CsbZIP genes in tea plant were identified for the whole genome. Phylogenetic analysis with Arabidopsis counterparts revealed that CsbZIP proteins clustered into 13 subgroups, among which 13 ABFs related to the ABA signaling transduction pathway were further identified by conserved motif alignment and named CsABF1-13, these belonged to the A and S subgroups of CsbZIP and had close evolutionary relationships, possessing uniform or similar motif compositions. Transcriptome analysis revealed the expression profiles of CsABF genes in different tissues  and under diverse environmental stresses . Several CsABF genes with relatively low tissue expression, including CsABF1, CsABF5, CsABF9, and CsABF10, showed strong expression induction in stress response. Thirteen CsABF genes, were examined by qRT-PCR in two tea plant cultivars, drought-tolerant “Taicha 12” and drought-sensitive “Fuyun 6”, under exogenous ABA and drought stress. Furthermore, CsABF2, CsABF8, and CsABF11, were screened out as key transcription factors regulating drought tolerance of tea cultivars. Subsequently, some potential target genes regulated by CsABFs were screened by co-expression network and enrichment analysis. This study update CsbZIP gene family and provides a global survey of the ABF gene family in tea plant. The resolution of the molecular mechanism of drought resistance in different varieties could be helpful for improving stress resistance in tea plant via genetic engineering.In plants, the bZIP family plays vital roles in various biological processes, including seed maturation, flower development, light signal transduction, pathogen defense, and various stress responses. Tea, as a popular beverage, is widely cultivated and has withstood a degree of environmental adversity. Currently, knowledge of the bZIP gene family in tea plants remains very limited. In this study, a total of 76  Camellia sinensis (L.) O. Kuntze] originated in the southwest region of China and have been cultivated and utilized for thousands of years. Today, tea is widely grown worldwide  leucine zippers (bZIPs) are a class of TFs that are widely present in the life cycle of plants and play an important regulatory role, participating in many important biological processes, such as seed maturation, flower development, light signaling, pathogen defense, and response to various biotic and abiotic stresses . With rethaliana , 91 in Oa sativa , 247 in ca napus , and 191aestivum .cis-elements (Abscisic acid responsive element-binding factors (ABFs) are the most prominent subgroup in the A-bZIP family and have been found to act at the core of ABA signaling, which implements adaptive responses to counteract water deficits in vegetative tissues in response to abiotic stress, such as drought, salinity or extreme temperature . ABFs arelements .Manihot esculenta Crantz, was found to specifically bind to the ABRE cis-element in the promoter of the major cell wall invertase gene MeWINV3 in vitro and in vivo to positively regulate drought tolerance (Brassica oleracea (cis-acting element in the promoter to resist drought stress. Overexpression of AtABF3 in Medicago sativa can reduce the transpiration rate and accumulation of reactive oxygen species (ROS) and improve drought tolerance  were analyzed by transcriptome data analysis. The expression differences of CsABFs between drought-sensitive “Fuyun 6” and drought-tolerant “Taicha 12” were further compared in order to screen key TFs regulating the drought resistance of C. sinensis and to identify potential regulatory candidate genes using co-expression network analysis. This study provides a new concept of the structure and function of the ABF gene in tea plants, valuable resources for improving the stress resistance of tea plants, and a basis for improving the quality of tea.We used the genomic data to identify the 76 Two-year-old tea cutting seedlings (Fuyun 6# and Taicha 12#) were obtained from Qianhe Tea Seedling Co., Ltd. in Quanzhou, Fujian Province. Seedlings with a height of 30–35 cm, complete root systems, and consistent growth were screened for domestication culture. Transition culture was performed with clean water and 25% Shigeki Konish nutrient solution every 7 days. Finally, the seedlings were transferred to the phytotron for hydroponic culture, and the conditions were as follows: illumination duration of 16 h light and 8 h dark alternately, room temperature of 23°C ± 1, air humidity of 45–50%, ventilation at intervals of 12 h, and the nutrient solution was replaced every 3 days.After the tea cutting seedlings grew new fibrous roots, 0.25 mM ABA was added to the culture solution. The second and third leaves were sampled after treatment for 0, 0.5, 6, and 24 h and then immediately placed in liquid nitrogen. In addition, 25% PEG-6000 was added to the culture solution to perform the drought treatment, the second and third leaves were sampled after treatment for 0, 1, and 3 days. The control group was cultured in normal nutrient solution. Total samples were stored at −80°C for qRT-PCR detection. Three biological replicates of each sample were taken for subsequent testing.o), maximum fluorescence (Fm), variable fluorescence (Fv), and photosystem II (PSII) maximum light energy conversion rate (Fv/Fm) were obtained. The calculation formula used was as follows:The leaves of Fuyun 6# and Taicha 12# treated with drought for 0, 1, 3, and 5 days were measured by a portable pulse-modulated chlorophyll fluorescence analyzer . Five sample leaves were tested in each treatment, and the results were averaged. First, the leaf was clamped by a dark adapted leaf clip. After 30 min of dark adaptation, the leaf was measured with IMA-min/B and blue at 450 nm. Then the initial fluorescence . The CsGAPDH gene was applied as an internal reference for real-time quantitative PCR (qRT-PCR) analysis. Suitable primers were designed for all selected genes by Primer plus 3.01, and only primers with a single melting curve and the amplification efficiency between 95–105% were selected for subsequent qRT-PCR analysis. All screened gene-specific primers are listed in –ΔΔCT method.Total RNA was extracted by the RNA-prep pure plant kit , and reverse transcription was performed using the GoldenstarbZIP genes in the Camellia sinensis genome, the reported AtbZIP sequences were downloaded from the Arabidopsis gene annotation database TAIR2. Based on 78 AtbZIP protein sequences, a blast search was performed in the C. sinensis genome annotation database of TPIA3  method, P-distance model, pairwise deletion, and 1000 bootstrap replicates. Multiple sequence alignments of CsABF were performed by DNAMAN. The Multiple Em for Motif Elicitation (MEME) suite (version 4.10.1)6 was used to identify the conserved motifs in all CsABFs. The parameters were as follows: maximum number of motifs: 6; number of repeats: any; maximum number of motifs: 50; optimal motif width: 6–200 amino acid residues.To investigate the phylogenetic relationship between the CsABF and CsbZIP gene families in tea plant, 78 bZIP in CsABFs were downloaded from the TPIA website, and the eight organs included apical bud, young leaf, mature leaf, old leaf, stem, root, flower, and fruit in appropriate seasons. The transcriptome data of CsABFs in response to drought and salinity stress  of more than 0.7 and then were used to construct the co-expressed network of CsABFs with Cytoscape 3.6.1  was performed on the experimental data using SPSS 22 , and multiple comparisons were performed using Duncan test to analyze the significance of the difference between the two treatments at the 0.05 level.AtbZIP genes as queries, 76 bZIP genes were identified from the latest assembled version database of the tea plant information archive (TPIA8). The integrity of all the bZIP domains was determined using the online tool SMART (see Text Footnote 4). The relevant information is listed in According to the reported Arabidopsis bZIP gene family into the 13 subfamilies of A, B, C, D, E, F, G, H, I, J, K, M, and S according to the basic domain and other conserved domains. Subgroup A is mainly involved in ABA and stress signal transduction, subgroup C is mainly involved in seed development and pathogen defense, subgroup D is involved in disease defense and physiological growth, and subgroup H plays a key role in photosynthesis; subfamily S is the largest bZIP subfamily in Arabidopsis and is involved in sugar signaling and stress pathways  and de-acclimation (CA3), while CsABF1 and CsABF5 showed no significant changes in CA1, but were increased in CA3. The expression of CsABF10 showed significant down-regulation in both CA1 and CA3. Under salt treatment, the expression levels of CsABF1, CsABF6 and CsABF9 were increased, and CsABF6 reached the highest expression level at 48 h. The expression level of CsABF7 obviously decreased. The results showed that there was no redundancy in the stress responses at transcriptional level of the CsABF family members, and no single gene could deal with more than two stresses. Based on our analysis, we consider that each gene show a specific answer to the stresses imposed and they might regulate downstream genes to deal with a complex environment.In order to analyze the different response strategies of Fm represents the maximum fluorescence value that can be absorbed by plants  in Arabidopsis. AtBamI can participate in the daily degradation of starch in guard cells to maintain stomatal openings. Under drought stress, AtBamI can also generate a carbon skeleton to support proline biosynthesis through the daily degradation of instantaneous starch, so as to cope with the osmotic pressure imbalance caused by drought and ensure the normal growth of plants. Therefore, we speculate that TEA008554.1 is involved in regulating the physiological process of starch degradation in tea leaves under drought treatment.Among the highly relevant candidate genes by Plants under drought stress can produce osmoprotective agents, such as sucrose, proline, LEA protein and antioxidant enzymes . Under tin vivo, and there is no consistent molecular label that can be used to distinguish drought-sensitive and drought-tolerant varieties. In T. aestivum, the drought-tolerant variety “Luhan 7” can resist drought by responding to light-signaling pathways, while the drought-sensitive “Yangmai 16” variety can improve the yield through pre-drought induction to increase post-flowering drought stress tolerance during the vegetative period  content to resist drought stress , we gained a better understanding of the role of TFs in key varieties of crops and provided a theoretical basis for breeding drought-resistant varieties at the molecular level.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/JL conducted the experiments and drafted the manuscript. JD analyzed the transcriptome data. LT and ML conducted part of the qRT-PCR experiment. XZ provided the selected experimental materials. SZ directed the construction of transcription factor co-expression network. XW designed the experiments. QC directed the experiments and revised the manuscript. All authors have read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


