The close relations between dogs (Canis lupus familiaris) and humans lay a foundation for cross species transmissions of viruses. The co-existence of multiplex viruses in the host accelerate viral variations. For effective prediction and prevention of potential epidemic or even pandemic, the metagenomics method was used to investigate the gut virome status of 45 domestic healthy dogs which have extensive contact with human beings. A total of 248.6 GB data  were generated and 325, 339 contigs, which were best matched with viral genes, were assembled from 46, 832, 838 reads. In the aggregate, 9,834 contigs (3.02%) were confirmed for viruses. The top 30 contigs with the most reads abundance were mapped to DNA virus families Circoviridae, Parvoviridae and Herpesviridae; and RNA virus families Astroviridae, Coronaviridae and Picornaviridae, respectively. Numerous sequences were assigned to animal virus families of Astroviridae, Coronaviridae, Circoviridae, etc.; and phage families of Microviridae, Siphoviridae, Ackermannviridae, Podoviridae, Myoviridae and the unclassified phages. Further, several sequences were homologous with the insect and plant viruses, which reflects the diet and habitation of dogs. Significantly, canine coronavirus was uniquely identified in all the samples with high abundance, and the phylogenetic analysis therefore showed close relationship with the human coronavirus strain 229E and NL63, indicating the potential risk of canine coronavirus to infect humans by obtaining the ability of cross-species transmission. This study emphasizes the high detection frequency of virus harbored in the enteric tract of healthy contacted animal, and expands the knowledge of the viral diversity and the spectrum for further disease-association studies, which is meaningful for elucidating the epidemiological and biological role of companion animals in public health. Dogs (Canis lupus familiaris), one of the most popular companion animals, have extensive interactions with humans through sharing spaces, occasionally biting and scratching, playing, and producing fecal waste. Besides, dogs also frequently hunt or scavenge wildlife, increasing the potential transmission risk of zoonosis, as exemplified by rotavirus and rabies virus –3.Domestic dogs are the potential source of zoonosis for human during the direct contact with infected dogs or indirect contact via dog feces . The infThanks to the development and application of next generation sequencing (NGS) technology in viral metagenomics, it has been practical for large-scale detection of known and unknown viruses in the reservoir hosts , 20, incIn this research, metagenome was applied to obtain an unbiased measure of the viral diversity in the guts of domestic dogs. The fecal viruses in specimens from sheltered and pet dogs were characterized, suggesting a wide range of viral sequences related to plant, animal, insect, and phages. This viral genome information from the enteric tract of healthy domestic dogs presented a baseline for fecal virome and is a good reference for future identification of composition changes, which may indicate the potential risk for public health security.All animal experiments followed the recommendations in the Guide for the Care and Use of Laboratory Animals of the Ministry of Science and Technology of the People's Republic of China. The Animal Care and Use Committee of Shanghai Academy of Agricultural Science reviewed protocols, including operation details as well as approaches to ameliorate animal suffering and euthanasia.2, 50 mM Tris-HCl, 5mM MgCl2, pH 7.5) after three rounds of freezing-thawing. The samples were centrifuged at 4°C for 5 min at 1,000 ×g, 3,000 ×g, 5,000 ×g, 8,000 ×g, 10,000 ×g and 12,000 ×g separately to remove the precipitate. After precooling on ice for10 min, the cell fragments were removed by 0.22 μm ultrafiltration tube and the supernatant was transferred to the ultracentrifugation tube containing 28% (w/W) sucrose to centrifuge at 300,000 ×g for 2 h using HIMAC CP 100 wx ultracentrifuge . The precipitate was suspended in buffer solution  and shook for 60 min at 37°C to digest non-particle-protected nucleic acids, then stored at 4°C overnight.A total of 45 fecal specimens of domestic dogs were collected from five pet hospitals located in four urban districts , in which the communities have large populations more than 10,000. Aiming to better reflect the conventional status of gut virome in domestic dogs, the dogs were randomly selected with the criteria of being healthy and behaving normally, and the vaccination situation was recorded. The fecal specimen was placed in the sterile-tipped eppendorf tube and frozen at −80 °C within 4–8 h of collection. One g of the fecal specimen was washed with 10 volumes of precooled sterile SB buffer , while the equivalent SB buffer was used as a blank control. The viral RNA was reverse transcribed according to the specification of SuperScript III reverse transcriptase (Invitrogen) with random hexamer primer. Afterwords, SMARTer Ultra Low input RNA kit was used to synthesize double strand cDNA. The double-stranded DNA fragments comprising of 3′ or 5′ overhangs were generated and end-repaired followed by A-tail adapter ligation. The whole genome was amplified with Qiagen kit according to manufacturer's instructions. The viral nucleic acids were quantified by the NanoDrop spectrophotometer (Thermo Fisher Scientific) and 1.5% agarose electrophoresis.Following manufacturer's instructions, the Next® Ultra™DNA Library Prep Kit for Illumina® (New England Biolabs) was used to generate the sequencing libraries and add the index codes. The library quality was assessed by the Qubit® dsDNA HS Assay Kit (Life Technologies) and Agilent 4,200 system . High-throughput sequencing was conducted on an Illumina Novaseq 6,000 and 150 bp paired-end reads were generated by the Magigene Company . Eighteen libraries were then constructed .The raw sequencing reads were processed to acquire the clean data using Soapnuke (v2.0.5)  for furthttps://www.ncbi.nlm.nih.gov/sra/PRJNA734701) were firstly assembled from contigs and then aligned using CLUSTALW with the default settings  technique. Except for the current research, there were only two previous shotgun metagenomic studies similarly investigating the fecal virome of dogs with diarrhea , 43. ComThe bacteriophages were the most common viral contigs identified from human and other animals fecal virome, especially from the samples with diarrhea , 44–47. Among the viruses identified in this study, astrovirus was detected mainly in puppies with diarrhea and occasionally in healthy dogs in previous research –54. And To investigate the frequency of different viruses, the shared viruses of all the nine databases were analyzed. Significantly, Alphacoronavirus was identified in all the nine databases. Coronavirus is responsible for a variety of severe diseases including gastroenteritis and respiratory tract diseases. This virus has a wide range of hosts, such as horses, mice, rats, turkeys, chickens, swine, rabbits, cattle, dogs, cats and humans . InfectiThe viral metagenomic analyses are useful for the investigation of viral populations in the feces of healthy domestic dogs, which is significant in elucidating the epidemiological and biological role of companion animals in public health.The data presented in the study are deposited in the SRA database, accession number (PRJNA734701).The animal study was reviewed and approved by The Animal Care and Use Committee of Shanghai Academy of Agricultural Science. Written informed consent was obtained from the owners for the participation of their animals in this study.HL designed the research. YS, BL, JT, JC, and XS performed the research. YS analyzed data and wrote the paper. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The incidence of bovine respiratory disease (BRD) and other health issues was monitored, as well as the mortality rate. Blood samples were taken at d0 and d30 to evaluate the immune functionality and the inflammatory status. Growth performances, feces chemical composition, and carcass characteristics were recorded. The BRD occurrence tended to be reduced (p = 0.06) in the Treatment group. The BHV-1 antibody production after vaccination was significantly improved (p = 0.031), as well as the bactericidal activity (p = 0.0012) in the Treatment group. No differences were found in the inflammatory status parameters. The final weight (p = 0.006) and the average daily gain at d30 (p < 0.0001) were significantly improved by the treatment. No differences were found in terms of carcass characteristics, while the fecal content of NDF (p < 0.0001), ADF (p = 0.0003), and starch (p < 0.0001) were significantly reduced by the treatment. The result of the present study suggests that the nutraceutical mixture used can support the animal’s immune systems, improving its ability to react against pathogens, as well as feed efficiency and growth performances during the whole fattening period.The effect of a nutraceutical mixture, based on live yeast (LY), mannan oligosaccharides (MOS) and organic selenium (Se) on health status, as well as immune functionality and growth performance in the fattening of newly received beef cattle, was evaluated. A total of 1036 Charolaise heifers were allocated into two experimental groups: (i) control group, without any nutraceutical support ( Globally, 700,000 people die each year due to infection with antibiotic resistant organisms (AROs), prospecting to rise up to 10 million deaths per year in 2050. At the European level, antimicrobial resistance (AMR) is estimated to be responsible for 33,000 deaths per year. Moreover, infection with antimicrobial resistant pathogens can lead to serious illnesses and increased hospitalization rate, with a stronger pressure on healthcare systems’ stability, efficiency, and economy [AMR occurs when microorganisms, such as bacteria, viruses, fungi, and parasites, become resistant to the medications normally used to fight them . The acqConsidering the importance of the problem, the European community is moving towards the implementation of new monitoring systems and regulations regarding the use of antibiotics in both human medicine and animal husbandry ,3,4,5.Indeed, even if the antimicrobial consumption in food-producing animals has decreased and is now lower than in humans, as reported by the latest European Centre for Disease Prevention and Control (ECDC) and European Food Safety Authority (EFSA) reports, the use of antibiotics in the farming sector is coming under increasing scrutiny, especially when used for prevention of disease, in the form of prophylaxis or metaphylaxis, in particular with antimicrobials commonly used in human medicine ,5,6. TheIn livestock farming, swine and poultry accounted for the highest use of antibiotics, while cattle are in third position in terms of milligrams per population correction units (PCU)  at a global level [However, within intensive beef cattle farming, there are still stages of the rearing period that require higher quantities of antimicrobials.In the beef cattle system, based on the fattening of weaned cattle imported from pasture areas, the arrival stage represents the most critical period for animal health, welfare and also antibiotics use . Newly rBesides being one the most common cause of morbidity and mortality, BRD is also associated with an overall reduction in productivity during the whole rearing cycle ,10,11. AActually, a reduction in the use of antimicrobials is required, especially in terms of prophylaxis and mass treatments . AlternaIn fact, in the last few years, natural products and organic minerals are increasingly being studied in animal nutrition, both in monogastric, such as pigs  and broiMost studies carried out in beef cattle focused their attention on live yeast (LY) , yeast-dS. cerevisiae species, currently used in livestock production for a variety of reasons encompassing performance enhancement and overall benefits to animal health and welfare [Live yeasts are probiotics, mainly belonging to the  welfare .S. cerevisiae, known as elements capable of improving animal productivity through a better gastrointestinal and ruminal health [Mannan oligosaccharides (MOS) are prebiotics composed of complex carbohydrate molecules, derived from the outer cell wall of l health .Selenium (Se) is a mineral involved in many different metabolic functions, principally related to the maintenance of the body redox balance and antioxidant defences, thus also regulating the immune system ,17,18,19Indeed, the hypothesis of the present study was that dietary