IMF compared with Hereford sires . Moreover, Angus-sired progeny had higher marble scores compared with Hereford-sired cattle .A further potential limitation is that sires used in this experiment were not a random sample, as they were selected for the project based on their EBV so that, within each breed, a spread of birthweight (restricted to the lighter 50%), gestation length, and liveweight at 600d was achieved. With greater selection intensity , then the expected correlation between EBV in different systems decreases . HoweverLastly, there was variation in the EBV accuracy, which ranged between 45 and 99% for birth traits, 69–99% for growth traits, 50–98% for carcass size traits, and 38–98% for carcass fat traits. The traits examined also vary in their published heritability estimates, namely, 0.44–0.68 for gestation length, 0.25–0.45 for birthweight, 0.12–0.70 for liveweight, 0.23–0.54 for carcass weight, 0.20–0.47 for EMA, 0.25–0.45 for rib fat depth, 0.15–0.49 for IMF, and 0.17–0.48 for marbling . Lower aOverall, BREEDPLAN EBV did predict progeny performance of the beef-cross-dairy cattle from this study, indicating that EBV derived from beef-breed data work in dairy-beef systems but may result in slightly less than the expected 0.5 unit increase in performance per unit of EBV. This was particularly true for birth and growth traits, except for 200d liveweight for both Angus and Hereford breeds. The relationships were less consistent for carcass traits. Hereford sires had better associations with carcass size traits, while Angus sires had better associations with carcass fat traits. Although EBV for carcass traits are currently useful, improvement in the information used to generate them is still required to increase their accuracy and ability to predict progeny performance. Beef-cross-dairy cattle could also be included in joint genetic evaluations, given the strong dairy component in the cattle slaughtered in New Zealand. New Zealand farmers should consider BREEDPLAN EBV when selecting sires to mate to dairy cows or when buying beef-cross-dairy calves for beef production, to ensure the resulting calves are born safely and on time, and then grow well to produce carcasses of suitable meat and fat composition.The raw data supporting the conclusions of this article will be made available on request to the corresponding author.The animal study was reviewed and approved by Massey University Animal Ethics Committee . Written informed consent was obtained from the owners for the participation of their animals in this study.RH, PB, NL-V, LC, and NM: conceptualization. NM, LC, RH, NL-V, PB, HB, NS, SM, and JM: methodology and writing – review and editing. NM and LC: investigation, data curation, and software. NM, LC, RH, and NL-V: formal analysis. NM and RH: validation, NM: visualization and writing – original draft preparation. RH, PB, NL-V, NS, SM, HB, and JM: supervision. NM, LC, RH, PB, and JM: project administration. RH, PB, and JM: resources. RH and JM: funding acquisition. All authors contributed to the article and approved the submitted version.This research was funded by Beef and Lamb New Zealand Genetics (DBPT2015). The primary author was funded by a R&D Fellowship Grant between Callaghan Innovation and Greenlea Premier Meats Limited-Massey University (GPMES1601/PROP-50347-FELLOW-GPMES) and the second author was funded by a Massey University Doctoral Scholarship. The contributions of the C. Alma Baker Trust NZ Ltd., Angus NZ, and NZ Hereford Association are gratefully acknowledged. The funders approved the design of the study but had no role in the collection, analyses or interpretation of data, in the writing of the manuscript, or in the decision to publish the results.JM is employed by Greenlea Premier Meats Ltd. .The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.