There is a worldwide outbreak of COVID-19, and as the number of patients increases, an increasing number of patients are recovering. However, no relevant systematic review or meta-analysis has been designed to evaluate the effects of acupoint herbal patching on the life of patients recovering from COVID-19.The following electronic databases will be searched from the respective dates of database inception to April 20, 2021: The Cochrane Library, Web of Science, EMBASE, MEDLINE, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Wanfang database, the Chinese Scientific Journal Database (VIP), and other sources. All published randomized controlled trials in English or Chinese related to acupoint herbal patching for COVID-19 will be included. The primary outcome was the timing of the influence of acupoint herbal patching on the quality of life of convalescent patients. Secondary outcomes were accompanying symptoms  disappearance rate, negative COVID-19 results rate on two consecutive occasions (not on the same day), average hospitalization time, clinical curative effect, and improved quality of life.The main purpose of this systematic review protocol was to assess the effectiveness and safety of acupoint herbal patching therapy for treating patients recovering from COVID-19.The conclusion of our study will provide evidence to judge whether acupoint herbal patching is an effective intervention for the quality of life in patients recovering.CRD42021246550 On March 11, the World Health Organization declared a pandemic state worldwide.–5 COVID-19 patients show typical respiratory symptoms, such as cough, fever, and lung damage, and other symptoms such as fatigue, myalgia, and diarrhea. The studies indicate that the main clinical manifestations of COVID-19 are fever (90% or more), cough (approximately 75%), and dyspnea (up to 50%). A small, but significant subset of patients has gastrointestinal symptoms. Preliminary estimates of case fatality, likely to fall as better early diagnostic efforts come into play, is approximately 2%. To date, there has been no effective drug to reduce infection and pandemic burden.,9 The importance of rehabilitation after COVID-19 has been emphasized according to the framework of the International Classification of Functioning, Disability, and Health. The WHO does not have rehabilitation guidelines for patients post–COVID-19. Therefore, a novel treatment strategy can effectively manage the quality of life of patients recovering from COVID-19 without serious adverse events.Coronavirus disease (COVID-19), the infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported on December 31, 2019.,13 The earliest records of AHP are traced back to the classic Prescriptions for Fifty-two Diseases (Wu Shi Er Bing Fang), where AHP was listed as a treatment method, and it is still widely used today.–16 AHP is a herbal patch that is applied to specific acupoints to stimulate the skin, meridians, and collaterals to produce preventive and therapeutic effects. Statistics from China suggest that approximately 100,000 people are treated with AHP every summer, and this number has increased by 13.14% from 2013 to 2014. At present, acupoint herbal patching as an adjuvant therapy is currently undergoing clinical trials in the Chinese Acupuncture Society, and the China Academy of Chinese Medical Sciences has selected more than 10 hospitals. Acupoint herbal patching has the advantages of rapid action and fewer side effects, simple and convenient, short course of treatment, good efficacy, safety and reliability, and easy acceptance by patients.Acupoint herbal patching (AHP) is an ancient Chinese medicine method in which acupuncture points on the skin are manually stimulated with herbs. AHP is a treatment method to prevent diseases by strengthening the immune system through the stimulation of acupuncture points with a small amount of various herbal preparations. It is necessary to conduct a systematic review to provide a convincing conclusion as to whether acupoint herbal patching is an appropriate method to treat COVID-19.Therefore, exploring more effective and safe treatments and improving the prognosis of patients with COVID-19 has become an important health problem. There is an urgent need to improve the quality of life of convalescent patients.22.1 to accomplish the systematic review protocol. This study was conducted for the secondary collection and analysis of original RCT data, so ethical approval or patient informed consent is not required.This systematic review protocol was registered with PROSPERO (registration number: CRD42021246550). We followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocol (PRISMA-P)2.22.2.1We will include articles related to acupoint herbal patching therapy for patients recovering from COVID-19. Due to language restrictions, we will search for articles in English and Chinese in order to obtain a more objective and accurate evaluation, and RCTs of acupoint herbal patching therapy for patients recovering from COVID19 will be eligible for inclusion.2.2.2All patients recovering from COVID-19 will be included regardless of sex, age, race, education, and economic status. Postoperative infections, psychopaths, and severe dermatosis were not included.2.2.3Participants in the intervention group were those who underwent acupoint herbal patching, regardless of the herbal regimen, acupoints selected, and patching time. There will be no restrictions on the age and original countries of the participants. In the control group, patients received medication, no treatment, sham or placebo acupoint catgut embedding, acupuncture/electro-acupuncture, etc. In addition, a review of trials evaluating acupuncture combined with another treatment compared with other typical treatments alone will be included.2.2.4The primary outcome was the influence of acupoint herbal patching on the quality of life of convalescent patients, and the secondary outcomes included accompanying symptoms  disappearance rate, negative COVID-19 results rate on 2 consecutive occasions (not on the same day), CT image improvement, average hospitalization time, occurrence rate of common type to severe form, clinical cure rate, and mortality.2.3The main sources of information that will be obtained in this study include electronic resource databases, which will be searched from the respective dates of database inception to April 21, 2021. We plan to search eight English and Chinese electronic databases, including the Web of Science, Cochrane Library, PubMed, EMBASE, SinoMed, Wanfang, China Science and Technology Journal (VIP), and China National Knowledge Infrastructure (CNKI) databases, for potentially eligible studies. We will also search for dissertations, conference proceedings, and reference lists of relevant included studies.2.4The strategy was created according to the Cochrane Handbook guidelines. All published RCTs on this subject were included. The primary selection process is shown in the PRISMA flowchart Fig. . The exe2.52.5.1http://www.prismastatementorg/) . The selection process is shown in the PRISMA flow chart (g/) Fig. . If the 2.5.2Two independent authors collected data from the selected eligible articles entered into an Excel form. The extracted information included the reference ID, name of the first author, time of publication, country, participant characteristics , intervention, randomization, study characteristics , outcome measures, duration of follow-up, adverse effects, and other detailed information. If there is any disagreement between the two authors in the literature data extraction, a third article participant will discuss the decision together. If necessary, we will contact the corresponding authors of the trials as much as possible for further information.2.5.3Two review authors independently evaluated the risk of bias to evaluate the quality of the studies using the Cochrane Collaboration's risk-of-bias assessment method. The following domains will be evaluated: random sequence generation, blindness of participants and staff, attrition bias, detection bias, selective result reporting, and other sources of bias. The risk of bias will be assessed and classified according to three levels: low risk, unclear risk, and high risk. Any discrepancies were resolved through discussions and negotiations with the third author. When a consensus on risk assessment cannot be reached by discussion, the third reviewer will make the decision.2.5.4Two authors will independently and cross-check the treatment effect by Review Manager 5.3.5, provided by the Cochrane Collaboration. Risk ratios (RRs) with 95% confidence intervals (CIs) were adopted if dichotomous data existed. Continuous data will be presented as the mean difference or standard mean difference with a 95% CI. Other binary data were converted into the RR form for analysis.2.5.5We will try our best to ensure data integrity. If the necessary data in the literature may be lacking, we will contact the corresponding authors by email or other contacts. If the missing data are unavailable, an intent-to-treat analysis will be performed as much as possible , and a sensitivity analysis will be performed to determine if the results are inconsistent.2.5.6 The heterogeneity of studies will be evaluated by the χ22 test will be used to detect statistical heterogeneity and the I2 statistic will be used to quantify inconsistency with RevMan5.3.5. The following criteria will be used: when the I2 test value is < 50% and P value > 1, we think there is no heterogeneity between these trials, and when the I2 test value is > 50% and the P value is < 1, there is significant heterogeneity between the included trials. The random-effects model will be applied if heterogeneity is still important.Cochrane Handbook for Systematic Reviews of Interventions2.5.7Funnel plots were created to assess reporting bias; once > 10 trials were included, funnel plots could be used to test for reporting bias. Dissymmetry funnel plots indicate a high risk of reporting bias, while symmetric funnel plots indicate low risk.2.5.8RevManV.5.3.5. software was used for all statistical analyses. We decided to use either a fixed-effects or random-effects model based on the heterogeneity levels of the included studies. If no substantial statistical heterogeneity is detected, the data synthesis will be processed using the fixed-effects model, and if substantial statistical heterogeneity is detected, the data synthesis will be performed using the random-effects model.If a significant level of heterogeneity is found, a descriptive analysis will be performed.2.5.9Subgroup analysis was performed based on the findings of the data synthesis. Factors such as different types of control interventions and different outcomes will be considered, and subgroup analysis will be conducted relevant to these categories.2.5.10We will conduct a sensitivity analysis to identify whether the conclusions are robust in the review according to the following criteria: sample size, heterogeneity qualities, and statistical model (random-effects or fixed-effects model).2.5.11 and will rate the quality by the following levels: very low, low, moderate, or high 4 levels.The Grade of Recommendations Assessment, Development and Evaluation (GRADE) will be a tool to evaluate the quality of the evidence,3,24 This study is the first to evaluate the clinical efficacy and effective prescription of AHP for patients recovering from COVID-19 and may benefit practitioners in the field of complementary and alternative therapies.To the best of our knowledge, there is no planned or published systematic review of the effectiveness and safety of AHP for patients recovering from COVID-19. The purpose of this study was to evaluate the effect of AHP on the quality of life of convalescent patients, accompanying symptom disappearance rate, negative COVID-19 results rate on two consecutive occasions, average hospitalization time, and clinical curative effect.4Ethical approval or patient informed consent was not required because this work was carried out using published data. We aimed to explore the clinical efficacy rate, functional outcomes, quality of life, and improvement of clinical symptoms of gastric ulcers. Finally, the results will be submitted to a peer-reviewed journal.Conceptualization: Heran Wang, Hailin Jiang, Yiran Han.Data curation: Jinying Zhao, Meng Meng.Formal analysis: Heran Wang, Jinying Zhao.Funding acquisition: Fuchun Wang.Investigation: Xuewei Zhao, Ting Pan.Methodology: Jinying Zhao, Meng Meng.Project administration: Tie Li, Fuchun Wang.Supervision: Fuchun Wang.Validation: Heran Wang, Yiran Han.Visualization: Hailin Jiang, Yiran Han.Writing – original draft: Heran Wang, Hailin Jiang.Writing – review & editing: Heran Wang, Tie Li, Fuchun Wang.


