Through a comprehensive analysis of the clinical randomized controlled trials of traditional Chinese medicine (TCM) combined with conventional western medicine (CWM) in treating type 2 diabetes(T2DM) in the past ten years, the clinical efficacy and safety of different TCMs combined with CWM were explored. This study aimed to provide specific suggestions for clinical guidance on treating T2DM.A literature search was conducted in CNKI, WanFang, VIP, CBM, PubMed, Embase, and Web of Science. The search time was limited from 2010 to the present time. The literature type was a controlled clinical trial study of TCM combined with CWM intervention in treating T2DM. The outcome indices of the efficacy evaluation included fasting blood glucose (FBG), 2-hour postprandial blood glucose (2hPG), glycosylated hemoglobin (HbA1c), adverse reactions, and clinical efficacy. Stata 15 and RevMan 5.4 software were used to conduct a network meta-analysis and a traditional meta-analysis.The results showed that shenqi jiangtang granule combined with sulfonylurea, shenqi jiangtang granules combined with metformin and jinlida granules combined with insulin had significant effects on reductions in FBG, 2hPG and clinical efficacy compared with western medicines alone, which included fasting blood glucose , blood sugar at 2 hours after a meal , and clinical curative effect .TCM combined with CWM has a very significant effect on treating T2DM compared with CWM alone. According to the network meta-analysis, the best intervention measures of different TCMs for different outcome indicators were obtained.identifier 42022350372. The prevalence of diabetes has been increasing in recent years, and it has become the ninth leading cause of death throughout the world. This disease is a major public health problem affecting the entire world. Long-term exposure to a hyperglycemic environment in patients with diabetes can lead to abnormalities in various immune cells, thus negatively affecting multiple organs and leading to many common complications . The impThe use of antidiabetic drugs is an ideal treatment method in clinical practice. Nevertheless, many drugs may lead to hypoglycemia, body fluid retention, cardiovascular disease, and other adverse reactions. However, there is a question as to how to choose the most effective treatment method exhibiting the most minor negative reactions. Currently, commonly used drugs for the treatment of diabetes include biguanides (metformin), sulfonylureas (SHD), dipeptidyl peptidase 4 inhibitors (DPP-IV), α-glucosidase inhibitors (AGI), and insulin (RI), among other drugs. According to the clinical efficacy, these drugs have very significant hypoglycemic effects. Some drugs, such as glucagon-like peptide-1 receptor agonist (GLP-1), can also reduce cardiovascular death and stroke in clinical diabetic patients, thus showing a perfect clinical effect. Drugs such as empagliflozin or liraglutide also reduce all-cause and cardiovascular mortality ; moreoveThe intervention measures that were included in this study included shenqi jiangtang granules (SQJT), jinqi jiangtang tablets (JQJT), jinlida granules (JLD), tangmaikang granules (TMK), tianmai xiaoke tablets (TMXKP), tianqi jiangtang capsules (TQJT) and CWM intervention. The included TCM is recommended according to China’s Guidelines for the Prevention and Treatment of Type 2 Diabetes (2020 Edition). The selection of TCM has been unanimously agreed upon by clinical experts, and it is the medicine that possesses a significant effect on the treatment of T2DM. Due to the fact that it was approved by the State Food and Drug Administration in 1995, SQJT has successively entered the National Essential Medicine list and the National Medical Insurance List, and it has also won the National Torch project. A considerable amount of research data has been accumulated in the past 20 years. JQJT was approved by the Ministry of Health of the People’s Republic of China on August 19, 1992, and it won the third prize in science and technology progress in 1993. Moreover, JLD, which was launched in 2019, is an innovative TCM developed under the guidance of collateral disease theory and has a significant clinical market. The TCM included in this study has a mature basis for early clinical application, and has good effects on the treatment of T2DM. The specific ingredients of TCM are shown in 22.1This network meta-analysis was conducted according to the PRISMA Extended Statement, and it was performed step-by-step in strict accordance with the PRISMA Checklist. This study has been registered on the International Prospective Register for Systems Evaluation (PROSPERO) website as CRD number 42022350372.The literature search time of this study ranged from January 2010 to October 2022. The literature search was conducted by searching the CNKI, WanFang, VIP, CBM, PubMed, Embase, and Web of Science databases and was screened according to the inclusion and exclusion criteria. The primary screening direction was a randomized controlled trial (RCT) of TCM combined with CWM in the treatment of T2DM. The included TCMs included SQJT, JQJT, JLD, TMK, TQJT, and TMXKP. In addition, the included CWMs were as follows: sulfonylureas (SHD), biguanides (metformin), dipeptidyl peptidase-4, α-glucosidase inhibitors (DPP-IV), alpha-glucosidase inhibitors (AGI), insulin (RI), and glucagon-like peptide-1 (GLP-1),which were uniformly divided into the category of CWM. Two researchers independently conducted a literature search, and the Chinese database used “Shenqi Jiangtang Granules”, “Jinqi Jiangtang tablets”, “Jinlida granules”, “Tangmaikang granules”, “Tianqi Jiangtang capsules”, “Tianmai Xiaoke tablets”, “Conventional Western medicine”, “Type 2 diabetes mellitus”, for the literature search. English databases under “shenqi jiangtang”, “jinqi jiangtang”, “jinlida”, “tangmaikang”, “tianqi jiangtang”, “tianmai xiaoke”, and “diabetes”, were retrieved in the form of subject words + free words. Two researchers independently conducted a literature search. After selecting the weight, some types of literature were screened according to the title and abstract. Finally, the final selection was performed according to the reading of the full text to obtain the final included literature.2.2The included research criteria were as follows. (1) Research on the treatment of T2DM with TCM combined with CWM that met the requirements of this paper, with traditional Chinese medicine including SQJT, JQJT, JLD, TMK, TQJT, and TMXKP and conventional Western medicine including SHD, metformin, DPP-IV, AGI, RI, and GLP-1. (2) Randomized controlled clinical trials (RCTs). (3) The intervention time being at least 2 months. (4) The included literature including at least one outcome indicator required by this study. (5) Adults with T2DM (≥18 years old). (6) Research data in the literature that was able to be obtained through public platforms.2.3The exclusion criteria for this study were as follows: (1) the publication was an animal experiment, an academic conference, a paper, or a nonrandomized controlled trial (RCT). (2) TCM and CWM that did not meet the requirements of the study. (3) literature published as an abstract only. (4) a sole focus on laboratory findings that were not RCTs, reviews, or reports. (5) repeated publications of literature. (6) the literature with complete data that could not be obtained after contacting the author.2.4Two researchers independently extracted the data of the included literature and assessed the bias risk of the included literature. Data extraction was performed according to the Excel table, which was prepared in advance. The extraction contents of the table was comprised of the author of the included literature, publication year, intervention group, age, sex, course of the disease, the total number of included studies, the grouping method of the clinical studies, whether the blind method was implemented, outcome indicators, intervention and follow-up times, specific measures of intervention, and the value of the outcome indicators, among other contents. If there was a dispute, a third researcher discussed it with the other researchers. We conducted a risk assessment of the included studies by using the Cochrane ROB Bias risk assessment tool that was used to assess the RCTs. The risk levels were high, medium, and low risk, and the literature was independently evaluated by two investigators by using the same standardized methodology. The risk of bias in the included literature was evaluated by considering randomization, assignment concealment, whether participants and researchers were blinded, the blind evaluation of outcome indicators, and selective reporting.2.5According to the consensus of clinical experts and previous experience, we selected FBG, 2hPG, HbA1c, clinical efficacy, and incidence of adverse reactions as important outcome indicators to evaluate the effectiveness of TCM combined with CWM in the intervention of T2DM.2.62 index to evaluate the heterogeneity among the studies and hypothesized homogeneity. For binary variables, the OR index was used. For continuous variables, the MD index was used. Moreover, we used 95% confidence intervals (CIs) to determine the clinical effect of the included study. We performed a frequency network meta-analysis by using Stata software to analyze indirect comparisons between different interventions. The probability of an intervention being the safest and most effective was estimated by using the area under cumulative ranking, and the relative ranking probability of different interventions was displayed. The effect values and 95%CIs of pair-to-pair comparisons between the interventions were clearly expressed by using league tables, and the inconsistencies of the results were confirmed using the node-splitting method and Bayes P value. However, inconsistencies could not be assessed because the network meta-analysis did not close the loop. Furthermore, a sensitivity analysis was used to determine the risk of bias in the included studies. According to the differences among the literature included in the intensive reading, the similarity hypothesis was formulated. Via the various statistical analyses, the different effects of intervention measures and clinical efficacy were completely analyzed.In this study, a combination of traditional meta-analysis and network meta-analysis was used to analyze the included literature. Traditional meta-analysis aims to explore the efficacy of direct interventions of different TCMs combined with CWM in the treatment of T2DM. In contrast, network meta-analysis is an overall comparison of various intervention measures; specifically, direct and indirect comparisons. We combined RevMan 5.4 software and Stata15 software package “net meta” to analyze the literature, wherein we used the I33.1After