supplementation of live yeast, mannan oligosaccharides, and organic selenium can positively affect the health status, the immune functionality, and the performance of fattening beef cattle in the arrival period, taking also into account the actual lack of specific studies in bibliography.The aim of the present study was to evaluate the potential effect of a nutraceutical mixture, composed by live yeast (LY) , mannan oligosaccharides (MOS) , and organic selenium (Se)  on health status, immune functionality, and growth performance in newly arrived beef cattlep = 0.003). Moreover, a significantly lower percentage of animals relapsed after the first pull of the pathology in the Treatment compared to the Control group (9.6 vs. 16.3) (p = 0.001).Data on health status and incidence of pathologies in the two groups are reported in p = 0.864), incidence of lameness (0.0 vs. 0.2) (p = 0.288), and number of animals moved to the infirmary pen (0.0 vs. 0.2) (p = 0.864) were influenced by the treatment.Neither mortality (0.7 vs. 0.8) (p = 0.031). Furthermore, the non-specific immune reactivity was better in the Treatment group, with a statistically higher serum bactericidal activity compared to the Control at d30 (84.30 vs. 80.86) (p = 0.0012). Conversely, at d30, the levels of γ-interferon were not influenced by the treatment (p = 0.302).Data on blood parameters, indicators of immune functionality, and inflammatory status are reported in Regarding the indicators of the inflammatory status , no statistically significant differences were found between groups.p = 0.006), as a result of a higher growth in the first month in the Treatment compared to the Control group (0.896 ± 0.18 vs. 0.803 ± 0.14) (p < 0.0001). Considering the hole period of 186 days, the trend seemed to be tending to statistical significance. Specifically, the difference between the two groups was 93 g/head/day during the adaptation stage and 31 g/head/day during the whole fattening period.Data on growth performance are reported in p > 0.05).Data on slaughtering performances and carcass characteristics are reported in p < 0.001), ADF (p = 0.0003), and starch (p < 0.001) in the feces of treated animals was significantly reduced at d30.Data on the fecal chemical composition are reported in The ever-increasing demand for a reduction in the consumption of antimicrobials has driven producers to seek more innovative and “natural” approaches in beef cattle farming. These innovative strategies can include specific feed supplements, such as live yeast (LY), yeast-derived products such as mannan oligosaccharides (MOS), as well as organic minerals such as organic selenium (Se), with nutraceuticals properties able to provide health benefits during the most critical rearing phases.The onset of pathologies, especially bovine respiratory disease (BRD), during the critical adaptation period is also correlated with poor growth performance during the entire fattening period, with an overall reduction in average daily gain of nearly 150–200 g/day, with peaks of over 300 g in case of multiple relapses . The priNutraceutical nutrients, such as LY, MOS, and organic Se, may act as important support for newly arrived beef cattle, due to both their immunological and functional properties. Indeed, they can act both directly on the specific and non-specific immunity as well as indirectly modifying the metabolism, leading to a better release of glucose and energy precursors from the feeds, usable by the immune system .The results of the present study underlined a positive effect of the treatment on health status, with reduced mortality and morbidity rate, and with a significant reduction in the incidence of BRD. The present findings are in line with the previous researches of Keyser et al. 2007) and of Fink et al. (2014) which reported a decrease in morbidity rate, in recovery time from BRD infection, and in the number of antibiotic treatments per animal, in beef cattle fed with LY during the arrival phase 07 and of,25,26,27This improvement in the health status can be explained by a better immune function. In fact, the result of the present study highlighted an increased antibodies production and serum bactericidal activity in treated animals, in line with previous findings of different researches ,14,15,23Furthermore, components of LY and yeast-derived products, especially β-glucans, have been shown to enhance non-specific immune function through improving the actions of macrophages, neutrophils, and eosinophils and increasing the clearance of pathogens, exerting a better protection activity against invading pathogens . Specifi30.Even if the result of the present study did not find significant changes in terms of both γ-interferon levels and inflammatory status , the improved serum bactericidal activity, detected in the treatment group, highlighted a better functionality of the non-specific immune defences. In normal conditions, serum bactericidal activity has to be higher than 90% [As previously stated, nutraceuticals, such as LY and yeast-derived products, may also exert an indirect effect on the immune system through an alteration of the metabolism, improving the energy availability in the form of glucose . In factThere are several possible explanations for the increase in glucose concentrations, mainly related to the stabilizing and promoting effects that LY and yeast-derived products can exert at the ruminal level. In fact, LY and its derivates act at the ruminal level as an oxygen consumer, decreasing the redox potential of the rumen, thus promoting a more favorable environment for the development of the ruminal microflora, mainly cellulose consumers, and lactic acid-utilizing bacteria . IncreasThe results of the present study agreed with those findings. Indeed, the reduced presence of NDF, ADF, and starch in the faeces of treated animals can be explained by better and higher digestibility at the ruminal level, considering that the nutritional management was the same in the two groups. Moreover, the higher availability of volatile fatty acids (VFA), highlighted in previous bibliographical studies, can also explain the better growth performances highlighted in the present study in the treatment group, as a result of a feed digestibility and utilization ,37,38,39The study was performed in a commercial farm, representative of the typical Italian intensive beef cattle farming system.0), all the animals were individually weighed and evaluated for the conformation, assessed on a 5-point scale  [n. 487; initial weight 325 ± 21 kg); and (ii) traditional nutritional management integrated, during the first 30 days after arrival, with a nutraceutical mixture composed by live yeast (LY) (5 g/head/day) (ActiSaf), organic selenium (Se) (3 mg/head/day) (SelSaf), and mannan oligosaccharides (MOS) (10 g/head/day) (SafMannan) (Treatment group) . The product was administered for the first 30 days after the arrival, while the animals were followed for the entire fattening period (187 days).A total of 1036 newly received Charolaise heifers, imported from France, were enrolled. At three days after arrival (dlopment) . The ani2 each), with fully slatted floor.The heifers were housed in a close barn with 104 pens with 9–10 animals each , and delivered once a day in the morning by a feed mixer wagon, provided with electronic scale to weigh the inclusion of each ingredient and the TMR unloaded. The TMR was studied to meet the growth needs of the animals, as required by the Nutrient Requirement Council [The two groups received the same feeding plan . The fee Council . The fatThe two experimental groups differed for the administration of the nutraceutical mixture in the Treatment group during the first 30 days. The pool, included directly in the mineral mix, was formulated to supply: (i) 0.0278 g/g of mineral mix on dry matter (d.m.) basis of LY, resulting in a total of 5 g/head/day; (ii) 0.0166 mg/g of mineral mix on dry matter (d.m.) basis of organic Se, resulting in a total of 3 mg/head/day; and (iii) 0.056 g/g of mineral mix on dry matter (d.m.) basis of MOS, resulting in a total of 10 g/head/day.In the control group a placebo, (15.00 g/head/day) of wheat bran was added to the mineral mix to maintain the same dry matter administered. The mineral mix differed between the two groups only for the first 30 days of adaptation.From day 0 to day 186, general health evaluations were conducted twice a day, with a direct examination of all the animals by the farm veterinary and qualified animal health care staff. Any case of morbidity and mortality were recorded, as well as the number of animals that needed to be moved to the infirmary pen, together with the motivation, with specific attention on the incidence of bovine respiratory disease (BRD) and lameness. Sick animals were considered affected by BRD if the rectal temperature was ≥40.0 °C and if both depression and respiratory scores differed from the normal health status  . BRD new0 and d30, blood samples were taken from 30 animals per group to evaluate some serum indicators of immune functionality and inflammatory status. Blood samples were collected by jugular venipuncture into 10 mL EDTA tubes and 10 mL no additive tubes  and immediately placed on ice. Then, the serum was extracted by centrifugation at 3000 g for 10 min at 4 °C and stored at −20 °C.At dThe titration of BHV-1 vaccination antibodies with a BHV-1 serum neutralization test was evaluated as an indicator of specific immunity modulation. The BHV-1 serum neutralization test was performed according to OIE (2012) .Non-specific immunity was evaluated with the analysis of the serum bactericidal activity and γ-interferon ,46.The inflammatory status was evaluated through the analysis of different acute stage proteins as haptoglobin (HPT), lipopolysaccharide binding protein (LBP), and interleukin 6 (IL6) ,48,49.0), at day 30 (d30), and at the day before slaughter (d186). The individual average daily gain (ADG) was then calculated for each period, namely from d0 to d30, from d30 to d186, and for the entire period from d0 to d186, using the following formulaIndividual body weight was recorded before morning feeding at three time periods, that covered the adaptation stage as well as the entire fattening period: on enrolment day (dADG = average daily gain (kg/head/day)Weight f = final weight of each periodWeight i = initial weight of each periodDays i–f = days between the start and the end of each periodAt the slaughterhouse cold carcass weights (CCW), carcass yield (CY), and SEUROP carcass rating scores (SCRS) were recorded for all the animals.30, before the morning feeding, fecal samples were collected on 30 animals per group. Then, all the different samples were pooled together to create only one sample per group. After the sampling procedures, the samples were sent to the laboratory, in order to determine nutrient excretion in the feces. Fecal samples were analyzed for analytical DM [At dtical DM . After ttical DM . All thetical DM . Starch tical DM ,52.Statistical analyses were performed using SAS 9.3 . The incidence of mortality, BRD, and its relapses and lameness were evaluated using a chi-square test.The blood parameters were evaluated through an analysis of variance for repeated measure (ANOVA), with the fixed effect of treatment, time, and their interaction. The animal was considered as the experimental unit.Each individual animal was also considered as the experimental unit for growth performance parameters, carcass characteristics, and slaughtering performance. A two-way analysis of variance (ANOVA) was performed considering the fixed effect of treatment, time, and their interactions. The same statistical analysis was performed for the evaluation of fecal chemical composition.p ≤ 0.05, while a p ≤ 0.001 represent a tendency toward significancy. Data are presented as least squared means and pooled standard error of the means (SEM).The significance level was set as The administration of a pool of nutraceuticals based on live yeast, mannan oligosaccharides, and organic selenium to beef cattle during the adaptation period resulted in a significant reduction in the bovine respiratory disease incidence, due to a significantly improved specific and non-specific immune defenses. Those data suggest an enhancement in the overall animal health and also a reduction in antibiotics use, in accordance with European regulations and with efforts to reduce the problem of antibiotic resistance. Moreover, growth performance and feed efficiency have been also optimized, as a result of the better general health status and more stable and healthier ruminal environment.


