Background: Stem cells have been associated with self-renewing and plasticity and have been investigated in various odontogenic lesions in association with their pathogenesis and biological behavior. We aim to provide a systematic review of stem cell markers’ expression in odontogenic tumors and cysts. Methods: The literature was searched through the MEDLINE/PubMed, EMBASE via OVID, Web of Science, and CINHAL via EBSCO databases for original studies evaluating stem cell markers’ expression in different odontogenic tumors/cysts, or an odontogenic disease group and a control group. The studies’ risk of bias (RoB) was assessed via a Joanna Briggs Institute Critical Appraisal Tool. Meta-analysis was conducted for markers evaluated in the same pair of odontogenic tumors/cysts in at least two studies. Results: 29 studies reported the expression of stem cell markers, e.g., SOX2, OCT4, NANOG, CD44, ALDH1, BMI1, and CD105, in various odontogenic lesions, through immunohistochemistry/immunofluorescence, polymerase chain reaction, flow cytometry, microarrays, and RNA-sequencing. Low, moderate, and high RoBs were observed in seven, nine, and thirteen studies, respectively. Meta-analysis revealed a remarkable discriminative ability of SOX2 for ameloblastic carcinomas or odontogenic keratocysts over ameloblastomas. Conclusion: Stem cells might be linked to the pathogenesis and clinical behavior of odontogenic pathologies and represent a potential target for future individualized therapies. Odontogenic tumors and cysts are a diverse group of lesions that have in common their origin from cells participating in the normal process of tooth formation or odontogenesis. Benign and malignant odontogenic tumors are rare, representing less than 1% of oral tumors .The most common benign odontogenic tumor is ameloblastoma (AMBL), a locally infiltrative neoplasm with a high recurrence rate that may occasionally undergo malignant transformation . AMBL ofOdontogenic cysts are of developmental and inflammatory origin. The most common developmental odontogenic cyst is the dentigerous cyst (DC), which is associated with the crown of unerupted teeth, grows slowly, and rarely recurs ,4. OdontThe odontogenic tissues develop through constant epithelial–mesenchymal interactions, where stem cells play a pivotal role . OdontogPrevious studies have focused on the expression of a limited number of stem cell markers in odontogenic tumors and cysts ,12,13,14Herein, we aim to provide a thorough systematic review of studies investigating the expression of stem cell markers in odontogenic tumors and cysts. The null hypothesis is that there are no significant differences in the expression of stem cell markers between various odontogenic lesions.The research question of the study was formulated using the Population, Intervention, Comparator, and Outcome framework as follows: “Are there any differences in the expression of stem cell markers between various odontogenic lesions?” . The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines  were appThe literature search was performed on 10 April 2023 through the MEDLINE/PubMed, EMBASE via OVID, Web of Science, and CINHAL via EBSCO host databases to identify articles published in peer-reviewed journals and written in the English language, which included the following keywords in the title or abstract:  and (stem cell* or pluripoten*). The search terms in each database are presented in The titles and abstracts of the retrieved studies were screened by three researchers  independently to identify original studies investigating the expression of stem cell gene markers in human benign or malignant odontogenic tumors, as well as odontogenic cysts of developmental or inflammatory origin . Case reThe full text of studies considered as suitable at previous search steps were investigated for eligibility by three researchers  independently and any cases with discrepancy were resolved by asking for an opinion from the other two authors (E.M.K. and K.I.T.) . EligibiIn articles including multiple gene markers or multiple methods, the eligibility criteria were applied on each marker/method individually. Genes known to be surface markers of embryonic stem cells (ESCs) or cancer stem cell biomarkers, with a principal role in stem cell phenotype induction and/or maintenance ,21,22, wStudies excluded from qualitative analysis at any search phase and the reasons for exclusion are presented in Four authors  extracted the following data in Microsoft Office Excel 365 spreadsheets:(1) Data regarding the reference, i.e., authorship, publication year, and journal, and the study population, i.e., sample type, number of patients, number of samples in each odontogenic lesion/control group, demographic characteristics, location of odontogenic lesions/control samples, whether a detailed histopathologic description or a reference  was