Knee osteoarthritis (KOA) is a degenerative disease in the knee joint, with chronic joint pain, swelling, stiffness, and dysfunction as the primary manifestations. Sinomenine hydrochloride injection is a proprietary Chinese medicine injection of sinomenine, the main active component of traditional Chinese medicine (TCM). Clinical studies show that Sinomenine hydrochloride injection has a good effect on the treatment of KOA. At present, there is still a lack of systematic reviews and meta-analyses to evaluate the efficacy and safety of sinomenine hydrochloride injection in the treatment of KOA. Our purpose is to supplement this deficiency.Randomized controlled trials of sinomenine hydrochloride injection in the treatment of KOA were searched for Eight electronic resource databases. We will use Review Manager 5.3 software for heterogeneity assessment, meta-analysis, and subgroup analysis. We will use the Cochrane Manual to assess the quality of the included studies, and use reporting biases assessment and sensitivity analysis to evaluate the reliability and stability of the results.This study will provide a high-quality synthesis to assess the efficacy and safety of sinomenine hydrochloride injection in the treatment of KOA.This systematic review evaluates the efficacy and safety of sinomenine hydrochloride injection in the treatment of KOA.INPLASY2021110057. At present, the drugs used to treat KOA mainly include analgesics, intraarticular corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs), and symptomatic slow-acting drugs for osteoarthritis. Although these drugs have specific effects for OA patients, they also increase the incidence of gastrointestinal ulcers and cardiovascular events, affecting their use by some patients.Osteoarthritis (OA) is one of the primary diseases affecting human health. It involves multiple joints and commonly affects the knee and hip joints. The pathological changes of Knee Osteoarthritis (KOA) are mainly the gradual degeneration of hyaloid cartilage and surrounding tissues  of the knee, resulting in joint pain, enlargement, stiffness and dysfunction, and even disability in severe cases. Sinomenine  is a monomer alkaloid extracted from the TCM Sinomeniumacutum, with anti-inflammatory, analgesic, and immunomodulatory effects.–8 Sinomenine hydrochloride injection is a sterilized aqueous solution made of sinomenine, which can be directly injected into the affected area through the joint cavity and exert the pharmacological effect of sinomenine. At present, there are many clinical research reports on the treatment of KOA by intra-articular injection of sinomenine hydrochloride.–14 However, no systematic evaluation has been published on this issue, and it is not clear whether sinomenine hydrochloride injection is effective and safe in treating KOA. Therefore, it is essential to conduct a systematic evaluation to obtain relatively convincing conclusions as to whether sinomenine hydrochloride injection can be a good choice as a complementary and alternative drug (CAM) for KOA.Traditional Chinese medicine (TCM) has a long history and has the advantages of natural curative effect, safety, and stability. It is a research hotspot in the treatment of many complex diseases.2This protocol is registered with INPLASY. Because this study only reorganizes and analyzes all data related to clinical trials, ethical approval is unnecessary.2.12.1.1The RCTs are eligible, whether or not the blind method is specifically described. There are no restrictions on languages. In addition, we will exclude systematic reviews, review literature, and literature whose full text is not available.2.1.2Patients should be diagnosed with KOA. No restrictions on country, race, age, or gender.2.1.32.1.3.1Sodium hyaluronate, triamcinolone acetonide, and other drugs were injected into the joint cavity.2.1.3.2Based on the control group, sinomenine hydrochloride injection was combined with joint cavity injection, or used sinomenine hydrochloride injection alone.2.1.42.1.4.1Total effective rate, Visual Analog Scale (VAS), Western Ontario and Mc Master University (WOMAC) Osteoarthritis Index.2.1.4.2Circumference of the knee joint, the knee joint fluid or serum interleukin-1β (IL-1β) level, the knee joint fluid or serum tumor necrosis factor-α (TNF-α) level, adverse events.2.2Randomized controlled trials (RCTs) of sinomenine hydrochloride injection in the treatment of KOA were searched in PubMed, Web of Science, Embase, Cochrane Library, Allied and Complementary Medicine Database (AMED), China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), Wanfang Database. The retrieval time is from a database construction to the present. Different search methods will be adjusted according to different Chinese and English databases. The search strategy was as follows, taking PubMed as an example Table .2.3The two researchers will import all the retrieved articles into Endnote X9, and use the software to filter and delete duplicate data. Then according to the inclusion and exclusion criteria, the literature was screened out, and the data was extracted independently. The extraction includes information such as the first author, publication year, baseline characteristics of the research object, and outcome indicators, and cross-check the extracted data after completion. In a disagreement, the two researchers discuss it or make a joint decision by a third-party researcher with a senior professional title Fig. .2.4Bias risk assessment was conducted by two reviewers based on the bias risk assessment tool recommended in the Cochrane Manual.2.52 < 50%, the heterogeneity among the included studies was considered minor, and the fixed effect model was adopted. If I2 ≥ 50%, the heterogeneity among the included studies was deemed significant, and the random effect model was adopted. Subgroup analysis was conducted according to different treatments in the treatment group, and sensitivity analysis was also used to analyze the sources of heterogeneity. A value P < .10 was considered to suggest statistical heterogeneity.Review Manager (Revman), version 5.3, was used to analyze the collected clinical research data. According to the difference of enumeration data and measurement data, the distribution was evaluated by relative risk (RR) and standardized mean difference (SMD), and the confidence interval  was 95%. If the heterogeneity I2.6We will use subgroup analysis based on different interventions and controls. This can analyze the sources of heterogeneity and enhance the persuasiveness of the conclusions.2.7 and Egger regression test were used to determine potential reporting bias.Funnel plot2.8We will conduct sensitivity analysis by removing one study one by one, and investigate the reliability and stability of the results.3Sinomeniumacutum is a TCM, which has the function of dispelling wind dampness, channeling channels, and collaterals, relieving urination. Sinomeniumacutum is often used to treat rheumatoid arthritis, OA, and gout arthritis. Sinomenine is the main active ingredient of Sinomeniumacutum. Studies have found that KOA is a chronic inflammatory process involving inflammatory mediators and a variety of cytokines. Cytokines TNF-α and IL-1β can inhibit cartilage matrix synthesis and promote cartilage degeneration and decline. Articular cartilage degeneration is the earliest and most important structural change of OA, including significant chondrocyte apoptosis and excessive extracellular matrix (ECM) degradation. The apoptosis of many chondrocytes reduces the number of cells in the cartilage tissue, weakens the ability to synthesize matrix, and leads to the synthesis and release of matrix-degrading enzymes, which further damages the cartilage matrix. Therefore, many drugs play a role in delaying the progression of OA by inhibiting the expression of inflammatory factors and chondrocyte apoptosis. Studies have shown that sinomenine can reduce synovial inflammation and cartilage degeneration by inhibiting the expression of inflammatory factors and chondrocyte apoptosis, thus delaying the progression of osteoarthritis. Sinomenine hydrochloride injection as an external preparation of sinomenine has been used ever more frequently in the clinical treatment of OA. This study gives an insight on whether sinomenine injection is efficacious and safe in the treatment of KOA, which will be useful to KOA patients, physicians, and decision-makers.Conceptualization: Zeling Huang, Xiao Mao, Zhenqiang Hong.Data curation: Zeling Huang, Xiao Mao, Junming Chen.Formal analysis: Junjun He, Shanni Shi, Miao Gui.Investigation: Zeling Huang, Xiao Mao.Supervision: Hongjian Gao.Writing – original draft: Zeling Huang, Xiao Mao.Writing – review & editing: Zhenqiang Hong.