literature retrieval in various major databases according to strict exclusion criteria, 64 studies were finally included. Two researchers independently extracted the included literature according to Excel tables. The flow charts and essential characteristics of the included literature are shown in 3.2This study conducted a detailed assessment of the risk of bias using Cochrane assessment methods. Random sequence generation, Allocation concealment, Blinding of participants and personnel, Blinding of outcome assessment, Incomplete outcome data, and Selective reporting were analyzed, and the results are shown in 3.33.3.13.3.1.164 studies, a total of 6204 patients, all included the outcome index FBG. After traditional meta-analysis and network meta-analysis of FBG, it was concluded that the number of studies on SQJT combined with Metformin and JLD combined with Metformin was the largest. According to the result of direct and indirect comparison of TCM combined with CWM treatment: TCM combined with different CWM has significant hypoglycemic effect compared with simple CWM, among which, SQJT combined with SHD and JLD combined with SHD compared with simple SHD have hypoglycemic effect value , ; SQJT combined with Metformin are better than Metformin alone, TMXKP combined with Metformin and TMK combined with Metformin, hypoglycemic effect value of respectively , , . The hypoglycemic effect of JLD combined with RI, SQJT combined with RI and JQJT combined with RI was significantly better than that of RI alone, effect value of respectively , ,  Figure 33.3.1.2According to the area ranking diagram under the FBG accumulation curve of the outcome index, SQJT combined with SHD had the best effect in reducing the FBG content among the intervention measures, while the hypoglycemic effect of CWM alone was significantly lower than that of other TCM combined with CWM. The sequence of hypoglycemic effect of comprehensive intervention measures is as follows: SQJT+SHD > SQJT+Metformin > JLD+SHD > JLD+RI > SQJT+DPP-IV > JLD+GLP-1 > SQJT+RI > SQJT+AGI > TMK+Metformin > JLD+DPP-IV > TQJT+Metformin > JLD+Metformin > JQJT+RI > TMXKP+Metformin > GLP-1 > AGI > SHD > DPP-IV > RI > Metformin, which proves that TCM combined with CWM has a significant effect on reducing FBG content, and SQJT combined with SHD has the most significant effect Figure 33.3.23.3.2.1A total of 59 studies, involving a total of 5772 patients, included 2-hour postprandial glucose outcomes. In this study, traditional meta-analysis and network meta-analysis of blood glucose 2 hours after meals showed that there were most studies on the comparison between SQJT combined with Metformin, JLD combined with Metformin and Metformin alone, and most of the studies were direct comparison between TCM combined with CWM and CWM, while there was no direct comparison between different TCM. According to the result of 2hPG, SQJT combined with Metformin, JLD combined with Metformin, TMXKP combined with Metformin and TMK combined with Metformin have significant hypoglycemic effects compared with Metformin alone, effect value of respectively , , , ; The therapeutic effect of JLD combined with SHD and SQJT combined with SHD was significantly better than that of SHD alone, and the effect values were  and ; The hypoglycemic effect of SQJT combined with RI and JLD combined with RI was better than that of RI alone, and the effect values were  and ; The above are the direct comparison between different TCM combined with CWM and simple CWM treatment, while the indirect comparison results between different TCM combined with CWM show that, the hypoglycemic effect of SQJT combined with Metformin is better than that of JLD combined with Metformin, TMXKP combined with Metformin and TMK combined with Metformin, effect value of respectively , , ; The therapeutic effect of SQJT combined with RI was better than that of JQJT combined with RI, and the effect value was  Figure 43.3.2.2According to the outcome index, the area sorting diagram under the 2hPG accumulation curve showed that SQJT combined with Metformin had the most significant effect on reducing the 2hPG. The therapeutic effect ranking of various interventions is as follows: SQJT+Metformin > JLD+SHD > SQJT+RI > JLD+DPP-IV > SQJT+SHD > JLD+GLP-1 > SQJT+AGI > JLD+RI > JLD+Metformin > TQJT+Metformin > TMXKP+Metformin > SQJT+DPP-IV > JQJT+RI > TMK+Metformin > AGI > SHD > GLP-1 > DPP-IV > RI > Metformin, which proves that TCM combined with CWM has a significant effect on reducing 2hPG compared with CWM alone. The league table clearly shows the 95%CI for each intervention Figure 43.3.33.3.3.1Fifty-seven studies with a total of 5,432 patients included HbA1c outcome measures. In this study, traditional meta-analysis and network meta-analysis of HbA1c showed that: Among the direct comparative studies of TCM combined with CWM and CWM alone, SQJT combined with Metformin and JLD combined with Metformin were the most relevant studies. According to the result of meta-analysis, SQJT combined with Metformin had a significant effect on reducing the HbA1c content compared with Metformin alone, and the effect value was ; SQJT combined with AGI had significant effect compared with AGI alone, and the effect value was . There was no significant difference in the comparison of other interventions Figure 53.3.3.2According to the area ranking diagram under the cumulative curve of the glycosylated hemoglobin content of the outcome index, SQJT combined with SHD have the most significant effect on reducing the HbA1c, and the therapeutic effects of various intervention measures are ranked as follows: SQJT+SHD > SQJT+Metformin > SQJT+DPP-IV > JLD+SHD > SQJT+AGI > SQJT+RI > JLD+GLP-1 > JLD+RI > TMK+Metformin > JLD+Metformin > JQJT+RI > JLD+DPP-IV > DPP-IV > TMXKP+Metformin > GLP-1 > SHD > TQJT+Metformin > AGI > RI > Metformin, it was proved that TCM combined with CWM had a significant effect on reducing the level of HbA1c compared with CWM alone Figure 53.3.43.3.4.1Eighteen RCTs, involving a total of 1867 patients, included the incidence of adverse reactions as an outcome indicator. In this study, traditional meta-analysis and network meta-analysis were performed on the incidence of adverse reactions. According to the result, SQJT combined with DPP-IV had more safety and lower incidence of adverse reactions compared with CWM alone, and the effect value was ; Compared with RI alone, JLD combined with RI had better safety, and the effect value was , there was no significant difference between other interventions Figure 63.3.4.2According to the area ranking graph under the cumulative curve of adverse reaction incidence of outcome indicators, JLD combined with Metformin was the best intervention measure, and the best ranking of various intervention measures was as follows: SQJT+Metformin > SQJT+DPP-IV > JLD+Metformin > JLD+RI > SQJT+SHD > TMXKP+Metformin > SQJT+AGI > JLD+DPP-IV > AGI > SHD > RI > DPP-IV > Metformin > TMK+Metformin Figure 63.3.53.3.5.1Thirty-two RCTs, with a total of 3,045 patients, included outcome measures of clinical efficacy. In this study, traditional meta-analysis and network meta-analysis of clinical efficacy were conducted. According to the result, compared with RI alone, JLD combined with RI and SQJT combined with RI showed better clinical efficacy, and the effect values were  and ; SQJT combined with SHD and JLD combined with SHD were more effective than SHD alone, and the effect values were  and , respectively; SQJT combined with AGI were superior to AGI alone, and the effect value was . The comparison results of other intervention measures were shown in the figure Figure 73.3.5.2According to the area ranking diagram under the cumulative curve of clinical efficacy of outcome indicators, JLD combined with RI was the best intervention measure, and the best ranking of various intervention measures was as follows: JLD+RI > SQJT+SHD > SQJT+RI > JLD+Metformin > SQJT+AGI > JLD+GLP-1 > JLD+DPP-IV > SQJT+Metformin > JLD+SHD > JLD+RI > AGI > DPP-IV > GLP-1 > SHD > Metformin > RI Figure 74According to the results of this traditional meta-analysis and online meta-analysis, SQJT combined with CWM and JLD combined with CWM have more significant effects on reducing FBG, 2hPG, HbA1c, and the incidence of adverse reactions, as well as by enhancing clinical efficacy, compared with CWM alone. JQJT combined with CWM, TMK combined with CWM, and TMXKP combined with CWM were superior to CWM alone in reducing FBG and 2hPG. After a comprehensive analysis, it was found that SQJT combined with CWM had the most comprehensive effect on the clinical treatment of T2DM.via the MAPK pathway and GluT-4 upregulation  The literature included in this study belongs to TCM; inevitably, most of the studies were domestic studies, with few relevant foreign studies. (2) As limited by statistical methods, some of the relevant methods that were included in the study were not optimal, and the quality was not good. (3) The intervention time was not long enough for the included studies, the efficacy in the future for a long period of time was not clear. (4) The sample size that was included in the study was not large enough. When considering the above mentioned aspects, we will focus on large-sample, multicenter, double-blind, and other high-quality clinical studies in the future to improve our research conclusions, with a view to providing more authoritative and instructive suggestions for the clinical treatment of T2DM.6Through the combination of this traditional meta-analysis and network meta-analysis, it was concluded that different TCMs combined with CWM had more significant clinical efficacy and safety in the treatment of T2DM compared with CWM alone, among which SQJT combined with CWM may be the best intervention measure, SQJT combined with SHD and Metformin is the best clinical method to reduce blood glucose content, and JLD combined with RI has the best clinical effect. The order of the best possible intervention measures for different outcome indicators was also obtained. The aim of the study outcomes is to provide some suggestions and help for clinical applications.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.KM and LZ were involved in study design, data collection, analysis, and manuscript revision. KM and ML contribute to data collection, data interpretation and manuscript revision. CT and CY participated in data analysis, data interpretation, manuscript drafting and revision, YZ and JZ were responsible for the concise and unobstructed language expression of the article and graphic production. KM is the guarantor of this work, and ML is the corresponding author of this paper, providing valuable suggestions for the overall framework and content construction of this paper. All authors contributed to the article and approved the submitted version.