provided to support the diagnosis of the included odontogenic entities, and the histopathological variants in case of solid ameloblastomas (AMBLs) ((2) Information about the method applied for the evaluation of stem cell marker(s)’ expression and the stem cell marker(s) as recorded by the protein/gene name provided by each publication and by the Human Genome Organization (HUGO) Gene Nomenclature  Table S. Methodo(3) Information about the expression results, i.e., number or percentage of positive cases and/or expression score, in case of studies on tissues, or percentage of positive cells in case of in vitro experiments, as well as the results of differential expression analysis . FinallyQuality assessment was performed by two investigators (G.L. and A.P.) independently, and any disagreements were resolved through discussion with a third author (E.M.K.). Based on the retrospective nature and small sample size of the eligible articles that did not include follow-up data, the risk of bias (RoB) was estimated with the Critical Appraisal Tool, proposed by the Joanna Briggs Institute (JBI) , appliedAiming to evaluate the discriminative ability of stem cell gene markers between different odontogenic entities, a meta-analysis was performed for markers whose expression was tested (a) between the same pair of odontogenic entities, (b) in at least two studies, and (c) was evaluated in the same microscopic compartment (epithelium or stroma). Meta-analysis was conducted on the studies that passed the selection criteria, using Meta-DiSc Version 1.4 , as prevThe systematic literature search yielded 246 records through four electronic databases, and 19 records manually . After 1Various combinations of benign and malignant odontogenic tumors, and odontogenic cysts with developmental or inflammatory origin, alone or compared with non-disease/lesional controls, constituted the study population . In 12 oThe exact number of patients who contributed the study samples was available in 15 out of 29 articles . DemograNineteen different stem cell markers were used to investigate the presence of cells with stem cell properties in odontogenic tumors and cysts . SOX2 exAll but one of the retrieved studies reported the expression of stem cell markers in odontogenic tumors and cysts based on immunohistochemical or immunofluorescence analyses . One stuAll evaluated stem cell markers were expressed in at least one odontogenic entity, and, according to most studies with available information regarding localization, they were predominantly expressed in the tumor parenchyma or cystic epithelium . Figure AMBL was found to express ABCG2 , ALDH1 , BMI1 1,40, CD13AOT expressed ALDH1 , CD44 3, c-Myc , and NesCD34, NANOG, and SOX2, but not OCT4, were expressed in the stromal cells of odontogenic myxoma . AmeloblExpression of ABCG2, BMI1, and CD133 at the mRNA and protein level was reported in cases of metastasizing AMBL, ACA, and clear cell odontogenic carcinoma . InteresOKC expressed ALDH1 , CD166 , CD44 3,46,48, cDC expressed CD44 ,48 and cCalcifying odontogenic cysts were positive for CD44 , but negFive immunohistochemical studies found expression of the CD44 protein in either the cystic epithelium ,48 or thSeven, nine, and thirteen studies were characterized by low, moderate (unclear), or high RoB, respectively , accordiEight studies met the selection criteria and were included in the quantitative analysis . Three, 2 = 0%), DOR had insignificant heterogeneity (I2 = 20.8%), Specificity had moderate heterogeneity with an I2 of 71.5%, and LR+ had high heterogeneity with an I2 of 78.4%. Finally, the diagnostic usefulness of SOX2 for the differential diagnosis of ACA and AMBL was high (Area Under the Curve (AUC) = 0.9022).In the ACA vs. AMBL meta-analysis for SOX2 expression , Sensiti2 of more than 80%. The discriminative ability of SOX2 between OKC and AMBL was outstanding (AUC = 0.9931).In the OKC vs. AMBL meta-analysis for SOX2 expression , Sensiti2 values of 65.6%, 53.3%, and 64.4%, respectively, while Sensitivity and Specificity had high heterogeneity with I2 values of 97.5% and 76%, respectively. Since only two studies were included, no summary Receiver Operating Characteristic (SROC) curve was produced and, thus, AUC was not calculated.In the AMBL vs. DF meta-analysis for SOX2 expression , Sensiti2 = 0%), while LR+ presented moderate heterogeneity (I2 = 61.8%). Sensitivity and Specificity had high heterogeneity with I2 of values of 97.1% and 97.5%, respectively. Since there were only two studies included, no SROC plot could be produced.In the OKC vs. AMBL meta-analysis for OCT4 expression , SensitiThe present study summarizes for the first time the evidence available in the literature on the expression of stem cell gene markers in odontogenic tumors and cysts, and further highlights the usefulness of SOX2 in the differential diagnosis of