Coronavirus disease 2019 (COVID-19) has had a tremendous impact on public health and socioeconomic conditions globally. Although non-pharmaceutical interventions (NPIs) such as social distancing effectively reduced the incidence of COVID-19, especially in Korea, demand for vaccination has increased to minimize the social costs of NPIs. This study estimated the potential benefits of COVID-19 vaccination in Korea.A mathematical model with vaccinated–susceptible–latent–infectious–recovered compartments was used to simulate the COVID-19 epidemic. The compartments were stratified into age groups of 0-19 years, 20-59 years, and 60 years or older. Based on the Korea Disease Control and Prevention Agency national vaccination plan for the second quarter of 2021, announced on March 15, we developed vaccination scenarios . Comparing scenarios without vaccination or with higher/lower vaccination rates and compliance, we estimated the numbers of COVID-19 cases that will be prevented by vaccination.The results projected 203,135 cases within a year after April 2021 without vaccination, which would be reduced to 71,248 (64.9% decrease) by vaccination. Supposing a vaccination rate of 150,000 dose/d and 100% compliance, social distancing interventions for those aged 20 or more can be retracted after January 1, 2022.We expect COVID-19 vaccination to be effective in Korea. Health authorities should minimize delays in vaccination and vaccine avoidance to maximize the effectiveness of vaccination and end social distancing early. Coronavirus disease 2019 (COVID-19) has had a tremendous public health impact globally. As of January 31, 2021, approximately 0.1 billion cases have been reported worldwide, including 2 million deaths [Fortunately, the development of COVID-19 vaccines was unprecedentedly rapid, and vaccination started in high-income countries such as the United States and United Kingdom in December 2020 . Health A discrete-time compartment model categorizing the entire population into several groups was used. The epidemic dynamics were simulated using parameters such as the number of contacts by an infectious individual, the transmission probability per contact, and the infectious period, starting with the numbers of susceptible, infectious, and recovered people. We used a vaccinated– susceptible–latent–infectious–recovered (V-SLIR) model to represent people who are vaccinated or in the latent period. Since vaccination is prioritized by age, we used a meta-population model that stratified each compartment into 3 subgroups by age .c) and a multiplier for the effective contact rate from the child group to the middle age group (φcm). Although we employed time-varying parameters for the within-group parameters, the between-group parameters were assumed to be constant to reduce the number of parameters. Details of the model, including equations and a schematic diagram, are described in the In designing the vaccine-dispensing scenarios, we prioritized vaccine targets as follows: first dose to those aged ≥ 60, second dose to those aged ≥ 60, first dose to those aged 20-59, and second dose to those aged 20-59 (no vaccination was assumed for those aged 0-19). Cross-vaccination was ruled out and the time gaps between the first and second doses were assumed to be 12 weeks for the AstraZeneca vaccine, 28 days for the Moderna vaccine, and 21 days for the Pfizer vaccine. For simplification, we assumed that the effectiveness of the vaccines from the COVAX facility would be the same as the AstraZeneca vaccine.Using the V-SLIR model, we predicted COVID-19 epidemics within 1 year after April 2021  that differed by vaccine-dispensing scenarios developed using some selected vaccination distribution rates, vaccination compliance (coverage), and durations of social distancing interventions. Nine scenarios were constructed as follows: (1) absence of a vaccination program, (2) a vaccination rate of 300,000 dose/d with 100% compliance, (3) a vaccination rate of 250,000 dose/d with 100% compliance, (4) a vaccination rate of 200,000 dose/d with 100% compliance, (5) a vaccination rate of 150,000 dose/d with 100% compliance, (6) a vaccination rate of 100,000 dose/d with 100% compliance, (7) a vaccination rate of 50,000 dose/d with 100% compliance, (8) a vaccination rate of 150,000 dose/d with 90% compliance, and (9) a vaccination rate of 150,000 dose/d with 80% compliance. As the main vaccination scenario, we assumed a distribution rate of 150,000 dose/d and 100% compliance according to the national vaccination plan for the second quarter of 2021. The highest vaccination rate  was based on the vaccine plan for January 28 [This study used aggregated data which is publicly open. No ethical approval was required.The mathematical model with a V-SLIR structure replicated the COVID-19 epidemic curve up to March 2021 reasonably well . The estSupposing no vaccination after April 2021 , there wA V-SLIR model incorporating a time-varying effective contact rate was used to predict epidemic dynamics in the post-vaccination period in Korea. This model showed that the social distancing strategy implemented in 2020 decreased the effective contact rate in Korea. In the analysis, we found significant benefits from vaccinations when administered at 150,000 dose/d with 100% compliance. However, if vaccine distribution is delayed (a lower vaccination rate), the benefits would be reduced. Even with the vaccination scenario, social distancing among those aged 20-59 and aged ≥ 60 (target population for vaccination) should be maintained until herd immunity is achieved.The benefits of vaccination in reducing the incidence of COVID-19 will help in the decision as to when social distancing for adults can be lifted. We believe that, with no delays in vaccination distribution, social distancing interventions could be lifted as early as January 1, 2022 without a resurgence of the epidemic in 2022. In this study, we found that lower compliance rates led to fewer cases in the prediction period. This unexpected finding was attributed to early vaccination of those aged 20-59 due to fewer vaccinations in the ≥ 60 group. The reason for this is that the number of the target population for the ≥ 60 group decreased in the scenario of lower compliance, which in turn would cause early completion of vaccination in the old age group and early introduction of vaccination in the middle age group. Although this might reduce the total number of cases, it would increase the number of cases in the ≥ 60 group, possibly causing more deaths considering the higher case-fatality rate in this age group.The results of our model presented specific numbers regarding the effects of vaccination on the number of confirmed cases and the end of social distancing. However, these figures could be easily affected by various model assumptions. Therefore, the following study limitations should be considered when interpreting our results. First, the parameters we use may need to be adjusted as necessary. For example, variants of the SARS-CoV-2 virus could increase the effective contact rate depending on their behavior . In addiIn conclusion, vaccination according to the national plan could substantially reduce the number of confirmed cases under social distancing interventions. Health authorities should maximize compliance and the pace of vaccination for a successful vaccination campaign.


Exposures to CO and formaldehyde were also positively associated with being overweight. IQR increase in TVOC was positively associated with increases in the risk of a high BMI, being abdominally obese and having a high body fat percentage. Two-pollutant models demonstrate that TVOCs presented the strongest risks associated with overweightness. We concluded that persistent exposure to indoor gaseous pollutants increases the risk of overweightness and obesity, as indicated by the positive association with BMI, abdominal obesity, and percentage body fat. TVOCs display the strongest contribution to obesity.This study aims to analyze whether exposure to indoor air pollution affects obesity. In our research, we recruited 127 participants, with an average age of 43.30 ± 15.38 years old, residing in 60 households. We monitored indoor air quality for 24 h, and conducted both questionnaire surveys and collected serum samples for analysis, to assess the relationship between indoor air pollutant exposure and obesity. After adjusting for demographic characteristics, the results showed that CO Estimates published by the World Health Organization (WHO) in 2016 revealed that worldwide prevalence of obesity has tripled since 1975, with nearly 13% of adults being obese; such prevalence is estimated to reach 18% for men and 21% for women by 2025 ,5. Even Exposure to ambient air pollutants poses adverse health effects on the general population. Specifically, particulate matter (PM) and volatile organic compounds (VOCs) have been associated with elevated blood pressure, decreased heart rate variability, and increased systemic inflammation and oxidative stress, all of which can lead to cardiovascular morbidity and mortality ,14. Prev2.5 and total volatile organic compounds (TVOCs) can decrease heart rate variability and elevate blood pressure 1.0, PM2.5, PM4.0, PM10), gaseous pollutants , temperature, and relative humidity were documented during the summer season of 2017–2018. TSP and PM levels were measured with an aerosol monitor . A multifunctional Q-Track monitor tracked the concentration of CO and CO2 ; TVOCs were monitored using a portable handheld VOC monitor . Formaldehyde was monitored continuously .The indoor air quality of the 60 households in which participants reside was monitored continuously for 12 h (PM 06:00 to AM 06:00 CST the next day) and 24 h to clearly demonstrate the real-time range of exposure concentrations; the 12 h timeframe was chosen to represent the hours in which residents were are home. Monitors were set up in the living rooms, the real-time concentrations of total suspended particle (TSP) and PM  were expressed as quartiles, along with the interquartile range (IQR). For the basic characteristics, the continuous variables were expressed as mean ± SD, and the binary variables were presented as percentages.With the monitoring time duration separated into two intervals, the 12-h and 24-h averages of the exposure concentrations for six air pollutants , and socioeconomic status , all of which potentially contribute to obesity. Furthermore, adjusted multiple logistic regression models were used to assess the association between exposures to IQR increases in air pollutant concentrations and the following obesity-related factors: overweight, abdominal obesity, and fat percentage. Both 12-h and 24-h exposure durations were examined. In addition to our crude model with no adjustment (Model 1), the second model (Model 2) adjusted for age and gender. The third model (Model 3), controlled for age, gender fasting glucose level, as well as aforementioned health behavior and socioeconomically-related covariates. Finally, two pollutant models were used to analyze the intensity of the effects of the two pollutants on obesity-related factors, after controlling for previously mentioned covariates that could affect obesity. Effects of multicollinearity were examined by calculating variance inflation factor (VIF).p value < 0.05 with a two-tail distribution.All analyses were performed using SAS software . Statistical significance was determined based on a The basic demographic characteristics of our study participants are listed in 2.5, PM10 and TVOC were 27.61, 28.74 and 112.48 μg/m3, which were comparable to those of 24 h. The mean and quartile concentrations of TVOCs and CO2 after 12 h of monitoring were consistently greater than those of 24 h. After adjusting for covariates, such as age, gender, health behaviors, and socioeconomic status, the associations between the indoor levels of TVOCs, formaldehyde and CO to CO2 are illustrated in 2, and that such an association was statistically significant, with coefficients of determination of 0.3505 and 0.3201 , abdominal obesity, or fat percentage, regardless of model adjustments. In our crude model without adjustment (Model 1), every IQR increase in exposure concentrations to CO was associated with an increased risk of becoming overweight, as indicated by an OR of 1.71 : 1.00, 2.91). A similar statistically significant association was evident with body fat percentage . IQR exposure to CO2 is associated with higher risk of overweightness , abdominal obesity , and high body fat percentage . Our second model that adjusted for age and gender (Model 2) demonstrated that per IQR increase in exposure to TVOC was associated with higher risks of overweightness  and abdominal obesity . Similar positive associations were evident with exposure to formaldehyde and CO2.2, with ORs of 2.70 , 2.69 , 2.25 , 2.46 , respectively. Most notably, exposure to TVOCs was associated with higher odds of abdominal obesity  and percentage body fat . Likewise, exposure to CO2 was also shown to be associated with statistically significantly higher risks of overweightness, abdominal obesity, and high body fat percentage.Furthermore, we also note that per IQR increase in exposure to CO is associated