Background: Pregnancy anemia is a global health concern. However, to our knowledge, there still has little consensus on the reference value of hemoglobin levels. Particularly, little evidence from China was accessible in most existing guidelines. Objective: To evaluate hemoglobin levels and anemia prevalence of pregnant women in China and offer evidence for anemia and its reference values in China. Methods: A multi-center retrospective cohort study was conducted among 143,307 singleton pregnant women aged 15–49 at 139 hospitals in China, with hemoglobin concentrations routinely tested at each prenatal visit. Subsequently, a restricted cubic spline was performed to reveal a non-linear variation of hemoglobin concentrations during the gestational week. The Loess model was used to describe the changes in the prevalence of different degrees of anemia with gestational age. Multivariate linear regression model and Logistic regression model were applied to explore influencing factors of gestational changes in hemoglobin level and anemia prevalence, respectively. Results: Hemoglobin varied nonlinearly with gestational age, and the mean hemoglobin levels decreased from 125.75 g/L in the first trimester to 118.71 g/L in the third trimester. By analyzing hemoglobin levels with gestational age and pregnancy period, we proposed new criteria according to 5th percentile hemoglobin concentration in each trimester as a reference for anemia, with 108 g/L, 103 g/L, and 99 g/L, respectively. According to WHO’s criteria, the prevalence of anemia sustainably increased with gestational age, with 6.2%  in the first trimester, 11.5%  in the second trimester and 21.9%  in the third trimester, respectively. In subsequent analysis, pregnant women in non-urban residents, multiparity, and pre-pregnancy underweight tended to have lower hemoglobin levels. Conclusions: This research, the first large-sample study to present a set of gestational age-specific reference centiles for hemoglobin levels in China, could be used to obtain a better understanding of the overall levels of hemoglobin in Chinese healthy pregnant women and ultimately offer clues for a more precise hemoglobin reference value of anemia in China. Anemia is a state in which the number of red blood cells or hemoglobin is not reduced enough to meet the physiological needs of the body . ParticuAppropriate guidelines for the measurement of hemoglobin and the definition of anemia are crucial for both clinical and public health medicine. The most widely used guideline of anemia is WHO’s recommendations, with severe, moderate, and mild anemia for pregnant women referring to hemoglobin concentrations of less than 70 g/L, 70 to 99, and 100 to 109 g/L, respectively. It should be emphasized that WHO’s guideline was first proposed based on five studies of predominantly white populations in Europe and North America, with little available data from China. However, reference for anemia should particularly consider complexities across different populations, especially with racial and environmental factors [In fact, several studies have already reported similar or even lower risks of low birthweight and stillbirth in pregnant females with mild anemia compared with those who had normal hemoglobin concentrations according to WHO recommendations ,8. PartiIn response to these issues, this study, by depicting the variation curve of hemoglobin levels with gestational age, aimed to provide clues for a more precise reference range of maternal hemoglobin levels during pregnancy in China.We used the data from a multi-center prospective cohort study designed to explore the correlation between serum vitamins A and E during pregnancy and preeclampsia from 2015 to 2020, recruiting pregnant women who received routine prenatal care during whole pregnancy at 180 hospitals in 23 provinces across three geographical regions in China. In order to guarantee data quality, at least one tertiary maternity hospital was invited as the research center in each province. This study collected results of maternal blood routine examinations and correspondent medical records in at least one follow-up during the 1st, 2nd, and 3rd trimesters of pregnancy.We conducted a multi-center retrospective study and a secondary analysis based on the prospective cohort. A total of 143,307 singleton pregnant women, aged 15–49 were recruited in this study. We used data whose records contained at least one hemoglobin measurement during 5–41 gestational weeks. Cases of pregnant women who did not have credible results of hemoglobin concentration (<30 g/L or >180 g/L), were conceived by assisted reproductive technology, or had pregnancy complications  were excluded from this study.All the procedures of this study were reviewed and approved by the Peking University Third Hospital Medical Science Research Ethics Committee (IRB00006761-2015277).Hemoglobin concentrations were routinely tested at the local laboratory at each prenatal visit. Anemia for pregnant women was classified by hemoglobin levels according to WHO definitions: severe anemia (<70 g/L), moderate anemia (70~100 g/L), and mild anemia (100~110 g/L).Provinces were divided into three geographical regions: eastern China , central China , and western China . Age, ethnic origin, education, Hukou , primigravida, labor year, height, and weight prior to pregnancy were extracted from medical records. Underweight, normal BMI, overweight, and obesity were defined as a BMI of <18.5,18.5–23.9, 24–27.9, and ≥28, respectively, by using the diagnostic criteria in Chinese adults.p < 0.05 was regarded as statistically significant.We summarized the baseline characteristics of pregnant women . We calcA total of 143,307 pregnant women with required data from 139 hospitals were included .In our study, the major labor years of participants were between 2015 and 2018(93.4%). The mean age of pregnant women was 28.78 (±4.48) years old. Most participants lived in urban areas (69.6%) and attained an educational of level more than high school (62.7%). The majority of participants were divided into the normal pre-pregnancy BMI group (69.7%) and were from eastern China (54%). The proportion of primigravid and multipara was 55.4% and 44.6%, respectively; 97.8% of participants’ ethnicity were Han and 21.8% of participants’ ethnicity were minorities .Results of hemoglobin concentration during 5–41 weeks of 143,307 pregnant women were calculated, in which 65,691, 69,184, and 56,042 participants had effective hemoglobin values in the first, second, and third trimesters, respectively. The mean (SD) and percentile of hemoglobin concentrations and the anemia prevalence according to gestational age were displayed in The prevalence of anemia of all degrees was presented in a slightly increasing trend by gestational age shown in We calculated hemoglobin concentrations and the prevalence of anemia according to trimesters in WHO criteria and our definition. As shown in p-BMI group.p < 0.001, 0.078 in the second trimester and p < 0.001, 0.115 in the third trimester. The hemoglobin level of multiparous women was significantly lower than that of primiparous women. Compared with normal pre-pregnancy BMI, the hemoglobin level of underweight pregnant women was significantly lower, and the hemoglobin level of obese and overweight pregnant women was significantly higher.As shown in This study innovatively demonstrated variations in hemoglobin levels and anemia prevalence by gestational age in 143,307 singleton pregnant women. Hemoglobin varied nonlinearly with gestational age, and the mean hemoglobin levels decreased from 125.75 g/L in the first trimester to 118.71 g/L in the third trimester. By analyzing hemoglobin levels with gestational age and pregnancy period, we proposed new criteria according to 5th percentile hemoglobin concentration in each trimester as a reference for anemia, with 108 g/L, 103 g/L, and 99 g/L, respectively. According to WHO’s criteria, the prevalence of anemia sustainably increased with gestational age, with 6.2%  in the first trimester, 11.5%  in the second trimester and 21.9%  in the third trimester respectively while anemia prevalence was 4.8% in the first trimester, 4.9% in the second trimester and 4.4% in the third trimester according to our new reference. We also depicted hemoglobin concentration levels in different trimesters and explored their associated factors, with non-urban residents, multiparity, and pre-pregnancy underweight associated with lower hemoglobin levels.In our study, we mainly found that hemoglobin levels demonstrated natural fluctuations in hemoglobin levels by trimester, due to fetal and maternal physiological demands. Generally, it is recognized that there is a normal 1.0 g/dL decrease in hemoglobin in 1st and 3rd trimesters, with hemoglobin concentrations diminishing an additional 0.5 g/dL in 2nd trimester of pregnancy .In subgroup logistic analysis, we found that pregnant women in eastern China had higher serum hemoglobin concentrations during pregnancy than those in central China and western China in the first trimester. Considering that eastern China is more developed than other areas of China, differences in the 1st trimester of pregnancy which reflects the basic iron amount probably arise from different levels of local economic development, lifestyle, and diet .As a reference to maternal anemia, according to WHO’s criteria, the prevalence of anemia was 6.2%, 11.5%, and 21.9% in 1st, 2nd, and 3rd trimesters of pregnancy, respectively, this was similar to the prevalence of anemia in China reported earlier ,13. It iIn all, considering that mild anemia by WHO has protective effects on fetal outcomes, our study indicated that, for Chinese pregnant women, the existing WHO recommendations might need some supplementation.Moreover, pregnant women with normal hemoglobin levels were vulnerable to adverse effects of excessive interferences, as WHO recommends daily routine supplementation with 30–60 mg elemental Fe/d (plus 400 μg folic acid) throughout pregnancy. In fact, although most studies reported that supplementation of anemic women with iron reduces the rate of anemia at term , the advFurthermore, although there did exist studies about maternal anemia in China, those studies only reported anemia prevalence, with little mention of precise hemoglobin levels. Therefore, this is the first to offer a pure perspective on anemia and hemoglobin levels of Chinese pregnant women, and its proposed progress might be further applied to or validate studies in other countries.It should be stressed that our study almost did not include moderate and severe anemia , so the It should be noted that due to certain reasons, the database of this study lacked accurate information on perinatal outcomes. Therefore, we could not evaluate relationships between hemoglobin levels and perinatal outcomes. However, our previous study might supplement this gap to some extent, offering a view of the relationships between anemia rates and perinatal outcomes . FurtherDespite controlling for many covariates in the multivariable-adjusted analyses, we did not measure several important factors, especially iron supplementation and transfusions of blood products during pregnancy, which may have confounded the observed associations because of the retrospective nature of this study. Furthermore, hemoglobin levels were also influenced by dietary habits. The usage of iron supplements/drug information and dietary habits were not included in most previous research. We are aware of this and will fill this gap in subsequent single-center studies.In addition, we did not take specific residence into consideration information in data collection, therefore it would not be possible to adjust for hemoglobin levels in pregnant women at high altitudes. Most subjects lived in provinces with average altitudes lower than 1000 m, where there is no need to adjust hemoglobin levels according to WHO guidelines. In the following multi-center study, we will collect the specific residence of the subjects and adjust the hemoglobin level according to the altitude of the residence before analysis.Moreover, we could not ensure appropriate standardization of hemoglobin measurements across different hospitals and regions, which might bring bias to the results, but it should be stressed that there already has a growing tendency that clinical laboratory results will achieve inter-accreditation among different hospitals in China.This is the first to offer a pure perspective on anemia and hemoglobin levels of Chinese pregnant women, and its proposed progress might be further applied to or validate studies in other countries. In this study, we proposed new criteria according to 5th percentile hemoglobin concentration in each trimester as a reference for anemia, with 108 g/L, 103 g/L, and 99 g/L, respectively. According to this reference, we found a potential reduction of anemia excessive interference of more than 1.4%, 6.7%, and 17.5% of pregnant women in China in the 1st, 2nd, and 3rd trimesters of pregnancy, respectively.Considering that there was little evidence according to maternal anemia from China, more cross-sectional studies and precise guidelines based on them should be considered essential in the effort to monitor maternal hemoglobin status better.