odontogenic lesions with divergent biological behavior.Most relevant studies investigated AMBL, OKC, DC, and RC, the first two apparently due to their aggressive biological behavior , and theSOX2 (SRY-box transcription factor 2) gene that is expressed in ESCs and adult tissue stem cells, and exerts an important role in the development of tissues of ectodermal origin, including the odontogenic epithelium [Among the eighteen stem cell markers identified in this systematic review , SOX2 waithelium ,56. SOX2ithelium . In addiithelium . Accordiithelium ,29,30. TFurthermore, the quantitative analysis performed in the present study indicated that SOX2 expression between OKC and AMBL is different. This finding is significant as it could be associated with differences in the pathogenesis of those lesions, while diagnostically it could be utilized in the identification of ameloblastic transformation in OKC. Previous studies have shown nuclear expression of SOX2  in the dPOU5F1 gene, is evaluated in multiple studies (SOX2 and POU5F1/OCT4 in xenograft mouse model assays were thought to represent reprogrammed cells capable of inducing tumorigenesis [The expression of OCT4 (Octamer-binding transcription factor 4), a member of the Pit-Oct-Unc (POU) family of transcription factors, encoded by the  studies ; howeverigenesis . Whetherigenesis  and SOX2igenesis ,29,30 inKLF4 gene was upregulated in OKC compared to DF, and immunohistochemistry showed strong nuclear expression of the KLF4 protein, mainly in intermediate layers, and focally weak expression in the basal layer of OKC epithelia [Of note, except for SOX2 and OCT4, the other two “Yamanaka factors” , i.e., Kpithelia . c-Myc ipithelia . Immunohpithelia . It is wpithelia ,68, furtCD44 gene, was also investigated in many studies  or high RoB, predominantly due to the omission of information related to the diagnosis and clinical characteristics of the lesions or patients’ demographics. High risk of bias for the aforementioned items was also found in our previous systematic review , emphasiA strength of the present systematic review is the inclusion of studies on human tissues, regardless of the fixation/processing method or the technique of stem cell marker evaluation, therefore resulting in more eligible studies. In addition, a thorough description of methodological details, as well as expression findings of the eligible studies is provided as supplementary material that may be useful in the design of future studies on stem cells’ expression. On the other hand, the fact that most stem cell markers were assessed only by one or two studies, as well as the small number of studies that investigated the expression of the same markers in the same odontogenic entities, may be regarded as study limitations.The present study reviewed systematically for the first time the pertinent literature on stem cell gene expression in odontogenic tumors and cysts. It is suggested that stem cells may be linked to the development and clinical behavior of odontogenic pathologies and represent a potential target for future individualized therapeutic approaches. The outstanding discriminative ability of SOX2 for OKC vs. AMBL, as indicated by our meta-analysis, may be associated with their origin from cell populations at distinct stages of odontogenesis. Finally, our meta-analysis highlighted the significance of the SOX2 marker in the differential diagnosis of ACA vs. AMBL, which is of diagnostic value and should be verified by further studies.


COVID-19 resulted in enormous disruption to life around the world. To quell disease spread, governments implemented lockdowns that likely created hardships for households. To improve knowledge of consequences, we examine how the pandemic period was associated with household hardships and assess factors associated with these hardships.We conducted a cross-sectional study using quasi-Poisson regression to examine factors associated with household hardships. Data were collected between August and September of 2021 from a random sample of 880 households living within a Health and Demographic Surveillance System (HDSS) located in the Harari Region and the District of Kersa, both in Eastern Ethiopia.Having a head of household with no education, residing in a rural area, larger household size, lower income and/or wealth, and community responses to COVID-19, including lockdowns and travel restrictions, were independently associated with experiencing household hardships.Our results identify characteristics of groups at-risk for household hardships during the pandemic; these findings may inform efforts to mitigate the consequences of COVID-19 and future disease outbreaks.The online version contains supplementary material available at 10.1186/s12889-023-16982-0. The COVID-19 pandemic resulted in enormous disruptions to life around the world. Beyond direct health