Femoral intertrochanteric fractures (ITF) occur frequently in the elderly, accounting for 45% of all hip fractures. Postoperative anemia after fracture tends to cause ischemia, hypoxia in cells, tissues and organs, increasing the rate of blood transfusion, risk of infection, disability and mortality. Meanwhile, traditional Chinese medicine is widely used in the treatment of anemia for activating blood circulation and removing blood stasis.This study is a prospective, outcome assessor-, and data analyst-blinded randomized controlled clinical trial. The objective of this proposed study was to investigate whether Shengyu Decoction could improve the symptoms of anemia after proximal femoral nail antirotation in elderly ITF patients. After qualifying for screening, patients will be randomized into 2 groups with an allocation ratio of 1:1. Hemoglobin concentration, HBL, and HHS score are outcome measurements. The other outcomes also included time to get out of bed, discharge to home, 30-day readmission rates, and mortality.ITF is commonly occurring in senior citizens, and those who are senior in age generally suffer 1 or more basic diseases, whose nutritional status is already poor. Trauma and surgical stimulation not only aggravate the existing disease or induce corresponding cardiovascular complications, but also worsen the nutritional status, which can easily cause postoperative anemia in patients. Because of the limited clinical modalities available for the treatment of postoperative anemia after fracture surgery, and most of them have various side effects that are not easily tolerated by the elderly. Therefore, from a traditional Chinese medicine perspective, we proposed a protocol using mild Chinese herbal decoction to treat postoperative anemia in ITF.Registration number: OSF Registration number: DOI 10.17605/OSF.IO/JQ6ZF. Survivors are prone to various sequelae, making this disease an important public health problem. In addition, the high cost of treatment makes it difficult. Both national health and social economy have a serious impact.Femoral intertrochanteric fractures (ITF) occur frequently in the elderly, accounting for 45% of all hip fractures. With the acceleration of the aging population, the incidence of femoral intertrochanteric fractures is also increasing. Among them, the proximal femoral nail antirotation (PFNA) has the advantages of easy operation, less trauma, and stable fixation. Its characteristic is that it maintains the firm fixation and biomechanical stability of AO. The essence of BO and minimally invasive surgery is suitable for various types of femoral intertrochanteric fractures, and is currently one of the main clinical surgical methods.,6 However, with the popularization and application of PFNA in the treatment of ITF, more and more scholars have found that although the amount of bleeding during the operation of PFNA is small, some patients show different degrees of anemia after the operation. Li analyzed the perioperative blood loss in 123 patients with ITF who underwent PFNA and found that the total blood loss from the admission day to the first and third postoperative day was 693.5 ± 359.6 mL and 863.8 ± 429.9 mL, of which the corresponding hidden blood loss was 86.8% and 89.4%, respectively. Tian found that 26 of 79 patients who underwent PFNA received 400 mL of blood transfusion and 22 patients received 800 mL of blood transfusion, warning the orthopedic staff to pay attention to perioperative anemia in PFNA patients. Postoperative anemia after fracture tends to cause ischemia and hypoxia in cells, tissues and organs, increasing the rate of blood transfusion, risk of infection, disability and mortality, triggering blood-borne diseases and affecting immune function, delaying postoperative recovery and prolonging hospitalization.,10 Blood transfusion is the most effective way of treating anemia, which enhances hemoglobin concentration and improves anemia in a short term, but there are various severe risks such as viral infections, immune allergic reactions, acute hemolytic reactions, etc. Meanwhile, the current clinical blood use guidelines are all restrictive transfusion thresholds (hemoglobin concentration <8 g/dL). Other treatments include nutritional support, iron supplementation, erythropoietin, erythropoietin, and use of hemostatic drugs, and these modalities are prone to various side effects.Surgery is currently recognized as the main treatment method, which can reduce pain, promote joint functional recovery, avoid many complications caused by long-term bed rest, and improve the quality of life of patients.Meanwhile, traditional Chinese medicine (TCM) is widely used in the treatment of anemia for activating blood circulation and removing blood stasis. It functions in many ways, such as engaging in multi-linked and multi-targeted regulation, improving the bone marrow hematopoietic microenvironment, restoring bone marrow hematopoietic function, and improving the quality of life of patients. Therefore, this study followed the principles of prospective, randomized, and controlled, aiming to explore the clinical efficacy of TCM methods on postoperative anemia in ITF patients who underwent PFNA, for the purpose of obtaining more completed information on safety and efficacy, and providing research methods and ideas for the treatment of postoperative anemia in ITF.22.1This research protocol follows the latest consolidated standards of reporting trials 2017  is responsible for the overall project and organizing Steering Committee meetings. PIs of sub-center departments are responsible for gathering experts to carry out the project. An independent Steering Committee will be responsible for affairs such as participants’ safety, meetings, recruitment and follow-up of participants, and quality control. The coordinating center is responsible for communicating protocol modifications and providing materials. It consists of a 2-week treatment period and a 6-month follow-up period. Outcome assessment at baseline, post-operative days 1, 3, 7, 14 days, 1 month, 3 months, and 6 months postoperatively.  by an independent third-party clinical research organization  and hid from the researchers by a senior data manager who is not involved in the study. The group assignment list will be sealed in light-blocking envelopes and be opened by the researchers following informed consent procedures and baseline testing.2.6Participants will be recruited from Longhua Hospital affiliated to Shanghai University of Traditional Chinese Medicine. Those patients eligible for enrollment and willing to participate in the study were initially evaluated at baseline and then finally identified through a combination of clinical presentation, physical examination, imaging and laboratory tests. Considering the age of the patients enrolled in this study, the investigator must obtain the consent of the patient's immediate family besides the patient's own informed consent to start the trial. Participants will be informed about the required cooperation in the study, the potential benefits of participating in the study, the possible adverse effects, risks and discomforts of participating in the study, and the associated reimbursement costs and confidentiality of personal information. Participants will also be informed of withdrawal from this study at any time during the study and that the investigator may discontinue your participation in this study at any time out of concern for your best interests. A data collection form including all variables of interest and all potential risks will be completed by the corresponding research center. All information obtained will be kept in an e-database for future statistical analysis. Recruitment will start in January 2022 and is expected to end in December 2023. Final follow-up of all participants will be completed on December 31, 2024.2.7This study is to be conducted in accordance with the principles of the Declaration of Helsinki and has been approved by the Sichuan Regional Ethics Review Committee on Traditional Chinese Medicine. Details of the trial program have been approved by the appropriate Institutional Review Boards. Prior to the clinical trial, the participants will provide written informed consent.2.8All investigators, physicians, nurses, patients, assessors, statisticians, and participants remained blinded to group assignment until the trial ended, when all statistical analyses were finished. If any clinically significant adverse events occur after the first dose that are potentially treatment-related, the study physician will re-evaluate the participant and the PI will determine whether unblinded treatment is necessary. If non-blinding is required, the allocation information will be provided.2.92.9.1Hemoglobin concentration is the main basis for the diagnosis of anemia and visual indicator of the patient's blood volume, therefore we consider it as an essential objective basis for assessing the efficacy of the treatment.2.9.23 + k2 ∗weight (kg) + k3. For men, k1 = 0.3669, k2 = 0.03219, and k3 = 0.6041, and for women, k1 = 0.3561, k2 = 0.03308, and k3 = 0.1833. In addition, the total red blood cell loss (TRBCL) was calculated according to the Gross formula: TRBCL (L) = PBV∗ (Hctpre − operation − Hctpost − operation), TBL(L) = TRBCL/Hctpre-operation + BVtrans. Finally, it can be derived that HBL(L) = TBL − VBL.–15HBL: HBL comprises a relatively high percentage of the total perioperative blood loss in ITF patients, which is the dominant cause of postoperative blood loss in intramedullary fixation systems and is strongly associated with postoperative anemia. HBL was calculated based on changes in Hct levels and estimated patient's blood volume (PBV). Following Nadler's formula, PBV (L) = k1∗height (m)HHS score: Anemia also interferes with postoperative joint function recovery in hip fracture patients and slows down the overall postoperative rehabilitation progress of patients16.Therefore, the Harris score was used to measure the degree of recovery of the patient's joint function after surgery, indirectly reflecting the patient's anemia. The Harris score consists of 10 questions, with 2 questions in the physician physical examination section (ROM and absence of deformity) and 8 questions in the patient-reported outcomes section.The other outcomes also included time to get out of bed, discharge to home, 30-day readmission rates, and mortality.2.10To ensure the safety of the participants, all data collection was conducted under the supervision of the program director. During each follow-up visit, the patients’ adverse reactions during the drug administration were recorded, especially subjective discomfort reactions such as gastrointestinal, cardiovascular and cerebrovascular reactions, in order to understand whether the drugs existed toxic side effects. In addition, the biochemical indexes of patients, particularly liver function and kidney function indicators, are examined at each follow-up visit to determine whether there is any damage to internal organs from the objective test results.2.11The sample size estimation was based on the mean and standard deviation of the primary efficacy parameters with reference to the pretest. α= 0.025, 1 sided test, and β = 0.10 were established. According to the results calculated by PASS 15.0 software , 30 patients per group were required. Due to an estimated dropout rate of 20%, 36 patients were eventually included in each group.2.12,17A detailed statistical analysis protocol will be formulated prior to all analyses. All data will be analyzed in the clinical research center of Longhua Hospital affiliated to Shanghai University of TCM by statisticians blinded to allocation using the SPSS 20.0 statistical software . After evaluating the data distribution, 2-sample t-test (or Wilcoxon rank-sum test) will be used for the analysis of continuous variables. For categorical data, the Chi-Squared test (or Fisher exact test) will be used. Outcome variables including hemoglobin concentration, hidden blood loss, HHS scores for hip joint-specific function will be summarized with means and SDs. For statistical analysis of continuous outcomes, changes in the scores before and after treatments will be regarded as dependent variables, with the baseline scores and research institutions as covariates and the groups as fixed factors, to perform the analysis of covariance. To verify the trends for each visit in the 2 groups, repeated measures analysis of variance will be performed. For categorical outcome data, the Chi-Squared test (or Fisher exact test) will be used.2.13Prior to the start of the trial, all physicians, nurses, and assessors participating in this study participate in a 1-month training period of 6 hours per day, 5 days per week, for a total of 120 hours. To ensure that all trial participants adequately understand the process of the trial. In addition, a common standard operating procedure (SOP) for the treatment will be provided and practitioners will follow this SOP. At the end of each week, the competency of the participants will be assessed. To guarantee the quality of the whole test, there will be 3 strictly supervised by trained quality supervisors. During the trial, the supervisor reviews case report forms and conducts 2 interventions per month. After verification of the case report form, the data will be input into the database independently by 2 full-time study members.3ITF is commonly occurring in senior citizens, and those who are senior in age generally suffer 1 or more basic diseases, whose nutritional status is already poor. Trauma and surgical stimulation not only aggravate the existing disease or induce corresponding cardiovascular complications, but also worsen the nutritional status, which can easily cause postoperative anemia in patients. Because of the limited clinical modalities available for the treatment of postoperative anemia after fracture surgery, and most of them have various side effects that are not easily tolerated by the elderly. Therefore, from a TCM perspective, we proposed a protocol using mild Chinese herbal decoction to treat postoperative anemia in ITF.Considering this objective, we conducted a systematic literature search before starting this trial to ensure its comprehensiveness. We have thoroughly searched PubMed, MEDLINE, EMBASE, Cochrane Library, ISI web of knowledge, Wan Fang Data, CNKI databases, Vip Journal Integration Platform (VJIP), and Chinese BioMedical databases from the inception to June 2021.This trial aims to observe the effectiveness and feasibility of this treatment and explore a way to rapidly correct postoperative anemia in TCM and promote patient recovery. Hopefully, this study will provide a theoretical basis and clinical evidence for the treatment of postoperative anemia after PFNA in elderly ITF patients and explore new ideas and methods for clinical treatment.Conceptualization: Xuequn Wu.Data curation: Yu Xiao, Yunlu Zhang.Formal analysis: Wei Lu, Yunlu Zhang, Hongbo Wan.Funding acquisition: Yu Xiao.Supervision: Wenhao Zhu, Zhaoxiang Fan.Validation: Wenhao Zhu, Hao Hu, Zhaoxiang Fan.Visualization: Yanqi Feng, Zhaoxiang Fan.Writing – original draft: Hao Hu, Yanqi Feng.