The high mortality risk in severe SARS-CoV-2 infections is tightly correlated to the extreme elevation of inflammatory markers. This acute accumulation of inflammatory proteins can be cleared using plasma exchange (TPE), commonly known as plasmapheresis, although the available data on performing TPE in COVID-19 patients is limited regarding the optimal treatment protocol. The purpose for this study was to examine the efficacy and outcomes of TPE based on different treatment methods. A thorough database search was performed to identify patients from the Intensive Care Unit (ICU) of the Clinical Hospital of Infectious Diseases and Pneumology between March 2020 and March 2022 with severe COVID-19 that underwent at least one session of TPE. A total of 65 patients satisfied the inclusion criteria and were eligible for TPE as a last resort therapy. Of these, 41 patients received 1 TPE session, 13 received 2 TPE sessions, and the remaining 11 received more than 2 TPE sessions. It was observed that IL-6, CRP, and ESR decreased significantly after all sessions were performed in all three groups, with the highest decrease of IL-6 in those who received >2 TPE sessions (from 305.5 pg/mL to 156.0 pg/mL). Interestingly, there was a significant increase in leucocyte levels after TPE, but there was no significant difference in MAP changes, SOFA score, APACHE 2 score, or the PaO2/FiO2 ratio. The ROX index was significantly higher among the patients who underwent more than two TPE sessions, with an average of 11.4, compared to 6.5 in group 1 and 7.4 in group 2, which increased significantly after TPE. Nevertheless, the mortality rate was very high (72.3%), and the Kaplan–Meier analysis identified no significant difference in survival according to the number of TPE sessions. TPE can be used as last resort salvage therapy that can be regarded as an alternative treatment method when the standard management of these patients fails. It significantly decreases the inflammatory status measured via IL-6, CRP, and WBC, as well as demonstrating an improvement of the clinical status measured via PaO2/FiO2, and duration of hospitalization. However, the survival rate does not seem to change with the number of TPE sessions. Based on the survival analysis, one session of TPE as last resort treatment in patients with severe COVID-19 proved to have the same effect as repeated TPE sessions of 2 or more. The novel coronavirus SARS-CoV-2 posed a significant challenge to the whole global health system owing to the high number of patients requiring hospitalization in a short period of time, resulting in a worldwide health catastrophe ,2,3. DurAmong the hypothesized treatment methods, there was an attempt to reduce the severe inflammation that occurs in severe COVID-19, triggering acute respiratory distress syndrome (ARDS) ,8,9. MulDespite the fact that vaccines are currently offered in most of regions worldwide, there are constraints in some regions because of problems with vaccine acceptance ,16,17,18Depending on the characteristics of the population, the mortality rate in severe cases of COVID-19 remains substantial ,22. DespSince a cytokine storm-mediated immune response triggers many complications and organ damage, it was hypothesized that eliminating harmful antibodies and cytokines might lower the severity of the disease. In light of these factors, TPE has been suggested as a viable therapeutic option for severe SARS-CoV-2 infections, although being reserved for those cases where other options failed. Therefore, the objective of this scientific project was to observe the role of plasma exchange therapy in lowering the level of inflammation in critically ill COVID-19 patients and whether it prevents severe complications and to find the optimal treatment protocol to improve patients’ survival according to the number of plasmapheresis sessions.Between March 2020 and March 2022, the research gathered data from the Clinical Hospital for Infectious Diseases and Pneumology in Timisoara, which accepted SARS-CoV-2-infected patients from western Romania. During this time period, several patients with severe forms of COVID-19 who required intubation and mechanical breathing were hospitalized in the intensive care unit (ICU). Patients admitted to the ICU with ARDS within this time frame were evaluated for inclusion in this research. It was found that exchange therapy was performed in 65 adult patients with significant respiratory impairment and no response to other treatments.The study took place in the intensive care unit of the Clinical Hospital for Infectious Diseases and Pneumology in Timisoara, which is affiliated with the Victor Babes University of Medicine and Pharmacy Timisoara. Signed informed permission was acquired from all participants or their legal guardians. The hospital’s Ethical Committee authorized the research for data collection and outcomes publication on 24 December 2021, with permission number 13037. Patients were identified from the hospital database and their associated paper records with all treatments, procedures, and laboratory analyses were registered. The inclusion criteria comprised the following particularities: (1) patients required to be at least 18 years old; (2) a diagnosis of COVID-19 established via a positive PCR test at the moment of admission ; (3) patThe current study analyzed the following variables: body mass index, age, age range, gender , the duration from COVID-19 diagnosis and TPE, mechanical ventilation , number of comorbidities, comorbidities , the laboratory profile , mean arterial pressure (MAP), body temperature, SOFA score, APACHE2 score, PaO2/FiO2 ratio, and mortality rate.To assess the effect of organ failure after the TPE session, liver enzymes, blood urea nitrogen (BUN), creatinine, pH, lactate, SOFA score , and APAn (%) and compared with the Chi-square test or the Fisher’s exact test, if the frequency assumption was not met for the Chi-square test. The test significance was described using a “p-value”, where a “p-value” lower than 0.05 was considered statistically significant.The statistical analysis was performed using GraphPad Prism version 6.0 for Microsoft Windows . Due to the lengthy and costly procedure of TPE, only 65 patients benefitted from TPE, therefore, the sample size and statistical power calculation were considered irrelevant. Data normality was tested with the Kolmogorov-Smirnov test. Normally distributed data were presented according to the mean value, as representative for central tendency, and the standard deviation as a measure of dispersion. The difference between the means of the three comparison groups was tested with the ANOVA test. Non-normally distributed data were described using the median and interquartile range (IQR) and compared with the Kruskal–Wallis test. Proportions were presented as Among the 65 participants, there were 41 patients who received only one session of TPE, thirteen who received 2 sessions, and the other eleven patients received more than two TPE sessions. p-value < 0.001). In addition, CRP levels were more elevated in group 3, compared to the other two . Although CRP and IL-6 were higher in group 3 patients, the median value of leucocytes was significantly higher in group 2 patients who underwent 2 TPE sessions . Furthermore, BUN was also the highest in group 2, with a median value of 71.5 mg/dL, compared to 54.0 mg/dL in group 1 and respectively 56.2 in group 3 . Regarding the blood analysis measured at admission in the ICU, the laboratory findings of patients with severe COVID-19 before TPE are presented in p-value < 0.001). LDH also decreased significantly in all three groups, with approximately 100 units in each group of patients. Regarding the CRP levels, the difference between groups remained significantly high, but there was no significant difference overall between the values measured before and after TPE. ESR decreased significantly after the TPE, although they remained the highest in group 3 of patients who received more than 2 sessions of TPE. Lastly, there was a significant increase in leucocyte levels after the TPE was performed; in group 1 they increased from 12.7 to 15.2, in group 2 from 17.0 to 18.5, while in group 3 they increased from 11.9 to 14.2 ×103/uL . One day after the first session of TPE was performed, the same blood parameters were measured to compare the changes that have occurred, as presented in p-value = 0.023). There was no significant difference in MAP change after TPE compared to the same groups before TPE. Among the studied parameters, neither the SOFA score, nor the APACHE 2 score, the oxygenation index, or the PaO2/FiO2 ratio changed significantly the following day after undergoing TPE. Similarly, there was no difference regarding the SOFA score, the APACHE 2 score, the oxygenation index, or the PaO2/FiO2 ratio among the studied groups before or after undergoing TPE. However, it was observed that the ROX index was significantly higher among the patients who underwent more than two TPE sessions, with an average of 11.4, compared to 6.5 in group 1 and 7.4 in group 2 . Furthermore, the ROX score increased after TPE, but without statistical significance, and it remained the highest in group 3, with an average of 13.1, as presented in p-value = 0.141).Plasma exchange is thought to enhance organ function by eliminating inflammatory and antifibrinolytic mediators, maintaining endothelial membranes, and replacing anticoagulant proteins to restore hemostasis. In the early stages of sepsis, the elimination of these chemicals may be beneficial ,32. GiveIn separate research including just seven patients, it was shown that all of them had elevated inflammatory markers before TPE and afterwards had favorable clinical and biological outcomes. According to the authors, the better outcome was attributable to the timely commencement of TPE on the first day of the cytokine storm, before intubation and mechanical breathing were required . In a piPlasma exchange can modify pathogenic inflammatory drivers in seriously ill COVID-19 patients, which, instead of protecting the organism, produce an exaggerated response to the virus. Depending on their molecular weight, this may decrease D-dimer levels, indicating that the patient’s condition has been artificially reduced rather than cured. Moreover, our findings are consistent with those of other studies in which the authors demonstrated a beneficial effect of plasma exchange by demonstrating decreased fatality rates in patients with D-dimers greater than or equal to 2 mg/L on plasma exchange therapy compared to patients with D-dimers >2 mg/L who did not receive plasma exchange . DespiteRelative to the reference group, plasmapheresis improved the mortality of patients with severe COVID-19 in our research. Various case series have regularly indicated a decrease in 28-day fatality related with TPE, ranging from 10% to almost 30% in patients with severe COVID-19, ARDS, and cytokine release syndrome. In one major trial, patients admitted with SARS-CoV-2 infection and cytokine storm syndrome were randomly assigned to undergo two sessions of TPE or conventional treatment, although it is unclear why it was considered that two sessions of TPE are sufficient . In compIn another trial, patients with severe COVID-19 underwent 5 sessions of TPE, compared with our study where the majority of patients received only 1 TPE session. In the respective study, there were no deaths recorded (0 vs. 35% in patients undergoing regular treatment for COVID-19) and no side events were reported ,41. In oNevertheless, the principle of removing inflammatory markers during the acute phase of severe COVID-19 infection still continues to be a plausible treatment method, considering the effects might vary from case to case individually. IL-1 has a crucial role in producing the cytokine storm that emerges in severe COVID-19, according to many studies . IL-1 inBesides the cytokine storm that is evident in severe COVID-19, there have been many reports regarding the coagulation disorders seen in these patients. One study aimed to evaluate the efficacy of TPE in correcting coagulation disorders in 60 critically ill COVID-19 patients . The patAnother study evaluated 20 critically ill COVID-19 patients with severe respiratory failure. The patients underwent TPE treatment, and their cytokine levels and respiratory function were monitored before and after the procedure . The resThe reduction of inflammatory cytokines and improvement of serum markers in patients with severe COVID-19 was described in a recent systematic review that included 267 patients . IL-6 reEven from the beginning of the new coronavirus pandemic, interleukin-6 (IL-6) has been a prognostic biomarker with significant clinical value that has distinguished between mild, moderate, and severe forms of the disease, raising an important question: if it could be controlled, could the SARS-CoV-2 infection evolution be halted? In several studies, attempts have been made to manage IL-6 by maintaining it within normal levels using a variety of medical techniques. One of the techniques was plasma exchange therapy, which dramatically decreased IL-6 levels . In reseAmong the limitations of the current study is the retrospective design itself. Since it was not organized as a clinical trial, there are many factors that could not be controlled. Ideally patients would be selected with similar characteristics that will not alter the effect of TPE. In our study, heterogeneity was high in all three groups, however, the laboratory findings before undergoing TPE indicated that there were not too many differences in the inflammatory status of the patients in each group. Another limitation of this study is the outcome measure, since only the short-term outcomes were measured. TPE treatments may assist in reducing the virus load, but combining TPE with passive antibody transfer from convalescents could be a worthwhile avenue for further exploration. The benefits and potential drawbacks of this approach would need to be thoroughly evaluated before making any conclusions. Further research is needed to fully understand the role of antibodies in the context of SARS-CoV-2 infection and to accurately evaluate their potential impact on the outcome of TPE treatments.Almost three years have passed since the onset of the pandemic, and the complex mechanism of the disease is not fully known, and the race to find an efficient treatment is still not over. From the available data, we found that TPE might be considered a complementary alternative therapy for COVID-19 patients with severe illness. Even after one TPE session it was observed that there was a substantial decrease in inflammatory mediators, improvement in coagulation function, and improvement in clinical status, in a non-inferior way compared to patients who underwent two or more sessions of plasmapheresis. The respiratory function was however significantly improved after two or more TPE sessions compared to only one session, but overall, the survival was not significantly influenced. However, the available literature and their outcomes are very variable, with the majority of them failing to indicate an improvement compared to a control group. Nevertheless, this method has not yet been statistically verified in trials with a larger number of patients in order to be considered reliable in terms of a proper study protocol and a significant improvement in patients’ survival.