effects . To adheth of 2020, intensified on March 20th, and ultimately a five-month-long state of emergency was declared on April 10th [In sub-Saharan Africa (SSA), national governments undertook considerable efforts to quell the spread of COVID-19 , 20. Mitril 10th . Economiril 10th . These dVulnerability is the collective effect of cultural, economic, institutional, political, and social processes that modify the experience of and recovery from a given hazard . In the In Ethiopia, those already burdened by social and economic disparities and limited in their ability to access resources are at greater risk for experiencing additional hardships during the pandemic: older adults, people with disabilities or pre-existing medical conditions, the poor, people living in congested residences and/or slums, pregnant women, and the unemployed , 10, 20.The setting for this study is a predominantly rural area in the Kersa District and an urban area in the Harari People’s National Regional State in Eastern Ethiopia , 36. Thementclass2pt{minimThis study is part of a larger examination within the Child Health and Mortality Prevention Surveillance (CHAMPS) network to understand the consequences of COVID-19 lockdowns for child health and mortality –14. We aThe questionnaire was structured into five sections: knowledge regarding the spread of COVID-19; food availability; COVID-19-related shocks and coping; under-five child healthcare services; and healthcare services for pregnant women. Questions in the survey instrument related to hardships associated with the pandemic period asked respondents to consider whether a given hardship had occurred since March 2020. Data collectors were drawn from the fieldwork teams of HDSS enumerators already trained and working in the HDSS. Data collection occurred between August and September 2021 and was carried out through tablet-based in-person interviews with adult household members. All of the 880 sampled households consented and participated in the survey. Data from the questionnaire were linked with data from the most recently completed HDSS round (collected from January to May 2020) to incorporate additional demographic data about the sampled household, specifically: age, sex, occupation, and education of the head of household; the number of children under 5 years of age and the number of adults over age 60 in the household; and household assets and residence construction materials. Data quality assurance and cleaning followed standard procedures for the HDSS , 38. IncThe primary outcome variable, Household Hardships, was generated as an additive index of the number of hardships a household reported experiencing since the onset of the COVID-19 pandemic ; it was coded as a count variable ranging from 0 to 9, with 1 point given for each hardship a household reported from the list in Fig. As an alternative representation of hardships used in a sensitivity analysis, we used principal components analysis (PCA) with varimax rotation to extract orthogonal factors from the variables in Household Hardships. The eigenvalues of the correlation matrix from PCA demonstrated that the first factor explained 40% of the variability in the data and the second explained 20%. Subsequent factors explained little variability. We opted to retain the first factor, which included job loss, business closure, farm disruption, livestock disruption, fishing disruption, and output deflation, as an index we termed Household Disruptions. Variables highly correlated with the factor were weighted against their eigenvector coefficients. Details related to the PCA results for the Household Disruptions are presented in Appendix Additional outcome variables were analyzed in a secondary analysis for households that reported experiencing at least one hardship during the pandemic. These outcome variables represented a variety of strategies that households may have employed in an attempt to mitigate experiences of hardship during the pandemic ; they were all coded Yes = 1 and No = 0 to signify if a given strategy was employed. A complete list of these additional outcome variables and corresponding descriptive statistics are presented in Fig. Right-hand side variables in our analyses included information on the head of household, characteristics of the household and its homestead, and information related to household awareness of local government responses to COVID-19. Head of household variables included age ; sex ; ethnicity (coded as Amhara = 1 (reference) and other = 2, which included Oromo, Somali, Gurage, Harari and Tigray); education , any level of education = 1); occupation (coded as 1 = farmer/domestic (reference), 2 = student, 3 = professional, 4 = sales, 5 = daily laborer, 6 = other employment, 7 = unemployed/retired). Household variables were urbanicity (coded as urban (Harar) = 1 and rural (Kersa) = 0); household