With the aging of society, the incidence of type 2 diabetes (T2DM) is increasing every year, and there is a clear correlation between T2DM and cognitive dysfunction. Acupuncture therapy has been widely used in the treatment of T2DM, but there is no systematic review on the treatment of T2DM associated with cognitive impairment. Therefore, this study aimed to conduct a meta-analysis of acupuncture in the treatment of T2DM with cognitive impairment to clarify its efficacy.A structured and systematic literature search will be conducted in the following databases up to April 26, 2021: PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science (WOS), China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Chinese Scientific and Journal Database (VIP), and Wan Fang database (Wanfang). We will use the Review Manager 5.4 software provided by the Cochrane Collaborative Network for statistical analysis. We then assessed the quality and risk of the included studies and observed the outcome measures.This meta-analysis further determined the beneficial effects of acupuncture on T2DM with cognitive impairment.The purpose of this meta-analysis was to explore the effect of acupuncture on patients T2DM with and cognitive impairment patients, and provide more options for clinicians and patients to treat T2DM with cognitive impairment.This systematics review will evaluate the efficacy and safety of acupuncture in the treatment of T2DM with cognitive impairment. Since all the data included were published, the systematic review did not require ethical approval.CRD42021245681. Currently, 366 million people worldwide have diabetes mellitus, and this number is expected to reach 552 million by 2030. Compared with normal people without diabetes, diabetes was associated with an increased risk of cognitive impairment by 1.25 to 1.91 times. T2DM is a risk factor for cognitive dysfunction, including cognitive decline, mild cognitive impairment, and dementia. It is estimated that 20% to 70% of T2DM patients have cognitive impairment, and 60% of patients have a higher risk of dementia.–7 Cognitive dysfunction can also worsen the compliance of diabetic patients worse, thereby aggravating diabetes, and the 2 form a vicious circle.Type 2 diabetes mellitus (T2DM), a metabolic disease characterized by a persistently high level of blood glucose, is caused by a progressive increase in insulin resistance and reduction in insulin secretion.–11 However, the mechanism of diabetic cognitive impairment is complex, and there are many related factors. The academic community has not reached a consensus in this regard, and further research and exploration are still needed. There is still a lack of targeted methods for the clinical treatment of cognitive dysfunction in patients with type 2 diabetes. Western medicine mainly focuses on lowering blood sugar, supplemented with drugs to improve cognitive impairment, such as pioglitazone, metformin, and irisin, to alleviate diabetes-induced central nervous system damage.,14 As an important part of traditional medicine, acupuncture has a good therapeutic effect on diabetes and its complications, such as regulating blood sugar and delaying central nervous system damage.,16 However, there is no systematic review of the efficacy of acupuncture in the treatment of diabetes mellitus with cognitive impairment. To the best of our knowledge, this is the first meta-analysis of randomized controlled trials (RCTs) to explore the effect of acupuncture on type 2 diabetes with cognitive impairment.At present, the pathogenesis of T2DM with cognitive impairment is not fully understood, and we can actively seek for the prevention and treatment of T2DM with cognitive impairment from the aspects of glucose metabolism disorder, insulin resistance, abnormal adipocyte secreting factor, disruption of neuronal calcium homeostasis, and poor lifestyle.2 and the corresponding checklist used. This systematic review protocol was registered in the PROSPERO International Registry of Systematic Reviews (ID: CRD42021245681).This protocol which has been reported is based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines2.12.1.1Only RCTs of acupuncture treating type 2 diabetes with cognitive impairment will be included in this study, without publication or language restrictions. Non-RCTs will be ruled out, including studies such as case reports, and studies without sufficient information about the randomized method or process.2.1.2Participants suffering from type 2 diabetes with cognitive impairment will be included, regardless of age, sex, nationality, and educational background.2.1.32.1.3.1We will include acupuncture and acupuncture-related therapies  to comprehensively describe the effects of acupuncture on patients with type 2 diabetes and cognitive impairment. Clinical trials with other forms of stimulation including moxibustion, bleeding therapy, cupping, laser acupuncture, pharmacoacupuncture, acupotomy, point injection, or acupressure, will be excluded. Additionally, limitations to intervention intensity, frequency, and duration were not involved.2.1.3.2Studies that are interfered with no treatment, an acupuncture-like intervention will be considered as a control group. Additionally, studies comparing acupuncture plus the concomitant treatment with that treatment will also meet the control group including criteria. However, studies comparing acupuncture with other traditional chinese medicine treatments have not been conducted.2.1.4The primary outcome measures were fasting blood glucose, 2 hours postprandial blood glucose (2hG), and glycosylated hemoglobin. In addition, improvements in memory and learning ability, spatial disorientation, motor function, and better emotional management of depression or anxiety will be assessed. Relative validated scales such as Minimum Mental State Examination (MMSE), activity of daily living (ADL), and neuropsychiatric inventory (NPI), will be employed to evaluate physiological and psychiatric changes, and the second observation index mainly includes triglyceride (TG), cholesterol (TC), insulin secretion (INS), and so on.2.1.5Randomized controlled clinical trials and quasi-randomized controlled trials will be included.2.2www.ClinicalTrials.gov/) for in-progress trials with unpublished data. Table We searched 8 electronic databases of PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science (WOS), China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Chinese Scientific and Journal Database (VIP), and Wan Fang database (Wanfang) to identify literature on RCTs for type 2 diabetes with cognitive impairment. We also searched the Chinese Clinical Trial Registry (ChiCTR) and ClinicalTrials.gov  will screen the titles and abstracts, respectively, to extract potentially eligible articles, and duplicated results will be excluded. Further identification will be carried out by reviewing the full text and analysis considerations to select eligible studies. Then, all reviewers will have a group discussion on the consistency of all the studies included, excluding and eliminating those that were not up to the theme topic until the final team consensus arrived. The selection process is fully elucidated in the following PRISMA flow diagram Fig. .2.3.2Then, 2 reviewers (RH and MM) will extract the title, first author, publication year, country, language, journal source; information of participants: sex, age, study design, sample size, intervention, type of measures, risk of bias assessment, and findings from included studies with Excel file. The results will be cross-checked by the 2 reviewers, and any disagreements will be resolved by consensus, with any ongoing differences in opinion being arbitrated by a third reviewer (HW).2.4I2 test was used for statistical analysis. When I2 was <50% or P > .05, it indicated that there was no statistical heterogeneity between the studies, and the fixed-effect model was selected to combine the effect amount; otherwise, the random effect model was adopted.We will use the Review Manager 5.4 software provided by the Cochrane Collaborative Network for statistical analysis. For continuous variables, the mean and SD of each study were obtained and pooled as mean difference (MD) or standardized mean differences (SMD) with a 95% confidence interval (CI). Statistical heterogeneity analysis was performed for the included clinical RCTs. The Cochrane 2.5The literature quality of this study was evaluated using the bias risk table proposed by the Cochrane Collaborative Network. The risk table includes 6 items: random sequence generation mode, whether to use allocation concealment, whether to blind the subjects and intervention providers, whether to blind the results evaluators, whether the results data are complete, whether to select the results report, and other bias sources. The criteria used to assess the risk of bias were “low risk,” “high risk,” and “unclear.” In this process, 2 evaluators independently evaluated methodological quality. In cases of disagreement, the third author intervened.2.6I2. When I2 > 50%, this indicates that there is heterogeneity between studies, and the source of heterogeneity should be further investigated. When I2 < 50%, interstudy heterogeneity was considered to be small, or there was no obvious heterogeneity.Before the combination of effect size, we will use Stata to assess the available study and patient characteristics to ensure similarity and to investigate the potential effect of heterogeneity on effect estimates. When interstudy heterogeneity exists, a random effects model is used. For comparison of each pair, heterogeneity was assessed by the statistic 2.7If there are >10 trials in accordance with the study, we can use Rev Manager 5.4 software to draw and analyze the funnel chart, and use the funnel chart to evaluate the potential publication bias.2.8Grading of recommendations assessment, development, and evaluation reliability study (GRADE) will be implemented to assess the quality of evidence. Based on the risk of bias, inconsistency, imprecision, indirection, and publication bias, GRADE grades evidence quality into 4 levels: high, medium, low, and very low.2.9Formal ethical approval was not required for this protocol. Because nothing of the information will be obtained from an individual participant, the systematic review does not require ethical approval.3 Many studies have shown that poor glycemic control is strongly associated with the development of cognitive dysfunction.,20 Acupuncture originated in ancient China and has been widely applied in the clinic for a long time. It is an important component of Eastern medicine. With the further study of TCM on type 2 diabetes and cognitive impairment, acupuncture can effectively improve the blood glucose level of patients and enhance the treatment effect. In recent years, many basic studies have also shown that acupuncture may improve the cognitive function of patients by improving the abnormal state of the cholinesterase system, regulating the synaptic plasticity of the hippocampus, and alleviating the inflammatory response of the central system.,22,23 This systematic review will evaluate the efficacy and safety of acupuncture in the treatment of T2DM with cognitive impairment. The significance of a review and meta-analysis is to evaluate its effect in a larger sample, and to summarize the current research results to further provide advice on clinical research, which will have a positive significance in protecting the cognitive impairment of diabetic patients.Type 2 diabetes is now considered an independent risk factor for mild cognitive impairment.Conceptualization: Ting Pan, Chunhai Chen.Data curation: Xue Zhou, Xuefeng LI.Formal analysis: Heran Wang, Meng Meng, Yiran Han.Funding acquisition: Xinhua Chen.Investigation: Xue Zhou, Xuefeng Li.Methodology: Ting Pan, Chunhai Chen.Supervision: Xinhua Chen.Validation: Heran Wang, Yiran Han, Xin Qian.Writing – original draft: Ting Pan.Writing – review & editing: Ting Pan, Xinhua Chen, Chunhai Chen.