Chicken choroidal whole mounts were exposed to ambient pressure (n = 20) and 40 mmHg (n = 20) in a PC-controlled, open chamber system for 24 and 72 h, respectively. VIPchor was significantly increased after exposure to 40 mmHg compared to exposure to ambient pressure. This increase of the VIPchor level, representing the intracellular choroidal VIP level, might argue for a retention of VIP within the neurons, consequently decreasing vasodilatation and choroid thickness.Autonomic ocular control is mediated by sympathetic, parasympathetic, and primary trigeminal afferent nerve fibers. Intrinsic choroidal neurons (ICN) contribute to this complex neuronal network. Vasoactive intestinal peptide (VIP), a major transmitter of ICN, mediates choroidal vasodilation and, thus, potentially choroidal thickness and intraocular pressure (IOP). Therefore, it was the aim of the present study to investigate the choroidal VIP level (VIPchor) in the presence of an increased atmospheric pressure in a chicken model. Methods: Chicken choroidal whole mounts were exposed to ambient pressure (n = 20) and 40 mm Hg (n = 20) in a PC-controlled, open chamber system for 24 and 72 h, respectively. The VIP concentration was analyzed by ELISA, and the total protein concentration was measured by the BCA assay. Statistical analysis was done using an unpaired two-tailed t-test. Results: The pressurization systems enabled choroidal whole mount pressurization (40 mm Hg) with humidifying, pressure, temperature, and gas exchange. Overall, the VIPchor level concentration was significantly increased at 40 mmHg compared to the ambient pressure . Subgroup analysis yielded a significantly increased VIPchor level at 40 mmHg compared to the ambient pressure after 24 h  and 72 h , respectively. The VIPchor elevation at 40 mm Hg ranged between 1.37- (24 h) and 1.54-fold (72 h) compared to the ambient pressure. No difference was observed between the VIPchor level at 24 h and 72 h (p > 0.05). Conclusions: The increase of the total choroidal VIP level, representing the intracellular VIP content, in the presence of an increased ambient pressure argues for a retention of VIP within the neurons, decreasing both vasodilatation and, consequently, choroid thickness. This finding might be a passive or even active function of ICN in the regulation of choroidal thickness, ocular integrity and IOP.Purpose: Autonomic control is important in maintaining ocular integrity. As recent data suggested that intrinsic choroidal neurons (ICN), an intrinsic choroidal autonomic control, may regulate choroidal thickening via release of the vasodilative vasoactive intestinal peptide (VIP), it was the aim of the study to investigate the level of choroidal VIP (VIP Autonomic control of the eye is mediated by a complex neuronal meshwork of sympathetic  and paraICN were described in 1859 for the first time . These nchor) dependent on different levels of ambient pressure in an in vitro avian model.IOP regulation is complex and still under investigation. The level of IOP is the steady state of the production in the nonpigmented ciliary body and outflow of the aqueous humor  . As (I) Gallus domesticus, type Ross, aged 6–8 weeks) were enucleated after slaughtering, which was performed for commercial purposes at a local farm. Forty eyes of 20 chickens  and (2) exposed to a pressure of twice the upper range of a regulated human IOP . Considering a time-dependent, yet not a circadian, effect, experiments with choroidal whole mounts were performed for 24 h (n = 10) and 72 h (n = 10), respectively. Keeping a constant temperature of 37 °C, the experiments were performed within an incubator. After 24 h, the culture medium was replaced. Considering inter-individual differences in tissue compositions, the choroidal whole mounts of the left eye were assigned to the pressure group and that of the right eye to the control group. The experiments were done subdividing the choroidal whole mounts into two groups: (1) exposed to ambient pressure (g) for 10 min (4 °C), and the supernatant was frozen immediately at −80 °C. VIP concentrations in the supernatant were analyzed using an enzyme-linked immunosorbent assay, namely the Chicken VIP Peptide ELISA Kit  according to the manufacturer’s protocol. The total protein concentration was measured by the Micro BCA Protein Assay . The VIP and total protein levels were measured using the MULTISCAN SPECTRUM and Skanlt software V 2.2 .After the incubation, the choroidal whole mounts were homogenized by the Precellys 24 homogenizer and lysing kit  in PBS with 3 cycles of 2 × 30 s at 5000 rpm. The choroidal homogenates were centrifuged at 14,000 rpm .Normal Gaussian distribution was tested using the Kolmogorov–Smirnov test. Group comparisons were performed using an unpaired two-tailed The construction of the pressurization system was done within the scope of contract work at the Department of Process Machinery and Plant Engineering Friedrich-Alexander-University-Erlangen-Nürnberg (FAU). The pressurization system consists of four parts e. The chThe gas is released from its container through a two-step pressure reducer. Before entering the chamber, the gas passes through a sterile filter, the first MFC vent (mass flow control) and a water tank. Then, the humidified and warmed gas enters the chamber. Immediately after the chamber, the gas passes a second MFC vent. The outflow of the second MFC vent is controlled by the computer. Through this outflow control, the pressure of 40 mm Hg is maintained consistently over an extended period. To ensure that the fluctuations in pressure are at a bare minimum, a computer program, which supervised the experiment, recorded the pressure in the system every minute. If a deviation of 1 mm Hg over a period longer than one minute was recorded, this section of the experiment was repeated. The pressure chamber is placed in an incubator to maintain a constant temperature of 37 °C.chor concentration was significantly increased at 40 mm Hg compared to the ambient pressure  compared to the ambient pressure . In addition, the mean VIPchor concentration was significantly increased after 72 h of pressure incubation at 40 mmHg  compared to the ambient pressure . The VIP increase was 1.37-fold (after 24 h) and 1.54-fold (after 72 h) at 40 mm Hg compared to the ambient pressure (chor concentration (72 h) was not significantly different compared to the VIPchor level (24 h) in the presence of 40 mm Hg (p > 0.05).The subgroup analysis yielded a significantly increased mean VIPpressure . The VIPIntraocular pressure is known to fluctuate over a 24-h period ,34,41. Achor concentration compared to the ambient pressure (1.37-fold). This increase of the mean VIPchor concentration lasted over the whole experimental observation period of 72 h compared to the ambient pressure (1.54-fold). Considering VIP as a potent vasodilator, consecutively increasing the choroidal blood flow ,46,47, tA multitude of laboratory devices have been developed for the treatment of cells and different human and animal tissues with increased ambient pressure in order to investigate their response to hypertensive conditions . CommercCarina moschata. This experimental study provided the first evidence of similar numbers of ICN in avian choroids compared to humans. Chicken models have already been used in a variety of different ophthalmological research topics, such as corneas disease, retinopathies, ophthalmological tumors, or glaucoma ,52. EspeSubsequent studies yielded similar amounts of ICN in different avian models, yet not in rats, mice, or rabbits ,11,14,20First described by Müller in 1959 , ICN conVIP is of special interest, as it was observed in the PPG and the ICN, providing a special form of intrinsic and extrinsic regulation . VIP, fiOverall, VIP is known to be a potent neurotransmitter further involved in the regulation of circadian rhythms , hormoneFocusing on the function of VIP within the choroid, smooth muscle relaxation and vasodilation are characteristics predisposing a regulatory function within the choroidal blood flow ,14,15. VConsidering these different aspects and a correlation between the blood flow and IOP , we assuClinical studies offer that choroidal thickening might compensate (passive) or even influence (active) IOP ,88,89,90The present study is not without limitations. The present experimental set-up was performed as an in vitro experiment in a chicken model. Thus, we used atmospheric pressure (as correlated for IOP) and an animal model for the analysis of VIP in ICN research. This set-up does not claim to represent the complex dynamic physiological conditions  within an in vivo chicken or even human eye. Further studies are necessary to investigate the clinical implications of VIP in regulating IOP and choroidal thickness.In the present study, we observed an increase in the total choroidal VIP level, representing the intracellular VIP content, in the presence of an increased ambient pressure. Thus, we assume that VIP is retained within the neurons, decreasing both vasodilation and, consequently, the choroid thickness. This finding might be a passive or even active function of ICN in the regulation of choroidal thickness, ocular integrity and IOP.