with higher risks of high BMI  and high body fat percentage . Our final model adjusted for age, gender, fasting glucose level, health behavior characteristics, and socioeconomic status (Model 3); we found that risks of overweightness became amplified for TVOCs, formaldehyde, CO, and CO2 is placed in a model combination with either formaldehyde or CO, CO2 remained as the stronger contributor to overweightness, with an adjusted OR (aOR) of 2.37  and1.86 , respectively. However, TVOC outweighs formaldehyde and CO as the stronger predictor of overweightness, as indicated by aORs of 2.60  and 2.22 . For abdominal obesity, TVOC was the stronger predictor in models with two-pollutant combinations of CO2, formaldehyde and CO. For high body fat percentage, our two-pollutant model with CO2 and formaldehyde shows that CO2 was a stronger predictor of high body fat percentage, with aOR of 2.21 ; however, the predictive power of CO2 diminished when compared to CO. Our analysis demonstrated indoor exposure to per IQR of CO, when compared to CO2, TVOC, and formaldehyde, is correlated with high body fat percentage, as indicated by adjusted ORs of 2.75, 3.69, and 4.46, respectively.Results of our two-pollutant models are presented in 2.5, PM10, CO, CO2, formaldehyde and TVOCs for 12 and 24 h. These concentrations demonstrated the degree to which residents’ time–activity patterns can affect participant exposure. Since residential time–activity patterns are unlikely to undergo drastic changes, the monitoring of indoor air quality can serve to indicate long-term exposure in a household; previous studies have applied similar logic [2, formaldehyde and TVOCs are associated with higher risks of attaining overweightness, developing abdominal obesity or obtaining high percentage body fat with varying strength. Per IQR increase in exposure concentration to indoor TVOC, in particular, is most significantly correlated with higher risks of overweightness and abdominal obesity.The results from our pilot study indicate that indoor gaseous air pollution is positively associated with overweightness, abdominal obesity, and high body fat percentage. Our investigation continuously monitored the household levels of PMar logic ,34. Spec2.5 and PM10 and overweightness, which is consistent with the conclusions reached by White and colleagues, where exposure to ambient PM2.5 did not demonstrate significant association to weight gain in adult African-American females [2.5 levels (ranged between 4.2 and 13.6 μg/m3) did not result in an increased risk for developing abdominal obesity [2.5 at both home and school fall short of establishing a positive association with BMI [Previous studies exploring the association between exposure to air pollution and obesity released conflicting results. Certain literature found air pollution to correlate with BMI levels and obesity in children; another longitudinal study observed synergistic effects of near-road air pollution and second-hand smoke on BMI status ,20. Howe females . Further obesity . Our reswith BMI . It is wwith BMI ,23; howe2 promotes obesity, the findings fall short of confirming such a connection [2 levels, but such correlation did not attain statistical significance [2 levels are positively associated with higher risk of overweightness and abdominal circumference, both of which can lead to obesity and manifest clinically as metabolic syndrome. Such results identified CO2 as an important obesity-related indoor air pollutant, which also is a well-known index of indoor air ventilation. In building physics, indoor CO2 concentration is indicative of air quality, ventilation efficiency, air exchange rates and has been associated with a higher risk of sick building syndromes and allergies [Although Danish scholars first proposed that at atmospheric COnnection . Anotherificance . Our mulllergies ,41.Household concentrations of CO typically originate from cooking activities, due to incomplete combustion of biofuels such as natural gas and kerosene. The toxic effects from CO exposure can manifest in the heart and cardiovascular systems, resulting in myocardial ischemia and increased cardiac arrhythmias ,43,44. HMost interestingly, we observed significant associations between indoor concentrations of TVOCs and risk of increasing body weight, abdominal circumference and percentage of body fat. We assessed these associations with TVOCs in two-pollutant models; after adjusting for covariates including age, gender, and health-related behavior habits, such positive correlations remain for the other two-pollutant combinations. Furthermore, our model indicated that presence of multicollinearity is low across all models, as indicated by VIF. These findings indicated that exposure to indoor TVOCs magnifies the risk of obesity, independent of poor indoor ventilation and other gaseous pollutants. Since household emissions of VOCs originate from passive emissions from paints and adhesives in furniture, the use of care products, such as laundry detergent or from cooking activities, further research examining which specific VOCs in households are correlated to increased risk of overweightness and obesity.The experimental limits of this study should be disclosed. Firstly, the current results have yet to reflect how household air pollution levels may vary from season to season, as our sampling time took place in the summer (July–September of 2017 and 2018). Secondly, results from our observational cohort study elucidated on association and not causality. Furthermore, specific constituents of PM, such as bioaerosols and heavy metals, should be evaluated in future studies. Moreover, the results of our findings may not be generalized to specific population subgroups, such as toddlers, the elderly, or those suffering from chronic diseases. Finally, the 127 participants lived in different indoor environments and work settings, as well as had different diet intakes for the duration of this investigation. Since these aforementioned variables were not controlled, the degree to which these variables affect the study outcome is difficult to evaluate. Future study could also consider recruiting more participants to ensure statistical power.2 (554.95 ppm) is positively associated with being overweight, indicated by a higher risk of high body mass index (BMI ≥ 25 kg/m3) with an adjusted odds ratio (aOR) of 2.46 (95% CI: 1.41–4.29) and also a higher risk of becoming abdominally obese ; exposures to CO and formaldehyde were also positively associated with being overweight. IQR increase in TVOCs is positively associated with increases in risk of high BMI , becoming abdominally obese , and obtaining high body fat percentage . Two-pollutant models, which were used to determine which air pollutant has more influence on the adverse health outcome, demonstrate that TVOCs present the strongest risks associated with overweightness.After adjusting for demographic characteristics, an interquartile range (IQR) increase in exposure to CO2, formaldehyde, and TVOCs by continuous monitoring is associated with indicators of obesity despite the abovementioned limitations. The adverse health effects associated with poor indoor air quality (IAQ) have been well documented [The present study established that indoor concentrations of CO, COcumented ,47,48,49


Our results encourage further studies of understudied biomarkers such as TPX2, and validates already broadly studied biomarkers such as MSH6, MSH2, or L1CAM, among others. Finally, our results present a significant step to advance the quest for biomarkers to accurately assess the risk of EC patients.Endometrial cancer (EC) mortality is directly associated with the presence of poor prognostic factors. Molecular prognostic factors have been identified, but none are used in clinical practice due to lack of validation studies. This study aims to validate a set of 255 prognostic biomarkers previously identified in an extensive literature review and explore new prognostic applications by analyzing them in The Cancer Genome Atlas (TCGA) and Clinical Proteomic Tumor Analysis Consortium (CPTAC) databases. A total of 30 biomarkers were validated and associated to a histological type (n = 15), histological grade (n = 6), FIGO stage (n = 1), molecular classification (n = 16), or they were associated to OS (n = 11), and RFS (n = 5). A prognostic signature composed of 11 proteins increased the accuracy to predict OS (AUC = 0.827). The study validates and identifies new potential applications of 30 proteins as prognostic biomarkers and suggests to further study under-studied biomarkers such as TPX2, and confirms already used biomarkers such as MSH6, MSH2, or L1CAM. These results are expected to advance the quest for biomarkers to accurately assess the risk of EC patients.Endometrial cancer (EC) mortality is directly associated with the presence of prognostic factors. Current stratification systems are not accurate enough to predict the outcome of patients. Therefore, identifying more accurate prognostic EC biomarkers is crucial. We aimed to validate 255 prognostic biomarkers identified in multiple studies and explore their prognostic application by analyzing them in TCGA and CPTAC datasets. We analyzed the mRNA and proteomic expression data to assess the statistical prognostic performance of the 255 proteins. Significant biomarkers related to overall survival (OS) and recurrence-free survival (RFS) were combined and signatures generated. A total of 30 biomarkers were associated either to one or more of the following prognostic factors: histological type ( Endometrial cancer (EC) is the fourth most common cancer in women in developed countries and the sixth in terms of mortality . Unlike To manage the diagnosis, treatment, and follow-up of EC patients, multidisciplinary evidence-based guidelines on selected clinically relevant questions have been developed and updated over the years by the European Society for Medical Oncology (ESMO), the European Society of Gynaecological Oncology (ESGO), the European Society for Radiotherapy and Oncology (ESTRO) and the European Society of Pathology (ESP) consortiums ,4. TheseThese prognostic factors should be determined at the moment of diagnosis since they will guide an optimal surgical treatment, which is the cornerstone treatment for EC; and after surgery, to provide the final diagnosis, stratification of the tumor, and guide the adjuvant treatment ,4. WhileThe histological diagnosis is determined through the histopathological examination of an endometrial biopsy, preferably obtained by aspiration . It shouMultiple imaging techniques are used to determine prognostic factors associated with the stage of the disease. Transvaginal ultrasonography (TVUS), or magnetic resonance imaging (MRI) will assess myometrial invasion, tumor size, and cervical invasion, while computed tomography (CT), MRI or positron emission tomography (PET-CT) will evaluate the lymph node status. However, these techniques are not sensitive enough, and they are not able to determine LVSI, which is a strong predictor of nodal metastasis, recurrence, and cancer-specific death ,8. Thus,Lastly, the emerging molecular classification needs to be determined for the risk assessment of EC patients. To simplify the whole molecular classification, the TransPORTEC group proposed a surrogate classification which is highly effective for most of EC cases and is based on the assessment of POLE sequencing, immunohistochemistry of mismatch repair proteins (MMR-IHQ), and immunohistochemistry of the p53 (IHQ-p53) protein to classify EC patients ,10,11. NColl-de la Rubia E et al., 2020  EC datasets were named as validated biomarkers.The 255 proteins identified in l., 2020  were subWe used the TCGA dataset to identify the potential genes with an impact on OS and RFS. DEGs with FDR < 0.05 and AUC > 0.6 at time points of 12, 24, 36 or 48 months were subsequently used to construct the Cox proportional hazards regression model to predict OS and RFS. survival package of R software. AUC values were calculated using survivalROC package of R for OS and RFS at time points 12, 24, 36 and 48 months. Risk scores for each patient were calculated as follows:n” is the number of related prognostic genes, “iexp” is the expression value of the gene i, and “icoef” is the log hazard ratio (LHR) in univariate Cox regression analysis [survivalROC package implemented in R. Comparisons between histological types (endometrioid EC vs. non-endometrioid EC) and histological grade (low-grade -G1 and G2- EC vs. high-grade -G3- EC) were performed using T Test. Tukey’s honest significance test was used to perform multiple comparisons for FIGO stage (I vs. II vs. III vs. IV) and for molecular classification (POLE vs. MSI vs. CN-LOW vs. CN-HIGH). An AUC value for each comparison was also calculated. The univariate Cox proportional hazards regression analyses were completed using the analysis . Then, tWe used the Panther database to identify the biological processes and pathways associated with the DEGs. A FDR of < 0.05 was considered as statistically significant . We repoWe recently used an exhaustive literature revision to compile a total number of 255 proteins as potential prognostic protein biomarkers . These wJiang T et al., 2018 