To investigate the frequencies and patterns of cardiovascular diseases (CVDs), including rheumatic and congenital heart diseases, among patients with abnormal hearts assessed by echocardiographic examination.This retrospective, descriptive registry reviewed abnormal echocardiographic findings of 1140 patients aged 0–100 years who were admitted to the cardiology outpatient clinic at a tertiary training institution in Mogadishu.Hypertensive heart disease (HHD) , valvular heart disease (VHD) ,and heart failure with reduced ejection fraction (HFrEF)  were the most frequent comorbidities. Congenital heart diseases (CHDs) were detected in 151 (13.2%) of the patients, with the most common ones including atrial septal defect (ASD)  and ventricular septal defect (VSD) . Rheumatic heart disease (RHD) was observed in 84 (7.4%) patients, among whom the most common age range was 16–30 years (40.5%), followed by 31–45 years (31%) and 0–15 years (15.5%). Mitral insufficiency  was detected as the most frequent VHD, followed by aortic insufficiency , and tricuspid insufficiency  and mitral valve stenosis  was the least common VHD.In the present study, we found that HHD was the most common comorbidity, followed by VHD, and HFrEF. Moreover, the most common VHD was mitral insufficiency and the most common CHD was ASD.The online version contains supplementary material available at 10.1186/s12872-021-02417-4. Cardiovascular diseases (CVDs) are the leading cause of death worldwide . The freEven though echocardiography is an easy-to-use, cost-effective, non-invasive, and reliable ultrasound-based modality, its use in many parts of Africa is still highly limited . TherefoThis retrospective, descriptive and observational registry reviewed the echocardiographic findings of patients aged 0–100 years who were presented to our outpatient cardiology clinic at a tertiary training hospital in Mogadishu, between January 1, 2019, and January 1, 2020. Overall, 6782 subjects admitted to the hospital were screened. 5642 individuals who had incomplete, unreliable data and/or those with completely normal echocardiographic findings were excluded from the analysis  and valves are within normal ranges by gender and age group , 9.Hypertensive heart disease (HHD) was diagnosed in the presence of signs of heart failure or criteria for concentric/eccentric LV hypertrophy  for stenotic valves and with the interpretation of qualitative , semiquantitative , and quantitative  measurements for valve insufficiency in at least one of the heart valves according to European Society of Cardiology guidelines for the management of valvular heart disease ) due to the presence of abnormal distribution. Categorical variables were expressed as number (n) and percentage (%). Continuous variables were compared using the Mann–Whitney U test and categorical variables were compared using the χp = 0.045). Overall, HHD was found to be the most common comorbidity , followed by VHD , HFrEF , and IHD .RHD was detected in 84 (7.4%) patients. Males tended to have older age, higher rates of diabetes mellitus, HHD, IHD, HFrEF, and DCM, whereas females had more frequent RHD . While the number of patients with tuberculosis was 202 (17.7%), constrictive pericarditis was diagnosed for various reasons in 9 (0.8%). Detailed demographic characteristics of the study population are listed in Table p < 0.001). On the other hand, HHD, IHD, HFrEF, VHD, and DCM were detected at higher rates in adults   were male, the median age was 60 IQR; 42–70) years and 113 (9.9%) were children. Children were more likely to be female (–70 yearsp < 0.001]. There were 182 (15.9%) subjects with grade II-IV diastolic dysfunction. Overall, 59 (5.2%) subjects had severe valvular pathology (regurgitation/stenosis) in at least one valve, while 336 (29.5%) had mild to moderate valve pathology in at least one valve. Mitral insufficiency  was detected as the most frequent VHD, followed by aortic insufficiency , and tricuspid insufficiency  and mitral valve stenosis  was the least common VHD (Table Median EF in the entire population was 60% (IQR: 40–65) and lower in males than in females [55 35–60) vs 60 (55–65), 5–60 vs 6To the best of our knowledge, this is the first echocardiographic study to comprehensively evaluate such a large cohort of patients in Somalia. Given inadequate healthcare services in Somalia, which is an active war zone, we consider that this study is of high value. In our investigation, HHD was the most frequent comorbidity (39.8%), followed by VHD (34.6%), HFrEF (30.8%), and IHD (24.4%), RHD (7.4%). Additionally, 13.2%, the majority of whom were children, of the study population were diagnosed with CHDs, with the most common being ASD, VSD, and PDA, respectively.Somalia's total population is estimated at 15.4 million, of whom about 4.5 million are children under the age of 14. Health institutions in Somalia often provide rather limited facilities for individuals with chronic illnesses and those in need of advanced care and unfortunately, no tertiary healthcare centers exist in Mogadishu and surrounding provinces, except for the region where this study was conducted. All these deficiencies prevent timely diagnosis by appropriate detection modalities, increasing the likelihood of poor outcomes in such populations. Moreover, delayed hospital admission, advanced maternal age, high rates of consanguineous marriage, and the presence of many infectious diseases that have not been eradicated nationwide may result in an increased incidence and prevalence of both acquired and congenital heart diseases. Yet, unfortunately, there are very few studies in the literature reporting the risk factors, profile, and echocardiographic characteristics of the African population. For instance, in an echocardiographic study conducted in Nigeria, Ogah et al.  determinDespite the decrease in the incidence of rheumatic fever/RHD over the last few decades, it remains one of the leading acquired health problems, especially in low-middle income countries . In an iThe prevalence of CHDs is relatively similar worldwide, ranging from 4 to 85 per 1000 births , 27. AltAs might be predicted, our study intends to raise public awareness rather than introduce innovation or examine a relationship.In this sense, the study will partially fill the data gap in Somalia, which is a war zone. Also, the presence of high rates of HHD, CHDs, and VHD reported in the study sheds light on the points to be improved in the healthcare system so that limited opportunities could be directed to the right areas. Most importantly, the serious lack of accurate diagnosis, treatment, follow-up, and data recording stages in the design and implementation phase have made the current study very difficult and may adversely affect the continuity and planning of other researches in the future. Therefore, we find it clinically crucial to articulate this challenge.First, a single-center and retrospective design of the study may be the main limitation for the generalizability of the study. Second, only patients with abnormal findings detected by echocardiography were included in the study and thus the incidence and prevalence of the diseases and risk factors could not be evaluated. Third, there could be errors in data collection, diversification, and standardization due to the absence or lack of diagnostic techniques or confirmation processes including transesophageal echocardiography, coronary angiography, cardiac catheterization, telephone interview, and address records. Fourth, the classification of CVDs may overlap due to the study design being only echo-based. It is likely that several patients with VHD also have RHD. Fifth, CHDs types such as bicuspid aortic valve, aortic coarctation, truncus arteriosus, single ventricle, etc. could not be diagnosed, probably due to the lack of diagnostic instruments and healthcare services mentioned above. Therefore, the distribution of CHDs in the general population is not fully reflected. Sixth, due to the retrospective nature of the study and country-specific conditions, echocardiographic evaluation was made by different echocardiographers, and intra- and inter-observer reproducibility analysis, thus, could not be performed. Finally, there were no clinical data of the patients regarding the treatment, follow-up, intra- and post-operative surgical notes, and mortality.First, the number of patients included in the study was relatively high. Second, this is the most comprehensive study to investigate the risk factors and CHDs together with echocardiographic findings in this region. Finally, the bias effect was minimized since there was no other tertiary healthcare center where the echocardiographic evaluation was performed and individuals who underwent echocardiography constituted the entire study population.In the present study, we found that HHD was the most common comorbidity (39.8%), followed by VHD (34.6%), HFrEF (30.8%), and IHD (24.4%). In addition, the most frequent valvular disease was mitral insufficiency (47.5%) and the most common CHD was ASD (3.2%). Further comprehensive studies with prospective design are warranted to improve inadequate healthcare services and raise public awareness and cultural knowledge in Somalia, a war zone where financial and healthcare opportunities are highly limited.Additional file 1. Demographic characteristics in children and adults patients.