Fluorescence-guided surgery (FGS) is used in many pediatric subspecialties but there are currently no standard guidelines or outcome data. We aimed to assess the current status of FGS in pediatrics using the Idea, Development, Exploration, Assessment, and Long-term study (IDEAL) framework. Clinical papers on FGS in children published from January 2000 to December 2022 were systematically reviewed. The stage of research development was measured considering seven fields of application: biliary tree imaging, vascular perfusion for gastrointestinal procedures, lymphatic flow imaging, tumor resection, urogenital surgery, plastic surgery, and miscellaneous procedures. Fifty-nine articles were selected. For each field of application, the overall IDEAL stage was determined to be 2a for biliary tree imaging , 1 for vascular perfusion for gastrointestinal procedures , 1 for lymphatic flow imaging , 2a for tumor resection , 2a for urogenital surgery , and 1-2a for plastic surgery . One report did not belong to any categories. FGS in children is still in an early phase of adoption and development. We recommend using the IDEAL framework as a guide and suggest developing multicenter studies to define the standard guidelines, effectiveness, and outcomes. Fluorescence imaging is an emerging intraoperative technique used in a broad range of surgical applications .Recently there has been an increasing use of fluorescence-guided surgery (FGS) in several fields of pediatrics. However, as a surgical innovation, there is still a lack of guidelines for the use of FGS in children.The assessment of innovative procedures is always a challenging process as the evolution of the technique itself, the surgeons’ learning curves, and the risk of subjective procedural quality are factors that need to be considered. The identification of these difficulties has led to the creation of the Idea, Development, Exploration, Assessment, and Long-term follow-up (IDEAL) framework that describes five stages of assessment. Each of these stages is based on the types of articles already published in which the technique was used  1,2,3].,2,3.1,2,In 2021, in response to the widening use of FGS, Ishizawa et al. used the IDEAL framework to identify the state of research for the use of fluorescence imaging across surgical fields and applications in adults [We decided to perform a systematic review of the current applications of FGS in pediatrics using the IDEAL framework, to assess its current status and suggest further developments in this field.http://www.prisma-statement.org/ accessed on 20 September 2022).This systematic review was made according to the Preferred Reporting Items for Systematic Reviews and Metanalysis Statement  affected by thoracic, abdominal, and urogenital diseases, malformations, or tumors. Preclinical studies, papers not reporting own clinical experience, and studies employing fluorescent dyes for diagnostic reasons only and/or describing neurosurgical, vascular, ophthalmological, otolaryngological, and maxillofacial surgical procedures were excluded.The selected articles were classified according to their field of application in seven categories: biliary tree imaging, vascular perfusion for gastrointestinal (GI) procedures, lymphatic flow imaging, tumor resection, urogenital surgery, plastic surgery, and miscellaneous procedures in case the reports did not belong to any of the previous categories.https://www.ideal-collaboration.net/the-ideal-framework accessed on 20 September 2022).Each article selected was assessed by using the IDEAL framework, as previously described , they were preclinical studies (n = 41), review articles (n = 8), articles describing otolaryngology (n = 1), neurosurgery procedures (n = 2), or the topic was not pertinent (n = 8). Overall, 59 studies were included in the systematic review, reporting on 558 patients in total.As shown in the PRISMA flow diagram , 1228 paOut of the 59 studies included in the final analysis, 7 (12%) articles focused on the real-time imaging of the biliary tree only, 8 (14%) on the vascular perfusion for GI procedures only, 12 (20%) on lymphatic flow only, 18 (30%) on tumor resections only, 6 (10%) on urogenital surgery only, and 4 (7%) on plastic surgery only. Three (5%) papers described several indications in the same case series, including urogenital surgery, biliary tree imaging, and tumor resection. One case report (2%) did not belong to any of these previous groups as the dye was administered via the mouth to assess the patency of the duodenum in a neonate with a duodenal web.Three dyes were used in these studies: indocyanine green (ICG) was the most used dye (58 out of 59 studies), whereas fluorescein sodium and methylene blue were used in only one study each.Focusing on imaging devices, the fluorescence signal was detected by different optical systems marketed by: Karl Storz in 14/59 (23%), Stryker in 11/59 (18%), Hamamatsu Photonics in 11/59 (18%), Firefly/Intuitive in 4/4 applications with robotic surgery, Medtronic in 5/59 (8%), Zeiss in 1/59 (1.7%), Sony in 1/59 (1.7%), Mizuho Medical Co. in 1/59 (1.7%), Panasonic AVC Networks Company in 1/59 (1.7%), and Zhuhai Dipu Medical Technology Co. in 1/59 (1.7%). Twelve articles (20%) did not disclose the imaging system employed.Our search yielded 10 eligible studies focusing on biliary tree imaging. Out of these studies, 2 were case reports, 7 were retrospective studies, and 1 was a prospective study. In total, 102 cases were published in this field with the highest number of patients in any study being 31. n = 86) [n = 15) [Seven papers described the use of ICG for guiding pediatric cholecystectomy n = 8 [6,7,8,9n = 86) . Two stu[n = 15) ,12. One [n = 15) . IntraveA dose of 0.4 mg/kg was the most commonly used to identify the biliary structures for laparoscopic cholecystectomies (range from 0.1 to 0.5 mg/kg) ,10. The Considering the application of fluorescence imaging during Kasai procedures, there is no consensus about the dose administered: 0.5 mg/kg of ICG was injected by Yanagi et al. and 0.1 mg/kg of ICG was administered by Hirayama et al. In both cases, ICG was intravenously injected 24 h before surgery ,12, provEven though FGS applied to biliary tree surgery is safe and effective, the lack of multicenter studies, prospective cohort studies, and randomized controlled trials (RCTs) suggest that the level of IDEAL is only Stage 2a.Certainly, prospective cohort studies are now needed to assess the advantages of fluorescence in biliary tree imaging compared to the standard technique.Our search yielded 8 articles regarding vascular perfusion applied for GI procedures. Six of them were case reports, one was a retrospective study, and one was a prospective study. In total, 28 cases were reported, with 13 being the maximum number of patients reported in any study. .A total of 5 articles described fluorescent angiography to assess bowel perfusion: 8 bowel resections and stoma creations for necrotizing enterocolitis , 1 PSARPn = 1), PSARVUP (n = 9), and pull-through (n = 4) [ICG was the dye employed in 7 out of 8 studies: it was injected intravenously (iv) intraoperatively in all 7 cases. Different doses were administered for each application. An amount of 0.2 mg/kg of ICG was injected during PSARP ( (n = 4) ,16. The An amount of 25 mg of ICG diluted with distilled water to a concentration of 2.5 mg/mL was injected into a peripheral vein just before surgery in a 15-year-old boy who developed delayed intestinal stricture after undergoing massive intestinal resection due to a small intestinal volvulus . No siden = 2) in patients with ARM [An amount of 0.3 mg/kg of ICG was administered during colostomy closure . The fluorescence signal was detected in 100% of cases, in particular, the fluorescein allowed the recognition of ischemic bowel segments in three patients which were not visible to the naked eye [Lastly, the only study that did not involve the use of ICG was that of Numanoglu et al. who employed fluorescein sodium (14 mg/kg injected during surgery) to detect bowel perfusion in patients affected by necrotizing enterocolitis  and lymphedema: 3 authors reported 14 cases of lymphedema where ICG was employed to guide lymphovenous anastomoses ,29,30 anKato et al.  showed aShirota et al.  reportedIndubitably, fluorescence lymphography can potentially be a precise tool for the identification of a chylous leakage site and lymphatic vessels; however, recommendations about the dose of dye, timing, and sites of injection need to be defined to demonstrate the benefits of fluorescent lymphography in pediatric surgery. The nature of the current studies in this field suggest that the evidence base is still at IDEAL Stage 1.Our search yielded 20 eligible studies focusing on fluorescence imaging during benign and malignant tumor resections. Out of these 20 articles, 8 were case reports, 11 were retrospective studies, and 1 was a multicenter study involving 2 tertiary lever referral centers . Each stFGS was applied to identify a broad range of pediatric tumors, to visualize not only the primary tumor, the resection margins, and metastatic disease, but also key vasculature and lymphatic drainage.In total, 10 out of 20 articles explored the use of fluorescence for liver resection and metastasectomies in cases of hepatoblastoma (HB). Overall, 136 fluorescence-guided procedures for HB have been published ,42,43,44As for other tumors, 3 articles were published about fluorescence applications on Wilms tumor resection. Overall, 22 procedures were described ,45,46. IA case report also showed the benefits of ICG injection into the normal renal parenchyma near the tumor in order to identify and sample lymph nodes after nephroureterectomy .Additionally, in a multicenter study, two tertiary-level referral centers independently began ICG fluorescence-guided nodal mapping: in one center they performed mapping with ipsilateral intra-parenchymal injection of ICG during minimally invasive tumor nephrectomy and in the other center they conducted mapping with peri–hilar injection during open tumor nephrectomy. Lymphatic mapping was successful in 88% of patients .Moreover, Esposito et al. ,10 showeAdditionally, several papers explored the application of fluorescence in non-neoplastic lesions: one case of lung lesion resection entailed granulomatous inflammation with focal necrosis , one casTo conclude, as the largest published study in this field , by usinDespite the variety of the published literature in this field and the consensus reached on the time and dose of ICG injection, the lack of larger multicenter studies and prospective clinical trials suggests that the evidence base is still at IDEAL Stage 2a.Our search yielded 9 articles focusing on FGS employed during urogenital procedures. All 9 articles were retrospective studies, involving less than 100 patients each. In total, 197 cases were reported, the maximum number of procedures performed in any study being 57. .n = 137) [n = 36) [n = 11) [n = 10) [n = 3) [The main applications were the detection of blood and lymphatic vessels during varicocelectomies (n = 137) ,10,51,52[n = 36) ,54, neph[n = 11) ,9,10,52,[n = 10) , and the [n = 3) .During laparoscopic varicocelectomies, according to Esposito et al., 2 mL of ICG solution (25 mg of ICG with 8ml of sterile water) was intraoperatively injected into the testis to detect and spare the lymphatics avoiding the risk of postoperative hydrocele. Under near-infrared light, the lymphatics were identified, appearing fluorescent. No adverse reactions were reported ,51,52. IDuring heminephrectomies, according to Esposito et al., ICG was injected into a peripheral vein at a dosage of 0.3 to 0.5 mg/kg just after the dissection of Gerota’s fascia. No adverse effects were reported. According to Herz et al., 0.5–1.0 mL of ICG solution (2.5 mg/mL), administered 30–60 s prior to surgery also showed good results and no side effects. Herz et al. described the advantages of arterial mapping during pediatric heminephrectomies attesting that ICG imaging helped detect the correct area of excision and in one case helped avoid a potential critical complication by identifying an artery to the healthy moiety . In 2021Considering nephrectomies, Esposito et al. ,52 showeDuring renal cyst deroofing, ICG (dosage 0.3 mg/mL/kg) was injected intraoperatively and intravenously just after the division of the Gerota’s fascia. In just one minute the fluorescence allowed the “non-fluorescent” area corresponding to the avascular cyst to be clearly distinguished from the “fluorescent green” area corresponding