where it was associated with worse prognosis [Among the 30 validated biomarkers, we encountered proteins that were significant for one or multiple prognostic parameters . TPX2 isrognosis , and recrognosis ,24.Regarding histological subtype, a total of 20, 36 and 18 genes/proteins were differentially expressed between endometrioid (EEC) and non-endometrioid (non-EEC) histologies in the TCGA-RNAseq, CPTAC-RNAseq, and CPTAC-prot datasets, respectively A. HoweveRegarding histological grade, six proteins in the TCGA-RNAseq cohort, 21 proteins in the CPTAC-RNAseq cohort, and seven proteins in the CPTAC-prot cohort showed different protein abundances between low-grade (grade 1 and grade 2) and high-grade (grade 3) EC. From those, six proteins were validated in two datasets, and were also previously described in other studies: ASRGL1, ATAD2, CDC20, and TPX2 E–H. ThusRegarding FIGO stage, three and 17 proteins showed differential abundances in the TCGA and CPTAC cohorts of patients, respectively, 10 of which were previously described in the literature. However, only PGR was validated in two cohorts of patients and its performance was limited to the comparison between stage I and II . Finally, this study permitted identifying a significant number of biomarkers that allow separating between different groups of the molecular classification. A total of 16 proteins  were confirmed, i.e., were statistically significant in at least two datasets . Specifin = 166), and low-risk groups (n = 167)  in two datasets A,B. In pn = 167) A,B. An 1Gene ontology and KEGG enrichment analysis were used to explore the biological functions of the initial 255 proteins, as well as the subgroup of the 30 proteins that were validated in this study. All of them were significantly associated to the following biological processes: cellular processes, biological regulation, response to stimulus, signaling, and metabolic processes. The set of validated genes had an increased association with reproductive processes A. AdditiRegarding the pathways analysis, the 255 proteins had a balanced association with multiple pathways, in contrast to the 30 validated biomarkers having a strong relation with the gonadotropin-releasing hormone receptor pathway, p53 pathway, p53 pathway feedback loops 2, interleukin signaling pathway, cell cycle, and integrin signaling pathway, as shown in Finally, as part of our literature search, we identified chemical probes that have been developed and are currently in different phases of clinical trials targeting some of our validated biomarkers. Specifically, small molecules for different applications have been developed against AURKB, ERBB2, ESR1, PGR, PLK1, and PTK2, as well as therapeutic antibodies against ERBB2 and VIM. In addition, current treatment for EC includes medroxyprogesterone acetate, hydroxyprogesterone caproate, and megestrol acetate targeting PGR, for inoperable patients or for advanced or recurrent tumors ,27. TheiEC is the most common malignancy of the female genital tract. Its early diagnosis is related to good prognosis and overall survival. During the diagnostic process, accurate identification of prognostic factors is crucial for assessing the preoperative risk of recurrence for each patient and guide the surgical treatment. Moreover, the assessment of prognostic factors after surgery is needed for final staging and to guide the adjuvant treatment. To increase the accuracy and objectivity on the diagnostic process, several studies have discovered and described prognostic biomarker candidates, but none of them have reached the clinical practice, mostly because of a lack of independent validation studies. This study focused on the validation of previously described 255 prognostic EC biomarkers. Here we performed an in silico validation of those biomarkers in two of the currently available molecular EC studies, specifically the RNA sequencing data generated by the TCGA and CPTAC and the proteomic data generated by the CPTAC, which compiled data from a total of 428 EC patients. The results obtained here are based on those datasets, which predominately include white and Non-Hispanic or Latino as the main representation for race and ethnicity, respectively. Additionally, in a significant number of cases race and ethnicity clinical data was not reported . Knowing that EC impacts differently in the overall survival depending on race [Our results revealed 30 biomarkers that show strong evidence for being prognostic EC biomarkers. Remarkably, only ESR1, PGR, ERBB2, L1CAM, MSH2, and MSH6 have been broadly studied as EC biomarkers in the literature . This stKommoss FK et al., 2018 [Another highlight in this study is the identification of biomarkers to classify EC according to the molecular classification. This classification has acquired an increasing relevance in this last year since it has been incorporated in the most recent clinical guideline of EC to improve risk assessment . Despitel., 2018  and theyRelated to OS and RFS, we developed an 11-biomarker signature, including ASRGL1, ESR1, FASN, HDGF, MACC1, MCM6, MCM7, MSH2, MSH6, PTK2, and TPX2, to predict OS at 48 months with an AUC = 0.827. This model improved the accuracy for the best performing biomarker alone at time points 12, 24, and 36 months. Contrary to this, the model of 5 proteins, including ATAD2, BUB1, MSH6, TPX2, and TRA2B, that predicts RFS only reached AUC = 0.712 at time point 48 months, and its performance was worse than the best performing biomarker to predict RFS alone for time points 12 and 24 months. MSH6 and TPX2 were included in both models; thus, they are highly likely to have an impact on the outcome of the patients. MSH6 is already a well-described protein required to classify patients in the new molecular classification, specifically the MSI group. TPX2 was highlighted in our study as a protein related to multiple prognostic factors. These findings highlight the importance of designing new studies to assess the prognosis of EC patients. Particularly, the need of studies specifically designed to identify biomarkers that can help in the prediction of EC recurrence, as currently it is not clear which are the proteins highly influencing the recurrence of the patients. Moreover, the proteins validated in this study have been described to have an important function in the biology of the tumors, having a role in the key pathways triggering cancer such as ERK, PI3K, WNT, as well as transcription signaling pathways. To support our findings, we also explored the prognostic role of these 30 biomarkers in other types of cancer , finding association of those with favorable or unfavorable outcomes of the patients depending on the protein and the cancer type.In summary, the 30 validated highlighted in this study have shown prognostic power in at least three independent cohorts of patients and thus, they seem promising candidates that merit further validation. Notably, their differential subcellular location should be considered in the design of clinical studies. The cytoplasmic and cellular membrane proteins such as ASRLG1, ATAD2, L1CAM, PGR, TPX2 or UCHL1 should be explored in tissues, whereas secreted proteins such as HDGF, PIGR, SCGB2A1, or TMEFF2 might be easily measured in biofluids, opening the way for a less invasive diagnostic process. In fact, some of the nuclear and cell membrane validated proteins  are already used in clinics to diagnose EC patients , while sin silico validation of the previously described biomarkers in currently available, broadly documented, and considerable in size cohorts of patients such as the TCGA and CPTAC datasets is a valid approach for prioritizing robust biomarkers in future studies. Furthermore, we encourage researchers to validate the 30 biomarkers described in this study in independent studies to achieve the main goal of improving the risk assessment in EC.Considering all the above mentioned, our results confirm that literature revision and further In summary, this study validates and identifies new potential applications of 30 proteins as prognostic biomarkers to discriminate for histological subtype and grade, FIGO stage, molecular classification, overall and recurrence-free survival. A model combination of 11-protein and 5-protein yield a higher accuracy to predict overall and recurrence-free survival, respectively. Our results permit to advance the quest for biomarkers to accurately assess the risk of EC patients.


Our study objective was to analyze the association between food consumption, inflammatory status and anthropometric development; (2) Methods: We performed a prospective observational analytical research during September 2020 and April 2021 on a group of 160 healthy subjects, aged between 6 and 12 years old, by analyzing food ingestion, the basal metabolic rate, anthropometric development and the inflammatory status; (3) Results: IL-6 was significantly correlated to the sum of skinfolds, along with both serum proteins and triglycerides. The skin folds were significantly correlated with the caloric intake and with total fat intake, next to saturated and trans fats. Unlike the skin folds, the body weight was significantly correlated with the caloric intake along with some vitamins, such as Vitamin A and Vitamin B12. Inactive mass increased with excessive folic acid, Vitamin E, Vitamin K and saturated fat intake; (4) Conclusions: The inflammatory status was influenced by the ingestion of micronutrients, total serum lipids and proteins. The anthropometric development was associated with the ingestion of carbohydrates, energy balance and energy intake. We can conclude that daily menu and nutrition imbalances can influence both the risk of obesity and the inflammatory status. Dietary imbalance causes changes either an excess or deficit in body weight, depending on the nutritional needs and the caloric intake. As known, physically inactive individuals that have a positive caloric balance may report a higher risk of obesity. On the other hand, a negative energy balance due to lack of food intake may increase the risk of malnutrition. In both cases, the consequence is improper anthropometric development, which means that each condition must be treated equally.Daily caloric intake should aim to reduce the risk of obesity or poor anthropometric development . Due to Changes in inflammatory status are mainly seen in adults , while lFew papers approached topics related to food intake and systemic changes ,18,19. TFollowing the worldwide obesity rate, various intervention and diagnostic procedures are in continuous development ,22. NumeOur study objective was to analyze the association between food consumption, inflammatory status and anthropometric development. The hypothesis is that daily energy intake together with several nutrients can influence the risk of obesity and the inflammatory ratio through IL-6 and IL-8.We performed a prospective observational analytical research during eight months period, over September 2020 and April 2021. All procedures, tests and measurements were performed in the Advanced Medical and Pharmaceutical Research Center (CCAMF) of ”George Emil Palade” University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Romania, on a group of 160 participants. No more than 18 participants were excluded due to a pre-existing chronic inflammatory status.Our research protocol was accepted (No. 259/14.11.2018) by the Ethical Committee of the ”George Emil Palade ” University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Romania and at the same time the protocol complied with the mentions regarding human experimentation and research protocols as required in the Declaration of Helsinki. Prior to research, all means of research were explained to the children and their parents/ caregivers. If the research measures were understood and accepted at the same time, the parents/caregivers signed the informed consent and the acceptance for their children to participate in the research.The following inclusion criteria were applied: children aged between 6 and 12 years old with no food allergies, acute or chronic pathologies. If any of these criteria were not met, the participants were excluded from the research.During one single visit, the participants went through the basal metabolic rate (BMR) measurement, next to the anthropometric measurements and the blood sampling. The food intake was analyzed by using a food diary, completed by the parent/ caregiver over 7 days period, as illustrated in We used the indirect calorimetry method to measure the BMR. Each measurement took place after a 12-h fasting period by using the Cortex Metalyzer 3B equipment  the MetaSoft 3 software  and the facemask. Study participants were not allowed to exercise for 48 h before testing, and were recommended a normal, balanced diet.The equipment was calibrated before each test with known O2 and CO2 concentrations, while the participants were adapting to the testing environment. In the beginning of the test, we measured heart rate , the systolic  and diastolic blood pressures  by using General Electric HEALTCARE B20 device . From the supine position, the energy expenditure was measured as kilocalories  per minute/hours/day. The respiratory coefficient (RQ) was measured next to oxygen consumption  and carbon dioxide production . By using these parameters, we appreciated the carbohydrate metabolism  next to the fat metabolism . Additional information was provided through the standard protocol and the MetaSoft 3 use: body mass index (BMI) and resting energy requirement  which was calculated automatically by applying the Harris Benedict equation .The participants underwent anthropometric measurements during one single visit. In the presence of the parent/caregiver, the participants remained in minimal clothing during all anthropometric measurements. The body weight and the body height were the common measurements. Each measurement took place in similar conditions as the BMR test, after a 12-h fasting period by using the ADE, GmbH M30404-01 calibrated thaliometer .We used the HARPENDEN Professional Skinfold equipment  to measure the following skinfolds: the biceps, the triceps, the subscapular, the suprailiac, the abdominal, the thigh and the leg skin fold. Allover, the age, the gender, the height and the weight next to the biceps, the triceps, the subscapular and the suprailiac skinfold values were used in the Durnin and Womersley formula  to deterAll anthropometric measurements took place in three successive repetitions at 20-s intervals. For each measurement, we calculated the average value that was later used in statistics. For each participant, we extrapolated the height for age (%) and the weight for age (%) percentiles. The normal range was listed between 5 and 95%. Under 5%, the participants were underweight and over 95%, the participants were considered overweight .