The excessive consumption of sugar, salt, and fat is associated with an increased risk of non-communicable diseases. Therefore, a study on estimating the added sugar, salt, and fat intake in certain populations is important for establishing specific recommendations aiming at improving diet quality, and thus public health. This study aimed to determine the food consumption pattern and the intakes of added sugar, salt, and fat from different food groups and food sources among the residents of South Jakarta, Indonesia. The study was conducted with a cross-sectional design, involving 323 respondents. Data on socio-economic conditions, health and nutritional status, and food consumption were collected. Food consumption data were acquired through the 2-day weighed food record. Results showed that the daily food consumption in the observed population reached 1868–2334 g/capita/day. The total added sugar intake in different groups of respondents ranged between 34.9 and 45.9 g/capita/day, with the highest values observed in school-age boys. Beverages and snacks were identified as the main added sugar sources in the respondents’ diet. The total salt intake ranged from 5.46 to 7.43 g/capita/day, while the observed fat intake reached 49.0–65.1 g/capita/day. The major food source contributing to the salt and fat intake included street/restaurant/fast food. Male subjects tended to consume a higher amount of salt and fat than female subjects. These findings can be used as baseline information for providing a strategy for reducing sugar, salt, and fat intakes, with strong implications for improving public health. Non-communicable diseases (NCDs), also known as chronic diseases, are reported to cause the death of 41 million people each year, equivalent to 71% of all deaths globally. NCDs usually occur around the age of 30–69, and over 85% of these “premature” deaths occur in low- and middle-income countries. The main types of NCDs are cardiovascular diseases , cancers, chronic respiratory diseases, and diabetes mellitus. The risk of dying from NCDs is strongly associated with physical inactivity, tobacco use, use of alcohol, and unhealthy diets ,3,4. ThiPoor diets are an important preventable risk factor for NCDs. A number of epidemiological and case-control studies reported the associations between excessive dietary sugars, salt, and fat and increased risk of NCDs, including obesity, hypertension, diabetes, cardiovascular diseases, and certain cancers . In addiThis was a cross sectional study, conducted for 2 months in Rawajati Village of Pancoran Sub-district, South Jakarta . The study received the ethical approval from the Health Research Ethics Commission, Faculty of Medicine, Diponegoro University (protocol no.: 24/EC/FK-RSDK/2015). The general population was classified into three different age groups . The minimum sample size required for each group was determined based on Cochran’s formula for the proportional variable as also used in the study of Anisyah et al. . Accordin = sample size; Z = 1.96 ; α = significance level; p = population proportion (assumed to be 0.5 since it was unknown); q = 1 − p; E = margin of error (assumed to be 14%).Note: The studied population included more than 100 households, which specifically had family members representing three different age groups: School-age children (6–12 years), adolescents (13–18 years), and adults (≥19 years). Thus, the total number of subjects was 323. The selection of subjects was purposively carried out by considering several characteristics, such as socio-economic status (including income and occupation), education level, and gender. The following additional inclusion criteria related to health status and diet were also implemented: Only healthy subjects, not suffering from NCDs such as i.e., diabetes, high blood pressure, and heart disease  and not undergoing a certain diet program, were included in the study. The data on food consumption pattern and subjects’ characteristics  were collected in this study. Subjects’ characteristics data, such as health status, education level, income, occupation, gender, and age, were recorded through interviews using a structured questionnaire. The body height, weight, and blood pressure were directly measured by trained project staff during the interview, while food consumption patterns were recapitulated using the weighed food record method for 2 days (weekday and weekend). Trained project staff conducted home visits during the study period to ensure proper recording and weighing procedures. All questionnaires were checked for the completeness and errors in the same day or the day after being administered. Missing data were collected by revisiting the respondents. This 2-day weighed food record method had previously been used by several research groups ,16,17 asTo obtain data on sugar, salt, and fat added to homemade foods/dishes, a food record was also carried out at the household level, together with the individual subject’s food record. The household food record was filled out by a person responsible for providing food in the household. The household food record allowed documenting detailed information about food ingredients used to produce homemade food, including their respective weights. At the same time, individual food records were filled out by each respondent, and verification by older siblings/parents was also carried out for food record data of school-age respondents.Food consumption data obtained from 2-day weighed food records were grouped based on two categories, namely the food group and food sources. Foods were classified into thirteen food groups, i.e., bakery products, beverages, cereals and cereal products, eggs and egg products, fish and fish products, fruits and fruit products, legumes and legume products, meat and meat products, milk and dairy products, chicken and poultry products, snacks, vegetables and vegetable products, and supplements. All food items were also categorized into three different sources: Processed foods, homemade foods, and street/restaurant/fast foods.Food consumption data were expressed in grams. The sugar, salt, and fat content of foods was determined by referring to various databases, such as The Indonesian Food Composition Table 2005 , The USD2 of those tested methods was 0.99).The term “sugar” in this study was referred to monosaccharides and disaccharides added to food during processing and serving (brown sugar and/or white sugar), as well as sugar present in honey, syrups, fruit juices, and concentrates. The amount of sugar added  in the processed foods was directly obtained from the food labels , while the amount of total added sugar in the homemade food and street/restaurant/fast food was determined by several ways, i.e., (a) recording the amount of sugar added when cooking or serving food, (b) recording the amount of sugar added based on the food recipe elaboration, both as a result of the interview session and browsing on the trusted recipe websites, (c) referring to The Food Composition Tables ,21 and UThe food sample for the digital refractometer analysis was firstly prepared as also performed in the Anthrone method described by Pomeranz and Meloan . The pre2 of those two methods was 0.94).The term “salt” in this study was the salt added in the form of NaCl when cooking, processing, and serving food. The sodium content (Na/g food) of the processed foods was obtained from the food labels , and the NaCl content was then calculated by considering the mole conversion factor. The determination of salt content in homemade food and street/restaurant/fast food followed several ways which were described in the section above for sugar, but the salt analysis for unavailable recipe information was conducted using a salt check meter  which had been calibrated by the argentometric titration method (Mohr method) as described in the AOAC Official Method 960.29   was calculated by multiplying the read value on the instrument by the dilution factor. The total NaCl and Na intake was calculated as follows:The total fat content of the processed foods was obtained from the food labels , while the determination of total fat content of homemade food and street/restaurant/fast food was performed by referring to The Food Composition Tables ,21, The t-test. Data homogeneity were tested using Levene’s test. Normality of the data was tested using Kolmogorov-Smirnov and Jarque-Bera’s tests. All statistical analyses were performed in the SPSS PASW v. 18 software .Results on subject characteristics, health and nutritional status, and food consumption pattern were processed using Microsoft Excel 2013 and expressed descriptively. The results on the health and nutritional status of respondents are presented in Tables 2 and 3 . The results on food intake from different food groups and food sources are presented in Table 4  and in Figure 1 , respectively. Details of the contribution of each food group to the daily calorie intake  are shown in n = 47) were dominated by private employees (63.8%) followed by government employees (10.6%), most of them with a senior high school (57.4%) and diploma/bachelor (29.8%) education. In addition, 72.4% of adult female respondents were housewives (not working outside) and 17.2% were self-employed/entrepreneur. The educational background of adult female respondents was also dominated by an education equivalent to senior high school (58.6%), and then followed by diploma/bachelor (27.6%). Overall, the education level of adult male and female respondents (n = 105) was dominated by senior high school equivalent (58.1%) and diploma/bachelor (28.6%).A total of 323 individual subjects with a proportional number of adults , adolescents , and school-age children  were observed based on various parameters, including socio-economic characteristics, health and nutritional status, and food consumption. Adult male respondents  was one of the inclusion criteria in this study, diabetes mellitus and hypertension were identified in 1.9% and 3.8% of adult respondents, respectively. At the same time, less than 40% of the respondents’ family members had a history of the aforementioned diseases or cardiovascular disease.The adolescent respondents were mainly from medium families (consisting of 5–7 family members) (48.6%) and small families (<5 family members) (37.4%), and their family incomes were mainly lower than IDR 5 million (50.5%) or between IDR 5 and 10 million (27.1%). Most of the adolescent respondents had normal height (94.4%) and normal BMI (75.7%). Four out of 51 male respondents showed the pre-hypertension indication.In accordance with the findings on adolescents, school-age children also generally came from medium (55.9%) and small (44.1%) families, and their family incomes were mainly lower than IDR 5 million (57.7%) or between 5 and 10 million (35.1%). Nearly 90% of school-age children had normal height. There was one school-age girl identified to be severely stunted (z-score below −3). The majority of school-age respondents were found to have normal BMI. In addition, there were two school-age children showing pre-hypertension indication.Eggs, chicken, and poultry products have been identified as the major sources of animal protein for all respondents , followed by fish and meat. Adult respondents consumed more legumes and legume products  than the other age groups (1.24% for adolescents and 1.38% for school-age children). Adult respondents also consumed higher amounts of fruits and fruit products compared to the other respondents’ groups , with male respondents found to consume higher amounts of those products than female respondents.The observed mean calorie intakes  were 1702 ± 533 for adults, 1762 ± 586 for adolescents, and 1705 ± 551 for school-age children group. Details of the contribution of each food group to the daily calorie intake can be seen in The differences in the sources of food consumed by different respondents’ groups can be seen in The conducted food record allowed identifying 461 different food items consumed by the respondents. Supplements were excluded from the list of food groups, since their contribution to the intakes of sugar, salt, and fat was considered negligible. Data sources used to determine the sugar, salt, and fat content of all food items are shown in According to the Indonesian Individual Food Consumption Survey (IFCS) 2014, the average added sugar intake of Indonesian population was estimated as 25.60 ± 23.15 g sugar/day , so it was lower than the present study findings. About 11.8% of the total population consumed >50 g sugar/day . HoweverThe total added sugar intake observed in this study was still lower than the US daily intake (2007–2010) which reached 12.5–23.5 teaspoons/day in adults (19–70 years old), 17.5–24.6 teaspoons/day in adolescents, and 14.3–21.5 teaspoons/day in children . AccordiThe collaborators of the Global Burden of Diseases (GBD), Injuries, and Risk Factors Study) Diet 2017 reported that beverages are the main contributor to the total sugar intake, with a worldwide sugar intake from sugar-sweetened beverages reaching 49 g per day, far higher than the optimal intake [The percentage contribution of different food sources to the total added sugar intake is shown in Generally, about 75% of salt intake in high-income countries comes from processed foods and meals prepared outside of the home. At the same time, most of the sodium consumption in many low- and middle-income countries, especially in Asia, comes from salt added at home during cooking and at the table or through condiments such as fish sauce and soy sauce ,35. The The results of the fat intake of all respondents based on different food groups are presented in The percentage contribution of different food sources to the total fat intake is shown in r = 0.76, p < 0.01) [According to the joint FAO/WHO recommendations, the maximum daily fat intake should not exceed 30–35% of the total energy intake (TE), depending on the stage of growth and development (age), gender, and a number of lifestyle factors . If the  < 0.01) . Accordi < 0.01) . The die < 0.01) .According to the IFCS 2014, the average total fat intake of Indonesian population was 53.3 g/capita/day, with 27% of the population consuming fat exceeding the recommended limit (>67 g/day) . In addiFrom this study we found that the total consumption of food, excluding water, ranged from 1213 (by school-age girls) to 1568  g/capita/day. The total added sugar consumption of the respondents was about 9-10 teaspoons per day (34.9–45.8 g/capita/day), with beverages and processed foods identified as the major contributors to the sugar intake. Although the observed values were still lower than the maximum value set by WHO, reducing the sugar intake can be associated with an improved health condition. The highest total salt intake was found in adolescent subjects , followed by adults  and school-age children . Street/restaurant/fast food greatly contributed to the total daily salt intake. The efforts to reduce salt intake still need to be undertaken in order to avoid risks of elevated blood pressure, cardiovascular disease, stroke, and coronary heart disease. The highest intake of fat was observed among the adolescents group (61.2 g/capita/day). Similar to the finding on salt intake, the major food source contributing to the fat intake was street/restaurant/fast food. Male subjects tended to consume a higher amount of salt and fat than female subjects. These findings can serve as baseline information for policy makers to improve the diet quality, especially in Indonesia. Actions towards improving the diet quality should be undertaken with a collaboration of a variety of actors throughout the food system, along with policies which target multiple food system sectors.