to the perfused renal parenchyma. No complications or side effects occurred ,52,55.Finally, Carty et al.  showed tOverall, the modality, timing, and dosage of ICG administration seem to be standardized for each procedure in this category; however, the main limitation is that only single centers’ experiences have been reported. Multicenter studies and prospective clinical trials need to be performed to demonstrate the clear advantages of FGS for such indications. The evidence base for this field is still at IDEAL Stage 2a.Our search yielded four articles regarding fluorescent imaging applications in plastic surgery. Two of them were case reports and two were retrospective studies. In total, 26 cases were reported with the maximum number of patients reported in any study being 13. .The main applications were the detection of flap perfusion, the assessment of vessels patency during revascularization procedures, and the visualization of vessels’ course and flow.In this field, intraoperative ICG angiography has the potential to be an objective method to assess intraoperative flap perfusion, thus enabling the surgeon to take additional measures to avoid any ischemic problems.Martins et al.  showed hFluorescence imaging was also applied during percutaneous sclerotherapy of venous malformations, especially in the face and hands, allowing non-invasive assessment of the real-time distribution of sclerosant .Only a few studies have been published on this technique, therefore, more cases and multicenter studies are needed to demonstrate the benefits of ICG fluorescence imaging in plastic surgery. The nature of the current studies for this field places the FGS in IDEAL Stage 1/2a.Only one case report could not be assigned to any of the previously described main groups: it reported a case of a 13-day-old patient who underwent ICG administration into the stomach during a laparoscopic duodenal web excision . Table . Just afDetermining the exact location of a duodenal web can be challenging, especially during minimally invasive surgery or if the web has a wind-sock shape. In this case report, fluorescence allowed the surgeon to identify the exact location of the web and guided the location of the proximal and distal duodenotomies. No intraoperative complications or side effects occurred.This application could be expanded for each intestinal atresia to assess the patency of the bowel and exclude multiple areas of atresia.A limitation of this study was that as this procedure was only used for one patient, more research is needed to fully understand the benefits.This systematic review is the first study publishing data about the development status of FGS in pediatric surgery using the IDEAL framework. Our aim was not only to identify the state of research of FGS in pediatrics but also to suggest further studies to be performed in the future, to mature this novel surgical technique into a standardized and effective technique.Since the last systematic review , the numThe most important limit is the nature of the studies published, which are mostly small case series and single-center studies. Moreover, for some applications, there is an extraordinary heterogeneity across the studies: indications, ICG dose, and outcomes of FGS are extremely variable. A uniform consensus on the dose and timing of ICG injection is not reached even in similar indications.Besides this, the level of evidence varies across the different surgical fields. For example, fluorescence imaging appears mostly beneficial for delineating hepatobiliary structures and vascular perfusion in urogenital surgery and tumor resection. Indeed, our IDEAL framework analysis indicates that the evidence base is in Stage 2a (Development) for these three fields, as the technique is considered safe and has been standardized. Prospective and collaborative cohort studies are now appropriate to finalize the consensus on methods and outcome measures for a future RCT.In the oncological field, FGS has been developing as a cutting-edge improvement in which precise margin definitions have the potential to lead to more radical tumor resections and better outcomes. The recent increase in publications in this field makes the tumor resection category almost ready to proceed to IDEAL stage 2b. Prospective studies to assess the effectiveness of the new technique against current standards will be pivotal to reaching this next stage.To reach the next IDEAL stage, it is not only important to accumulate more cases, but it is also important to achieve a more uniform protocol for establishing the optimal timing and dosage for ICG injection and for a more defined selection of patients with regard to tumor depth from the surface. In fact, as Cho et al. stated, tumors at a depth of <10 mm in the liver/lung surface were all visible under the ICG camera but one of the clear current limitations for its clinical use is related to the limited tissue penetration (up to 10 mm) of near-infrared light ,60.On the other hand, some fields of pediatric surgery are still in the early phase of adoption. For example, fluorescence imaging for vascular perfusion in GI procedures and lymphatic flow imaging are at an IDEAL stage 1. The reason for this is that most articles report single-center experiences for a small number of patients involved. To make more broad conclusions about the effectiveness of FGS, more studies need to be published to assess its effectiveness in these fields of pediatrics.Although the literature supports the useful role of ICG imaging in the evaluation of flaps perfusion, there seems to be less interest in employing fluorescence imaging in plastic surgery considering that only four reports emerged from our research. An explanation could be that, despite the clear benefits of fluorescence imaging, equipment and ICG access and time constraints in the operating theatre may limit its daily adoption.Despite the recent advances in FGS, further developments are still feasible. In this regard, in the field of pediatric cancer surgery, preclinical studies are investigating new technologies to maximize the fluorescent signal from the tumor and to minimize the background noise. NIR-II (wavelength: 1000–2000 nm) fluorophores and tumor-targeted fluorescent probes seem to be promising tools for achieving higher contrast, increased sensitivity, and improved tissue penetration depths ,64.Finally, complementary analytical tools, such as artificial intelligence (AI), will be integrated into an FGS system to enhance the decision-making capability of fluorescence optical imaging. In this aspect, one of the most revolutionizing breakthroughs was the introduction of the Internet of things (IoT) concept within surgical practice. Internet-based image-guided surgery has a lot to offer by incorporating data from different sources and making them available to the surgeon in real-time, for example by allowing the surgeon to visualize preoperative and intraoperative images of the anatomical structures of interest overlaid in real-time .FGS applied to biliary tree imaging, urogenital surgery, and tumor resection is safe and feasible in pediatric surgery, providing real-time information for surgical decision-making. Multicenter, prospective clinical studies, and RCT are required to standardize the use of FGS in these fields of application.Lymphatic flow evaluation, vascular assessment for GI procedures, and plastic surgery are other promising applications of fluorescent optical imaging in children, but more cases need to be published to evaluate their effectiveness in pediatrics.


The groups did not differ significantly in clinical presentation, imaging, treatment, or ophthalmic findings. Our findings provide preliminary evidence that CCL2 may be involved in the pathogenesis of PTC and may serve a potential target for therapy in PTC.Pseudotumor cerebri (PTC) is a disorder characterized by increased intracranial pressure in the absence of a structural lesion or other identifiable cause. Cytokines, which are involved in the regulation of immune responses and inflammation, have been implicated in the pathogenesis of PTC. In a prospective, cross-sectional study at three centers in Israel, we analyzed cerebrospinal fluid (CSF) samples from 60 children aged 0.5–18 years, including 43 children with a definitive diagnosis of PTC and a control group of 17 children. Levels of IL-4, IL-10, IL-17, CCL2, CCL7, CCL8, CCL13, BDNF, and IFN-γ were measured using ELISA kits. Levels of CCL2 were significantly higher in the PTC group compared to the control group ( Pseudotumor cerebri (PTC) is a syndrome consisting of elevated intracranial pressure (250 mm water in adults and 280 mm water in sedated children), a chemically and hematologically normal cerebrospinal fluid (CSF) composition, and papilledema with occasional abducens nerve paresis . PTC is A prospective, cross-sectional study was conducted in the pediatric departments of three medical centers in Israel: Bnei Zion, Schneider Children’s, and Hillel Yaffe medical centers. Participants were children examined at the centers from 1 January 2020 to 30 December 2022. Children with pseudotumor cerebri, aged 0.5–18 years, were assigned to the study group (CSF was collected before treatment). Children whose clinical symptoms were consistent with increased intracranial pressure and who underwent lumbar puncture (LP), but where PTC was ruled out, served as a control group. An ophthalmologist and a pediatric neurologist conducted a thorough evaluation of all the children. The collected data included a wide range of information, such as clinical symptoms, imaging outcomes, treatment details, ophthalmic examination, and an analysis of the cerebrospinal fluid (CSF). Each hospital obtained its own ethical approval, and the caregivers of all participants provided written informed consent. The local Helsinki committee approved the study.The CSF was investigated for the following cytokines: IL-4, IL-10, IL-17, CCL2, CCL7, CCL8, CCL13, BDNF, and IFN-γ. The samples were stored at a temperature of −80 degrees Celsius and analyzed at the end of the study. Samples were analyzed using the Luminex xMAP multiplex cytokine assay testing kit—a sandwich enzyme-linked immunosorbent assay (ELISA) kit.p < 0.05. Statistical analyses were performed using SPSS software version 21 .Patients with and without PTC were compared via the chi-square test or Fisher’s exact test, where appropriate, for the categorical data and via independent t-tests for the continuous variables. Odds ratios and their 95% confidence intervals were computed. Significance was considered to be CSF samples from 60 children were collected. Forty three were diagnosed with pseudotumor cerebri, and the other seventeen children in the control group. The distinctive features of the two groups are outlined in The Luminex xMAP panel was run for IL-4, IL-10, IL-17, CCL2, CCL7, CCL8, CCL13, BDNF, and IFN-γ. Only CCL2 was detected in the CSF at significant levels,  and it wWe found significantly higher CCL2 levels in the CSF of the pediatric PTC group compared to the control group. This finding was consistent with Dhungana et al.’s  finding CCL2 is a chemokine that is involved in the recruitment of monocytes to sites of inflammation. CCL2 activates β1 integrins and regulates the adhesion and chemotaxis of macrophages . FibroblEdwards et al. , in a smWe also found no differences in levels of brain-derived neurotrophic factor (BDNF) and IFN-γ between pediatric patients with PTC and the control group. BDNF plays a crucial role in the regulation of neuronal survival, structure, and function, particularly in brain regions responsible for intricate cognitive processes. Studies indicate that disruptions in the signaling pathway of BDNF may contribute to the cognitive deterioration seen in specific neuropsychiatric and inflammatory conditions . InterfeThe differences between our findings and those of previous studies may be due to differences in patient populations—specifically, the fact that we looked at pediatric patients with PTC, while all other studies examined adults. There are some known differences between adult and pediatric PTC patients, mainly in the greater prevalence of the male sex and not being obese in young children .The underlying causes of PTC remain undisclosed . While tOur study, while larger than previous studies , was stOur study provides preliminary evidence that CCL2 may be involved in the pathogenesis of PTC. Additional research is required to validate these findings and explore the therapeutic potential of cytokines as targets for PTC treatment.