◦C and stored until analyzed. All samples were analyzed on one occasion. The Cobas Integra 400 Plus  was used to determine the level of cholesterol (80–200 mg/dL), creatinine , triglycerides (50–150 mg/dL) and total proteins (66–87 g/L). We determined both IL-6 (<3.8 pg/mL) and IL-8 (<15 pg/mL) serum levels. Each parameter was measured from the sample by using the DYNEX DSX AUTOMATED ELISA SYSTEM  based on an immuno-enzymatic assay.Following similar fasting conditions, 15 mL of venous blood were collected from each participant. After each collection, the blood samples were kept for 15 min at room temperature, were centrifuged at 80 rpm and sampled in 12 µL micro tubes. In the end, the blood samples were frozen at −80The reagents were brought to room temperature. During the first stage, the samples, standards and controls were added to the wells, which were lined with a monoclonal antibody for IL-6 and IL-8. After the incubation period, the IL-6 and IL-8 present in the sample, standard or control unrelated to the fixed antibody was removed by washing with a wash buffer. After the washing process, a solution containing a monoclonal antibody to IL-6 labeled with an enzyme-biotin was added. We further added the streptavidin-HRP conjugate. The analyzer read the absorbance of each well spectrophotometrically. The IL-6 and IL-8 concentrations were determined after reading the absorbance for each well and after the interpolation on the calibration curve. The cytokine concentration was directly proportional to the color intensity of the well.We used a seven-day (n = 7) food journal to get data over daily food intake. The journal was made available to the participants by using the google form platform . Completion time was estimated at 10 minutes. Each journal had three sections. The first section was to identify the participant. Every day we received information regarding food intake, time, type of food and food quantity. The food quantity was measured by using calibrated scales, which were made available to them during the research. Fluid intake was measured as well by using the third section of the questionnaire. The intake was estimated by reporting the amount consumed daily (liters per day).We used USDA’s Food Composition Databases , a propeThe statistical evaluation was carried out with the GraphPad Prism 6.0 software , with a level of significance set at α = 0.05. The tests used for the inferential assessment were: Mann–Whitney test for the differences and the Spearman r test for assessing the relation between two analyzed parameters. The data were presented by using descriptive data as the median value, the minimum-maximum values and the variation coefficient (CV). Due to food intake variability, the average values were not used in this study.The research results are illustrated by applying a systematic passage through each relevant subject regarding food intake, caloric need and related changes in body mass.All participants passed the anthropometric measurement stage. The weight and the height were measured to determine the body mass and the anthropometric development stage according to age.The median age in the study group was 10.3 years old (6 to 12 years old), CV = 19.67%. Following the anthropometry measurements, the median body weight was between 22.7 and 75.5 kg with a median value of 46.1 kg and 26.07% CV. The body weight for age was 57%, whereas the height for age reached 67%, both with maximum values near 100%. Furthermore, the BMI was 18.5, while the fat mass ratio was between 6.6 and 39.3 with 16.7% median value.p = 0.0001, r = 0.653).Based on the BMR measurement, oxygen consumption was 0.24 L/min, unlike 0.21 L/min VCO2. The basal metabolic rate reached 1676 kcal/day, while the resting theoretical energy needs were 1376 kcal/day. The difference between the two numerical values was 17.9%  compared to the fat metabolism, which reached 74 grams per day (CV = 38.9%), as illustrated in The carbohydrate metabolism was equivalent to 906.1 kcal median value and 54.06% of the daily energy requirements, unlike fat metabolism, which was equivalent to 688.2 kcal, and 41.06% of the daily energy needs. We assume that the remaining energy is allocated to protein, meaning no more than 5 to 10% and 83.8 to 167.6 kcal/day equivalent to 20.31 to 40.87 grams of protein per day. The median protein intake was 79.2 g/day, followed by 72.53 g/day fat and 207.6 g/day carbohydrate, as further detailed in p = 0.0383, Mann–Whitney U = 8104, despite minimal quantitative differences in median values. We did not obtain a similar result regarding fat intake (p > 0.05). However, during the BMR measurement the lipid requirements were 74 g/day, unlike 72.53 g daily intake (p > 0.05). Similar results were found in daily micronutrient intake  are significantly different to carbohydrate intake (207.6 g/day), as seen through t intake .Serum IL-6 was between 0.05 and 5.98 with a median reach of 1.41 pg/mL. IL-8 was between 0.72 and 38.9 with a median value of 7.09 pg/mL. The cholesterol median value was 144.7 mg/dL, with maximum values reaching up to 245.3 mg/dl, whereas triglycerides reached 49.46 mg/dL median value, with maximum values of 150 mg/dL. All measures were correlated to energy and macronutrient intake, as further illustrated in p = 0.0045, r = 0.27) and daily fiber intake , while daily sugar intake was significantly correlated with changes in serum parameters . Further, Vitamin A , Vitamin C  and Vitamin B1  where all correlated to IL-6 concentration. With one exception: calcium intake , daily food intake failed to correlate with IL-8 (p > 0.05), as further detailed in Overall, food intake influenced the inflammatory status under both changes in body weight and body mass. As such, IL-6 value was significantly correlated with both polyunsaturated fats  and body weight  were as well higher. Yet, IL-6 was significantly correlated to the sum of the skin folds  along with both serum proteins  and triglycerides . As expected, the skin folds were significantly correlated to the body weight  result which confirms the existing relationship between food intake, body mass and body weight.As cholesterol was higher, the serum concentration of total proteins , next to saturated  and trans fats . Carbohydrate intake  was correlated with the body weight and with sugar intake . Unlike the skin folds, the body weight was significantly correlated with the caloric intake  along with some vitamins, such as: Vitamin A  and Vitamin B12 . Inactive mass increased with excessive folic Acid , Vitamin E , Vitamin K  and saturated fats .The skin folds were significantly correlated with the total caloric intake and with total fat intake (In many situations, the information regarding the energy demand is obtained by using equations. Through these, we notice that the differences between direct and indirect methods do not differ most of the time by more than 5–10% ,32, but As in other papers ,35, actiFood intake has both an energy and a nutritional component, starting from the role and the importance of each macronutrient. Even if there are important metabolic differences between carbohydrates, proteins and lipids, we cannot question the presence of one, the lack of another and thus the body weight control . In our As against carbohydrates and fats, protein intake increases satiety. This is also the reason why the energy intake decreases. According to Carbone JW et al. , an enerDietary fats can have important roles in several metabolic disorders, while affecting insulin resistance in normal weight individuals . In our Daily energy intake influences anthropometric development and various serum biochemical parameters. As seen in our results, micronutrients can influence the inflammatory status, starting from changes in body weight usually related to macronutrients and energy intake.In the current research, the energy intake failed to correlate to serum cholesterol, triglycerides next to both IL-6 and IL-8. Furthermore, the macronutrients failed to correlate with serum parameters. The only exceptions are the carbohydrates next to the proteins, which were statistically significantly correlated with total serum proteins, unlike Praveen S et al. . TherefoInflammatory status will change with body mass, but not with daily food intake. Yet, saturated fats failed to correlate, whereas polyunsaturated fats were negatively correlated, which shows us that quality fats can decrease the inflammatory status. However, during a short-term period, fat intake failed to influence the inflammatory status as described by Telle-Hansen VH et al.  in a revUnexpected, micronutrients influence the serum changes discussed earlier. Most likely, the main changes are secondary to food intake, which can provide a smaller or larger amount of each micronutrient. Therefore, the daily calcium intake was significantly correlated to both IL-8 and serum proteins. An increased intake of calcium limited IL-8 concentration whereas being related to serum proteins. However, according to Hendy GN et al.  the cytoBy implementing the study protocol, we managed to analyze the anthropometric development of young individuals aged between 6 and 12 years old. The anthropometric study and its conclusions have a different connotation by its relationship with the daily food intake and the basal metabolic rate. Based on our study outcome, one can observe that there are limited statistical relationships between the macronutrient intake and body weight. A series of more important relationships were rather seen between caloric intake and body mass. We measured changes in body mass under fat intake, namely due to a higher saturated fat. The result was similar if significant amounts of simple carbohydrates were consumed, which limited the intake of various micronutrients. Overall, replacing processed foods with high nutrients products reduced the risk of dyslipidemia and the risk of changes in both IL-6 and IL-8 by less important changes in body mass.Nevertheless, we further mention a number of limitations of the current research. The most important limitation is the study sample. This sample allows us to observe functional changes, while an exact conclusion is formulated by studying a larger sample. However, this research proposed a punctual analysis of energy metabolism, food intake and blood sample parameters. Among the blood tests, future research should include IL-4, IL-10 and IL-13, which we did not use, to draw conclusions that are more accurate on a larger group of participants. It also becomes important to sample the study group, based on the anthropometric data.Each macronutrient has an important role in anthropometric development and health. In our study, the inflammatory status was influenced by the ingestion of micronutrients, total serum lipids and serum total protein unlike macronutrients. The anthropometric development was associated with the ingestion of carbohydrates, energy balance and energy intake. Specifically, there were no positive differences in carbohydrate intake by increasing sugar consumption compared to the energy and the nutritional needs. Furthermore, the intake of foods containing protein and lipids favored an increased cholesterol and serum triglycerides values, with positive changes in body weight, body mass and IL-6, but without significant changes in IL-8.We can conclude that daily menu and nutrition imbalances can influence both the risk of obesity, which can, therefore, increase the inflammatory status and the risk of several nutritional and anthropometric health related issues, which are usually seen in both adolescents and adult groups with changes in body weight.