Mitophagy is a type of autophagy that selectively degrades mitochondria. Mitochondria, known as the “powerhouse of the cell”, supply the majority of the energy required by cells. During energy production, mitochondria produce reactive oxygen species (ROS) as byproducts. The ROS damage mitochondria, and the damaged mitochondria further produce mitochondrial ROS. The increased mitochondrial ROS damage cellular components, including mitochondria themselves, and leads to diverse pathologies. Accordingly, it is crucial to eliminate excessive or damaged mitochondria to maintain mitochondrial homeostasis, in which mitophagy is believed to play a major role. Recently, the molecular mechanism and physiological role of mitophagy have been vigorously studied in yeast and mammalian cells. In yeast, Atg32 and Atg43, mitochondrial outer membrane proteins, were identified as mitophagy receptors in budding yeast and fission yeast, respectively. Here we summarize the molecular mechanisms of mitophagy in yeast, as revealed by the analysis of Atg32 and Atg43, and review recent progress in our understanding of mitophagy induction and regulation in yeast. C. elegans ), exist ,20,21,22Saccharomyces cerevisiae (S. cerevisiae), Camougrand et al. first observed mitophagy using mitochondria-targeting fluorescent protein and identified Uth1 as a mitophagy-related gene [Uth1 in mitophagy has since been disproven [Autophagy was first thought to be the nonselective degradation of cytoplasmic compartments, and it was unclear whether or not mitochondria were degraded selectively by autophagy. In yeast, ted gene . Althougisproven , the obsisproven . Atg11 hisproven ,27. Thusisproven ,28.Komagataella pastoris and Atg36 in S. cerevisiae, localize on peroxisomes and interact with Atg11 upon pexophagy induction [S. cerevisiae [Candida glabrata and Pichia pastoris, but not in fission yeasts [The cargo specific receptor is involved in selective autophagy in yeast. For the Cvt pathway, the cargo (the Ape1 complex) binds to the Atg19, a receptor to form the Cvt complex, and Atg19 interacts with the adaptor protein Atg11 . Similarnduction ,30. Atg1revisiae ,28. Atg3n yeasts . DeletioWhen mitophagy is induced, Ser114 and Ser119 on Atg32 are phosphorylated, which is essential for the Atg32-Atg11 interaction and mitophagy . FurtherMost of the selective autophagy receptors have a W/Y-X-X-L/I/V sequence termed the Atg8 family interacting motif (AIM), where X can be any acidic amino acid . Atg8 isAdditionally, it is speculated that the mitochondrial phosphatidylserine decarboxylase 1 (Psd1) recruits Atg8 to the mitochondria as Psd1 plays a particular role in mitophagy induced by nitrogen starvation. It is suggested that Psd1 provides PE for Atg8 lipidation and/or elongation of phagophore membrane, thus leading to recruitment of Atg8 to the mitochondria .S. pombe [S. pombe is highly dependent on the AIM-mediated Atg43-Atg8 interaction. The AIM-dependent mitophagy process observed in S. pombe is consistent with mitophagy in mammals. Here, mitophagy receptors, such as BNIP3, NIX, FUNDC1, BCL2L13, and FKBP8, interact with the Atg8 mammalian homolog LC3 family proteins via an LC3-interacting region (LIR) on the receptors, where this interaction has been shown to be crucial for mitophagy [Recently, mitophagy receptor Atg43 was identified by genome-wide screening for mitophagy-defective mutants in S. pombe . Atg43 iitophagy ,40,41,42Mitophagy can be induced in various ways. For example, mitophagy is induced by preculturing yeast in a medium with a nonfermentable carbon source and shifting it into a nitrogen starvation medium with a fermentable carbon source. In nonfermentable carbon source media, the cell obtains energy only from mitochondrial OXPHOS and promotes mitochondrial biogenesis. Then, in the nitrogen starvation medium with a fermentable carbon source, the cell begins obtaining energy from glycolysis and eliminates superfluous mitochondria via mitophagy. Another way to induce mitophagy is to culture yeasts in a medium with a nonfermentable carbon source until the stationary phase . MitophaMitophagy is regulated at the transcriptional and posttranslational modification levels. Here, we discuss the mitophagy regulatory mechanism at each level.ATG32 is suppressed in nutrient-rich conditions and is induced by the inhibition of TOR by nutrient starvation or rapamycin treatment in S. cerevisiae and K. pastoris. The DNA-binding protein Ume6 and the histone deacetylase complex Sin3-Rpd3 directly interact with the promoter region of ATG32 to repress its transcription. This repression of ATG32 transcription by the Ume6–Sin3-Rpd3 complex is released by TOR inhibition [ATG32 and ATG11 transcription in glucose-rich conditions. It is speculated that the Paf1 complex decreases ATG32 transcription by binding to the ATG32 promoter region and dissociates when yeast is exposed to glucose-starvation conditions [ATG32 during starvation requires N-terminal acetyltransferase A (NatA), which consists of the catalytic subunit Ard1 and adaptor subunit Nat1. Deletion of NatA led to severe mitophagy defect due to a lack in Atg32 expression [It has been shown that transcription of hibition  , inhibits Atg32 expression and mitophagy [ATG32 [ATG32 and mitophagy.An antioxidant, itophagy ,50. Addiy [ATG32 . These fThe Atg32 protein is synthesized in the cytosol and is integrated into the mitochondrial outer membrane (MOM). It was recently reported that the Atg32 C-terminal domain was integrated into the MOM depending on the translocase of the outer membrane (TOM) receptor, Tom20. By contrast, the cytosolic N-domain of Atg32 greatly relied on the mitochondrial import complex (MIM) .As previously discussed, mitophagy induction leads to phosphorylation of Atg32 at amino acid residues Ser114 and Ser119. This phosphorylation results in the interaction between Atg32 and Atg11. Importantly, the phosphorylation at Ser114 is more critical for mitophagy and the Atg32–Atg11 interaction than that at Ser119 . AlthougMitogen-activated protein kinases (MAPKs), namely, Slt2 and Hog1, and the mitogen-activated protein kinase kinase, Pbs2, were reported to be required for mitophagy. Slt2 was required not only for mitophagy but also for pexophagy and influenced recruitment of mitochondria to the PAS . On the YME1 or prevention of Atg32 processing by C-terminal tagging of Atg32 led to a defect in mitophagy and the disruption of the Atg32–Atg11 interaction , a mediator for ER–mitochondria contacts in yeast, is necessary for mitophagy ,63. ArtiCandida albicans, Mcp1, a part of membrane contact sites called vacuole and mitochondrial patches (vCLAMPs), was reported to be necessary for mitophagy. The Mcp1 is a protein localized on both mitochondria and vacuole. MCP1 deletion caused the accumulation of abnormally enlarged mitochondria due to failure in mitophagosome formation and corrupted stability of mitochondrial DNA [In rial DNA .It is thought that mitochondrial fission separates the damaged portions of the mitochondria from the mitochondrial pool, and the separated mitochondria are eventually degraded by mitophagy. The fusion and fission of the mitochondria occur in response to various intracellular and extracellular stimuli ,67. It wS. cerevisiae. This inhibits mitophagy and activates other types of autophagy, such as ribophagy, the Cvt pathway, and macroautophagy. This finding suggests that regulation of mitophagy via ubiquitination/deubiquitinating, common in mammals, exists also in yeast [The Ubp3-Bre5 deubiquitination complex is translocated to mitochondria during mitophagy in in yeast ,72.S. cerevisiae is mitophagy receptor Atg32. The phosphorylation of Atg32, which is mediated by CK2 and is inhibited by the Ppg1–Far complex, triggers mitophagy. Thus, mitophagy is regulated by the balance of kinase and phosphatase. The question that remains is how the phosphorylation of Atg32 by the kinase and phosphatase is controlled and what the upstream signaling pathway connecting the mitophagy-inducing stimuli to Atg32 phosphorylation is. In addition, the mitophagy receptor Atg43 in S. pombe was recently identified. Here, Atg43 interacts with Atg8 via the AIM, and this interaction is crucial for mitophagy. One of the remaining questions is how the activity of Atg43 is regulated in S. pombe.Mitophagy is a physiological process conserved in eukaryotic organisms, ranging from unicellular cellular organisms, like yeast, to multicellular organisms, such as mammals. In this review, we summarized the molecular mechanism and regulation of mitophagy in yeast. The key factor for mitophagy in Recently, it was reported that Atg32 was required for spermidine synthesis via its involvement in the production of the spermidine precursor S-adenosylmethionine. Spermidine induces nitric oxide production during heat stress, which is necessary for cytoprotection . It woulMitophagy has a vital role in mitochondrial homeostasis. Therefore, abnormalities in mitophagy are thought to be the cause of various diseases relating to mitochondrial dysfunction. The progression of our understanding of mitophagy in yeast is likely to open the door to further knowledge of diseases involving mitochondrial abnormalities.