Shiftwork sleep disorder is one of the most common health-related effects of Shiftwork, particularly among healthcare workers. It is a chronic condition that is directly related to a person’s work schedule. In Ethiopia, although a mental health strategy is in place, little attention is given to studies that focus on shiftwork sleep disorders among nurses. This study aimed to determine the magnitude of shiftwork sleep disorder and associated factors among nurses working at public hospitals in Harari Regional State and the Dire Dawa Administration.Institutional based cross-sectional study was conducted from June 1–30, 2021 among 392 nurses selected by a simple random sampling technique. A structured interviewer-guided self-administered questionnaire was used for data collection. The International Classification of Sleep Disorders 3rd edition (ICSD-3), Bargen Insomnia Scale (BIS) and Epworth Sleepiness Scale were used to assess shift-work sleep disorder. The data were entered into EpiData and exported to SPSS for analysis. Bivariable logistic regression was used to see the association between the outcome and the explanatory variables. Bivariate and Multivariate analyses were performed, and AOR with 95% CI was used to measure the strength of the association. Those variables with a p-values of < 0.05 were considered as statistically significant.In this study, the magnitude of shiftwork sleep disorder among nurses was 30.4% (95% CI: 25.4–34.5). Being female , working an average number of nights > 11 per month in the last 12 months , and khat use in the last 12 months  were significantly associated with the shiftwork sleep disorder.The study revealed that about one-third of the nurses had a shiftwork sleep disorder implying a high burden of the problem among nurses in the study setting, which endangers nurses, patients, and the healthcare system. Being female, working an average number of nights > 11 per month in the last 12 months, and khat use showed statistically significantly associated with the shiftwork sleep disorder. Early detection of shiftwork sleep disorder, having a policy on khat use and considering rest/recovery while scheduling work time should be addressed to prevent shiftwork sleep disorder. Shiftwork refers to a broad range of non-standard work schedules, ranging from occasional on-call overnight duty to rotating timetables, to stable, permanent night work, and programs demanding an early awakening from nocturnal sleep . It inclStudies done in developed and developing countries showed that a significant number of nurses suffer from shiftwork sleep disorders , 9 ResulIn Asian countries, cross-sectional studies conducted among nurses revealed that the prevalence of SWSD was 24.4% in Japan , 32.2% i% of them had signs of insomnia, and of all the participants, 78.5% were sleepy, 16.5% were very sleepy, and 5% were severely sleepy [The findings of a cross-sectional study conducted on nurses working in hospitals in the south of Iran showed that 56y sleepy . Studiesy sleepy , 20. A cy sleepy .Similarly, a study in Ethiopia found that about a quarter 25.6%) of the nurses experienced SWSD . Differe.6% of thThe shift-work sleep disorder can be associated with decreased attention and deficit in cognitive functioning which in turn decreased performance that may contribute to a higher propensity for mistakes/near misses/accidents. It is also associated with an increased prevalence of medical disorders such as cancer, decreased quality of life, and increased risk of mood disorders (anxiety and depression) –33. StudNurses use or abuse different types of substances, like non-prescribed medications, alcohol, khat or cigarette to alleviate the stress associated with shift work , 41. ShiIn Ethiopia, there are no policies designed to prevent shiftwork-related sleep disorders. There is a paucity of information regarding the extent of SWSD among nurses, particularly in Eastern Ethiopia. This study tried to explore the association of SWSD with depression, anxiety, and stress that were not addressed in the previous studies done in the country. Therefore, the findings from this study could generate local evidence that would inform policymakers & local planners to design cost-effective strategies that reduce adverse health outcomes of SWSD among nurses in Ethiopia.An institution-based cross-sectional study was conducted from June 1–30, 2021 at four public hospitals in Harari Regional State and Dire Dawa Administration, Eastern Ethiopia. Harar is the capital city of the Harari Regional State. In the city, there were two public hospitals, Hiwot Fana Specialized University Hospital (HFSUH) and Jugal General Hospital (JGH). The health management information system of the hospitals reported that there were 256 nurses in HFSUH and 103 nurses in JGH. In Dire Dawa Administration, there were two public hospitals namely, Dilchora Referral Hospital (DRH) and Sabian General Hospital (SGH). According to the hospitals’ health management information system report, there were 163 nurses in DRH and 93 nurses in SGH.All nurses who were working in the four public hospitals in Harari Regional State and Dire Dawa Administration. Those who had work experience of greater than 6 months were included, whereas all nurses with diagnoses of any type of sleep disorder and nurses working in a standard non-shift day program were excluded from the study. The sample size was calculated using the single population proportion formula for the first objective. Accordingly, the estimated sample size was 323 including the 10% non-response rate. The sample size was also calculated for the factors associated with SWSD, and was determined by double population proportion formula using EpiInfo software, considering the following assumptions: 95% confidence level, 80% power, 1:1ratios, exposed vs. non-exposed were 35.3%, and 21.4%, AOR: 3.1; from a previous study done in Addis Ababa  with 10%Data were collected by interviewer-guided self-administered questionnaires prepared in the English language. Data were collected by eight BSc and four diploma nurses and supervised by four BSc nurses. A two-day training was given to the data collectors and the supervisors on the objective of the study, data collection procedures and ethical aspects of the entire data collection process. The questionnaire was pretested among 10% of the total sample size before the actual data collection at Bisidimo General Hospital, Eastern Hararghe Zone, Oromiya Reginal State.The questionnaire comprised, socio-demographic information, shiftwork-related characteristics, substance and sleep aid medication use, and the existence of clinical and mental health-related characteristics such as depression, anxiety, and stress symptoms. A shiftwork sleep disorder was assessed by using the International Classification of Sleep Disorders-third (ICSD-3), which helps to determine sleepiness and insomnia . The ICS< 0.25 in the bivariable logistic regression analysis were taken to the multivariable logistic regression to identify factors associated with SWSD and a significant statistical association was declared at a p-value of < 0.05. Adjusted odds ratios with corresponding 95% confidence intervals were used to show the strength of the association. The model fitness was checked by the Hosmer-Lemeshow model fitness test and its p-value was 0.624. The independent variables did not exhibit collinearity or multi-collinearity.Before data entry, the questionnaires were checked for completeness, consistency and clarity. Coded data were entered using EpiData v-3.1 software  and expoOut of 392 randomly selected nurses, 369 nurses participated in this study, yielding a response rate of 94%. The mean age of the study participants was 31.25 (SD ± 6.97) years and ranges from 20 to 60 years. More than half  of them were male and about 197 (53.7%) were married. Most of the study participants  were BSc degree holders, 157 (42.5%) had work experience of fewer than 5 years and close to one-third  worked in a medical-surgical unit  were working in a two-Shiftwork program. Two hundred twenty-four (60.7%) of them were working 8–11 night shifts per month and about two-thirds,  of nurses took a nap during their night shift. In this study, 37(10%) nurses reported that they had used prescribed sleep medication and 19(5.1%) reported they have used non-prescribed injectable sleep medications in the last 12 months  reported having a diagnosed chronic illness, and of these, 23 nurses (6.2%) had diabetes mellitus. Regarding mental health, 16 (4.3%) reported having a history of diagnosed mental illness in the past, while 13 (3.5%) had a family history of mental illness. Similarly, depression, anxiety, and stress were present in 100 (27.1%), 109 (29.5%), and 61 (16.5%) of the study participants, respectively.  had ever used Khat in their lifetime, while 154(41.7%) had used Khat in the last 12 months, of the total, 61 (16.5%) had ever used tobacco products, and 300 (81.3%) had used caffeine in the previous 12 months.  (95% CI: 25.4–34.5) of the nurses had shiftwork sleep disorder. In this study, 132 (35.8%) full filled the criteria of ICSD-3 , 104(28.2%) had excessive daytime sleepiness and 138(37.4%) of the nurses had insomnia . The odds of SWSD were 2.3 times higher among nurses who worked more than 11 nights per month in the last 12 months on average than those nurses who worked less than 11 nights per month in the last 12 months on average . The possibility of SWSD was increased by nearly about five folds among the nurses who used khat in the last 12 months compared to the nurses who did not use khat in the last 12 months  . Being female, working more than 11-night shifts on average per month in the last 12 months and nurses who consumed khat in the last 12 months were significantly associated with SWSD.According to this study, nearly one in every three nurses suffered from a shiftwork sleep disorder that adversely affects the health of nurses, and patient’s safety, satisfaction, and rendered care quality. Empirical evidence indicated that circadian rhythm sleep disorders, insomnia, and excessive sleepiness are widespread in night-shift workers that are associated with substantial morbidity including accidents and absenteeism . The resIn the Ghanaian study , shiftwoBeing female appeared to be associated significantly with SWSD, which was in line with the systematic review conducted in 2011 and a coIn the current study, working more than 11-night shifts per month on average in the last 12 months showed an association with SWSD; this finding was consistent with the study done in Addis Ababa, Ethiopia  and SoutConsuming khat in the last 12 months was positively associated with SWSD; this association might happen due to Cathinone . Using khat reduces dopamine re-uptake and activates dopaminergic pathways involved in the regulation of sleep. After the khat session, the user usually experiences a depressed mood, irritability, anorexia, and difficulty sleeping  and thisThis study included nurses in different types of hospitals like teaching hospitals, specialized hospitals, and general hospitals, and it was a multicenter study which generates vital evidence. The study used the standard and validated tools which facilitated approximating the burden of SWSD.Though several efforts were made, this study had its limitations. Those nurses diagnosed with SWSD could also be diagnosed with some other forms of sleep disorders. Yet, some other nurses might have been transferred to daily shiftwork schedules Asking nurses who were expected to have knowledge about the adverse effects of substance use might introduce the risk of social desirability bias. There was also the risk of recall bias, and no measure was taken to minimize it. The nature of a cross-sectional study design was another major limitation since it cannot show temporal relationships between the dependent and the independent variables.About one-third of the nurses working at public hospitals in Harari Reginal State and Dire Dawa Administration, Eastern Ethiopia had SWSD. Being female, working an average number of nights > 11 per month in the last 12 months, and khat use showed a positive statistically significant association with the shiftwork sleep disorder. The prevention of shiftwork sleep disorder should focus on early detection, having a policy on khat use, and taking rest/recovery into account when scheduling work time. Moreover, longitudinal, and controlled trial studies will be necessary to highlight the effect of SWSD on the well-being of the nurses, patients’ safety, and the health care system.