The pooled SMD values were not altered in sensitivity analysis. There was no publication bias. In conclusion, statin treatment significantly increases the circulating concentrations of GPx and SOD, suggesting an antioxidant effect of these agents (PROSPERO registration number: CRD42021271589).Statins may exert protective effects against oxidative stress by upregulating specific antioxidant mechanisms. We conducted a systematic review and meta-analysis of the effect of statins on three key antioxidant enzymes: glutathione peroxidase (GPx), superoxide dismutase (SOD), and catalase. The electronic databases PubMed, Web of Science, and Scopus were searched from inception to July 2021. The risk of bias was assessed with the Joanna Briggs Institute Critical Appraisal Checklist and certainty of evidence was assessed using the GRADE framework. In 15 studies, reporting 17 treatment arms in 773 patients , statins significantly increased the concentrations of both GPx (standardized mean difference, SMD = 0.80, 95% confidence interval, CI 0.13 to 1.46,  Elevations in circulating cholesterol concentrations significantly increase the risk of atherosclerosis and its clinical manifestations, particularly myocardial infarction, ischemic stroke, and peripheral arterial disease ,2. StatiOxidative stress, through the generation of reactive oxygen species (ROS) and oxidized LDL, is considered to play a key pathophysiological role in the onset and the progression of atherosclerosis ,13,14. SThe effects of statin treatment, singly or in combination with other therapies, on oxidative stress have been extensively studied both in experimental models of atherosclerosis and in humans ,20,21. IIn order to investigate the complex interplay between statins and antioxidant mechanisms, we conducted a systematic review and meta-analysis of studies reporting on the effects of statin treatment on the circulating concentrations of GPx, SOD, and catalase in patients with different cardiovascular risk profiles. We hypothesised that statin treatment would significantly increase GPx, SOD, and catalase concentrations regardless of specific agents used.We searched for articles published in PubMed, Web of Science, and Scopus, from inception to 31 July 2021, using the terms “Glutathione Peroxidase” or “GPx” or “GSH-PX” or “Superoxide Dismutase” or “SOD” or “Catalase” and “Statin”. The abstracts and articles were screened by two independent investigators. The article references were also searched for additional studies. Pre-defined inclusion criteria were: (a) reporting of GPx and/or SOD and/or catalase concentrations in blood, erythrocytes, plasma, or serum at baseline and after statin treatment; (b) ≥10 participants; (c) English language; and (d) full-text availability. Data extracted included the country, type of biological matrix, age, sex distribution, GPx, SOD, and catalase concentrations before and after treatment, disease condition studied, statin and dose used, and treatment duration.The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for analytical studies was used to assess the risk of bias. Scores ≥ 5, 4, and <4 indicated low, moderate, and high risk, respectively . The Grap-value < 0.05 indicating statistical significance. When required, the means and standard deviations were derived from the corresponding medians and interquartile ranges [p < 0.10) and the I2 statistic  [2 values ≥ 50%, a random-effects model was used. Sensitivity analysis was performed to assess the influence of each study on the overall risk estimate by sequentially removing individual studies [p < 0.05 for both), and the “trim-and-fill” procedure [Because of the different units of measurement  used to express the concentrations of GPx, SOD, and catalase, standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated to build forest plots of the differences in GPx, SOD, and catalase concentrations before and after statin treatment, with a e ranges , medianse ranges , or fromgeneity) ,41. In t studies . Publicarocedure ,44,45. WWe initially identified 1988 articles. A total of 1970 were excluded (duplicates or irrelevant). After reviewing the remaining 18 articles, 3 were further excluded, leaving 15, reporting 17 treatment arms in 773 patients , for final analysis  27,46,4,57,58,59A total of 13 studies, reporting 14 treatment arms in 558 patients , presented data on GPx concentrations ,58. ErytThe risk of bias was low in 11 studies ,55,57,582 = 96.0%, p < 0.001). Pooled results showed that circulating GPx concentrations were significantly higher after statin treatment . In sensitivity analysis, the corresponding pooled SMD values were not substantially modified when individual studies were sequentially removed , the Egger’s test (p = 0.24), or the “trim-and-fill” method.There was no publication bias according to the Begg’s test . Specifically, GPx concentrations post-treatment were significantly higher in the studies assessing erythrocytes . In studies assessing erythrocytes, the SMD with individual statins  was similar . As 11 out of 13 studies had a low risk of bias (no rating change required), there was extreme and unexplained heterogeneity , there was a lack of indirectness (no rating change required), the imprecision was low , the effect size was large , and there was no publication bias (no rating change required), the overall level of certainty was considered high .A total of 8 studies, reporting 10 treatment arms in 542 patients , presented data on SOD ,59. FourThe risk of bias was low in all studies ,54,56,592 = 96.9%, p < 0.001), random-effects models were used. Pooled results showed that the circulating SOD concentrations were significantly higher after statin treatment . In the sensitivity analysis, the pooled SMD values were not modified when individual studies were omitted , the Egger’s test (p = 0.61), or the “trim-and-fill” method.No publication bias was observed with either the Begg’s test . Non-significant differences in SMD  were observed between studies measuring SOD in plasma . In both cases, however, no heterogeneity was observed (I2 = 0.0%). The SMD with individual statins  was similar . The final level of certainty was high  due to the low risk of bias in all studies (no rating change), the extreme and unexplained heterogeneity (downgrade one level), the lack of indirectness (no rating change), the low imprecision (upgrade one level), the large effect size , and the absence of publication bias (no rating change).A total of 3 studies, reporting 4 treatment arms in 61 patients , presented data on serum catalase ,56,58. TThe risk of bias was considered low in all studies ,56,58 T.p = 0.391). There was a low between-study heterogeneity . In the sensitivity analysis, the corresponding pooled SMD values were not substantially modified when individual studies were sequentially omitted . This was downgraded to very low  after considering the low risk of bias in all studies (no change), the low heterogeneity (no change), the lack of indirectness (no change), the high imprecision (downgrade one level), the small effect size , and the lack of assessment of publication bias (downgrade one level).Statins significantly increased the circulating concentrations of the antioxidant enzymes GPx and SOD, but not catalase, in patients with various cardiovascular risk burdens. The observed SMD values for GPx (0.80) and SOD (1.54) suggest a large effect size, and therefore the presence of tangible antioxidant effects . Further2O2, a precursor of the highly reactive radical OH•, to H2O and their corresponding alcohols. While eight isoforms of GPx have been reported in humans (GPx1-8), GPx1 is the most abundant and commonly measured isoform [2−•, into O2 and H2O2 [2O2 into O2 and H2O [The presence of hypercholesterolemia, singly or in combination with other traditional cardiovascular risk factors, favours the production of ROS by NADPH oxidase, xanthine oxidase, the mitochondrial electron-transport chain, and uncoupled nitric oxide synthase ,61. This isoform . The thrand H2O2 . By cont and H2O . The key and H2O . The ass and H2O .Our meta-analysis supports a significant antioxidant effect of statins through the upregulation of GPx and SOD. The absence of tangible effects of statin treatment on the concentrations of catalase needs to be interpreted with caution due to the small number of eligible studies identified (n = 3). While these data are encouraging in terms of atheroprotection, the exact mechanisms involved in the statin-mediated upregulation of antioxidant enzymes require additional in vitro and in vivo studies. Furthermore, appropriately designed interventional studies are warranted to determine whether the beneficial effects of this class of drugs in terms of primary and secondary cardiovascular prevention are, at least partly, mediated by specific antioxidant effects that are independent of cholesterol lowering.The relatively small number of studies identified for analysis and the extreme between-study heterogeneity when reporting GPx and SOD concentrations represent the significant limitations of our study. However, virtually no heterogeneity was observed in a subgroup of studies investigating SOD concentrations specifically in serum of plasma. Additional limitations include the different biological matrices used for the assessment of GPx and SOD, and the lack of serial assessment of these enzymes throughout the treatment period. Significant strengths include the lack of publication bias and the high certainty of evidence with GPx and SOD, suggesting that the effect of statins on these enzymes is both genuine and biologically plausible.Statin treatment significantly increases the circulating concentrations of the antioxidant enzymes GPx and SOD using a range of biological matrices, suggesting the protective effects of these agents against oxidative stress. Intervention studies are warranted to investigate the antioxidant effects of statins as important mediators of their beneficial effects for primary and secondary cardiovascular prevention, to determine the most suitable biological matrix for GPx and SOD assessment, and to identify specific patient groups that are more likely to benefit from a combined antioxidant and the lipid-lowering effect of this class of drugs.