Post-anesthetic shivering is one of the most common complications after anesthesia. Ketamine has been considered to be an effective treatment for post-anesthetic shivering, but the evidence for its therapeutic benefit after spinal anesthesia is limited. The aim of this study was to compare the effects of intravenous ketamine with intrathecal meperidine in the prevention of post-anesthetic shivering after spinal anesthesia for lower limb orthopedic surgeries.In a double-blind randomized parallel-group clinical trial, a total of 150 patients scheduled for lower limb orthopedic surgeries under spinal anesthesia were selected and randomly divided into three equally sized groups of intravenous ketamine (0.5 mg/kg), intrathecal meperidine (0.2mg/kg) or intravenous normal saline (as placebo). The intensity of shivering in patients were evaluated during surgery and after transfer into the post anesthesia care unit. Also, changes in patients' drowsiness, nausea, vomiting, pruritus, mean arterial pressure, heart rate, and arterial oxygen saturation (SPO2) during surgery and until the end of anesthesia were evaluated.In all times of evaluation  patients in control group showed a greater intensity of shivering compared to other groups. However, patients who received intrathecal meperidine experienced significantly lower intensity of post anesthetic shivering (p<0.05). The results showed a significant mean arterial pressure and heart rates differences between the three groups, only on 20 and 60 minutes after initiation of spinal anesthesia. The incidence of nausea, vomiting, and pruritus was not significantly different in all three groups, although all patients who received ketamine experienced drowsiness after surgery (p<0.001).The results of the present study showed that, although both intrathecal meperidine and intravenous ketamine could effectively prevent postoperative shivering after spinal anesthesia in lower limb orthopedic surgeries, intrathecal meperidine was associated with more efficacy benefits and a lower frequency of side effects such as post-anesthesia drowsiness. Postoperative shivering is one of the most common complications after general or regional anesthesia as an unpleasant and stressful experience in patients, which can exacerbate postoperative pain . The prePrevention or treatment of postoperative hypothermia and shivering consists of pharmacological and non-pharmacological interventions. Non-pharmacological modalities include the use of heating blankets, keeping the patient warm and preventing temperature loss before and after surgery, inhaling hot and humid oxygen, and preventing the over-cooling of the operating room environment. Despite the promising results, the efficacy of these nonpharmacological treatments are largely limited and unknown , 10. VarAlthough different strategies are used for postoperative shivering management, there is no proven strategy to prevent it. Among opioids, meperidine is known for its potential ability to treat postoperative shivering after general and regional anesthesia. In addition, it has been shown that the effect of meperidine on postoperative shivering control is better than morphine and fentanyl . KetaminConsidering the potential preventive efficacy of combination of intravenous ketamine with intrathecal meperidine for postoperative shivering, the aim of this study was to compare the effects of intravenous ketamine with intrathecal meperidine in the prevention of postanesthetic shivering after spinal anesthesia for lower limb orthopedic surgeries.Study design and sample: In a double-blind randomized parallel-group clinical trial, a total of 150 patients who were admitted to Imam Khomeini Hospital in Sari, Iran, for lower limb orthopedic surgery using spinal anesthesia were evaluated. The study was conducted between March 2017 and January 2019.Inclusion and exclusion criteria: The inclusion criteria were elective lower limb orthopedic surgery (knee and below-knee), using spinal anesthesia, age between 18–65 years, ASA Class I, II, no drug addiction, no neurological diseases, no fever, no symptoms of high intracranial pressure such as headache, nausea, vomiting, blurred vision, diplopia), BMI<30, no contraindications for spinal anesthesia known and allergy to meperidine or ketamine. Patient dissatisfaction with continuing to participate in the study, preoperative temperature >38°C or <35°C, receiving blood or blood products during surgery and occurrence of any complications during surgery were considered as exclusion criteria.Intervention: Eligible patients were randomly allocated into three groups (two intervention groups and one control group), with an equal sample size. In the first group of interventions, 15 mg of bupivacaine 0.5% in normal saline  was administered intrathecally. Immediately after spinal anesthesia, 0.5 mg/kg of ketamine in normal saline  was intravenously infused. In the second group of interventions, 15 mg of bupivacaine 0.5% and 0.2 mg/kg of meperidine in normal saline  was injected intrathecally. In addition, immediately after spinal anesthesia five ml of normal saline was infused intravenously. In the control group, 15 mg of bupivacaine 0.5% in normal saline was injected intrathecally . Also, five ml of normal saline was infused intravenously. During the present study, the intraoperative room temperature was maintained at 23–25°C. Also, all patients received intravenous fluids at room temperature.Randomization and blinding: Eligible patients were divided into three equal groups to participate in the study, using a computerized list of random numbers. Patients were blinded with regard to study groups. Also, a nurse anesthetist who were unaware of patients' group, assessed the outcomes of the study. To ensure allocation concealment, the allocation sequence was constructed by an anesthesiologist who was not involved in recruitment.Data collection: In this study, a researcher-made checklist was used to collect data. This checklist was included patients' demographic and clinical characteristics such as age, sex, weight, height, mean arterial systolic and diastolic blood pressure, heart rate, oxygen saturation (SPO2), pruritus, nausea, vomiting, drowsiness-restlessness and the duration of spinal anesthesia and surgery. These data were recorded immediately before the start of anesthesia and every 20 minutes until the end of the surgery and admission to the post anesthesia care unit. The checklist was completed by a nurse who was blinded from the study groups and had received sufficient training to fill the questionnaire. In addition, at the beginning of the study, patients' weight was measured in kg and height in cm, and the BMI of the patients was calculated by dividing the weight (kg) by the square height (m2).Outcomes: In this study, the primary outcome was the intensity of shivering which was evaluated at 3 minutes before the onset of spinal anesthesia, as well as 20, 60, 80, 100 and 120 minutes after the onset of spinal anesthesia. Shivering was graded with a defined scale by Crossley et al. .Sample size calculation: A priori sample size was calculated using GPower3.1 with the formula for calculation of samples of repeated measures, based on a presumed effect size of 0.1, a statistical power of 80%, and a type I error of 5%. The overall proper sample size was found to be 135 participants. We therefore recruited 150 patients to account for any dropouts.Statistical analysis: Data were analyzed using SPSS software package . In this study, descriptive statistics  and inferential statistics  were used. P-value <0.05 was considered statistically significant.Data sharing: All relevant data and methodological detail pertaining to this study are available to any interested researchers upon reasonable request to corresponding author.In total, 150 patients were included in the study, which was divided into three groups with an equal sample size . In the intravenous ketamine, intrathecal meperidine and control groups 64%, 76%, and 72% of patients were male. The mean age of patients in the ketamine intravenous, intrathecal meperidine, and control groups was 41.24 (SD=12.71), 40.4 (SD=15.51), and 39.69 (SD=11.31) years, respectively. Other demographic and clinical characteristics of patients were shown in Primary OutcomeShivering: Before onset the anesthesia, there was no differences between three groups in terms of intensity of shivering. However, there was a significant difference between three groups  in terms of shivering intensity after initiation of spinal anesthesia. So that in all times of evaluation  patients in control group showed a greater intensity of shivering compared to other groups (p<0.05) ((p<0.05) .Secondary OutcomesHypothermia: The results showed that before the onset of spinal anesthesia, there was no differences between three groups in terms of the occurrence of hypothermia (p=0.142). However, there was a significant difference between three groups in terms of hypothermia after 60, 80, 100 and 120 minutes after onset of spinal anesthesia. Patients in control group experienced greater degree of hypothermia in abovementioned time intervals compared to other groups (p<0.05) ((p<0.05) .Changes of SPO2, MAP and Heart rate: The results showed that there were no significant differences between three groups in terms of SPO2, in all times interval of evaluation.Regarding MAP and heart rate, the results showed a significant MAP and heart rates differences between the 3 groups, only on 20 and 60 minutes after initiation of spinal anesthesia .Side effects: The results showed that the rate of vomiting in the intravenous ketamine group was 4% (2 cases in 50 patients), in the intrathecal meperidine group was 4% (2 cases in 50 patients), and the in the control group was 4% (2 cases in 50 patients) (p=0.323). Nausea was occurred in 4 cases (8%) of the intravenous ketamine group, 6% in the intrathecal meperidine group (3 cases), and 8% in the control group (4 cases) (p=0.132). None of patients in intravenous ketamine and control groups experienced pruritus after spinal anesthesia, however, 4% (2 cases) of patients in the intrathecal meperidine group had pruritus after spinal anesthesia (p=0.210). The rate of drowsiness in the intravenous ketamine group was 100%. However, post-anesthesia drowsiness was not occurred in any of patients in the intrathecal meperidine and control groups (p<0.001) (p<0.001) .The results of the present study showed that, although both intrathecal meperidine and intravenous ketamine could effectively prevent postoperative shivering after spinal anesthesia in lower limb orthopedic surgeries, intrathecal meperidine was associated with more efficacy benefits and a lower frequency of side effects such as pruritus. In recent years, researchers have investigated the effects of various pharmacological agents for prevention or treatment of postoperative shivering , 17–18. In our study it has been revealed that patients who received intravenous ketamine had higher MAP and HR compared to patients who received intrathecal meperidine. Although, these differences were statistically significant only in 20 and 60 minutes after anesthesia. This finding was not supported by other studies that evaluated the prophylactic effects of ketamine for postoperative surgery , 21. In