size , 2 = 3-4 individuals, 3 = 5-6 individuals, 4 = 7-8 individuals, 5 = 9+ individuals); children under age 5 ; adults over age 60 ; monthly income , 2 = 1,201-2,000 Birr, 3 = 2,001-3,000 Birr, 4 = 3,001-4,600 Birr, and 5 = >4,600 Birr; based on exchange rates at the time of the survey, this is roughly equivalent to 1 = Less than 33 USD (reference), 2 = 33 to 55 USD, 3 = 55 to 83 USD, 4 = 83 to 127 USD, and 5 = More than 127 USD ; and a wealth index based on a list of household assets (coded as an 1 = poorest (reference), 2 = poorer, 3 = middle, 4 = richer, 5 = richest). See Appendix Household Hardships or the PCA-based index of Household Disruptions  [Data cleaning and analysis was performed using R version 4.2.0 . Educatirequest) . Adjusterequest) , 45. GivOnly 13% of households reported not experiencing any of the measured hardships; the remaining 87% experienced at least one hardship Fig. . Other cA majority of households (66%) were headed by a male household member Table . AverageAfter adjusting for other variables Fig. , the numBaseline predicted counts of household hardships experienced during the pandemic based on urbanicity are presented as a facet grid in Fig. Among households that reported experiencing at least one hardship during the pandemic, the most common household response was reducing food consumption, which was reported by 24.4% of affected households see Fig. . Other cDetailed results are presented in Figs. C.1 - C.5 in Appendix In this study, we examined the prevalence of household hardships during the COVID-19 pandemic in a rural and an urban community in Eastern Ethiopia. We further examined demographic, economic, and social characteristics associated with these hardships as well as strategies households used to mitigate consequences of these hardships. Almost 90% of households reported experiencing at least one hardship since the onset of the pandemic; 75% of households reported experiencing at least 4 hardships. Risk factors for experiencing these hardships included demographic, economic, geographic, and social characteristics. Residing in a rural area magnified the strength of the associations for several household risk factors.Households were more likely to report a higher number of hardships if the head of household had no education or worked as a farmer or in subsistence activities (housewife). Households were also more likely to report experiencing a higher number of hardships if they resided in a rural vs. an urban area, had a larger number of household members, had less monthly income, and were poorer compared to other households in the community. The pattern of association for both monthly income and household wealth is suggestive of a dose-response; households with less wealth and less monthly income were at significantly higher risk for experiencing a higher number of hardships. These associations are consistent with the vulnerability framework that we outlined, which identifies characteristics of individuals and households anticipated to increase the risk of negative outcomes in disaster situations –27. The Our findings are also consistent with risk factors commonly reported in studies on negative consequences of COVID-19 from other resource-limited countries, particularly in Africa, and other research from Ethiopia , 15, 20.Mitigation efforts in Ethiopia included social distancing, lockdowns, and emphasizing hygiene protocols . We antiHouseholds that experienced hardships during the pandemic relied upon a variety of coping strategies to mitigate harmful effects; implementation of these strategies varied to a degree by the type of hardship a household experienced. Households that experienced the loss of employment by a household member or observed increasing costs of business or farming inputs were more likely to utilize the broadest combination of household responses to pandemic hardships. Compared to urban households, rural households were more likely to implement each of the response strategies, even after adjusting for demographic, economic, and social characteristics as well as pandemic-related hardships.The findings from this study are specific to these communities and are not generalizable to other contexts, but they are consistent with findings reported in other studies from Africa , 15, 20.Households living in rural Eastern Ethiopia were at greater risk of experiencing a variety of hardships during the COVID-19 pandemic compared to urban households, even after adjusting for demographic, economic, and social risk factors. Moreover, the strength of the associations between household hardships and demographic, economic, and social risk factors was greater for rural households compared to urban ones. These results suggest that socioeconomic differences between urban and rural areas may have been amplified during the pandemic. Interventions to ameliorate the consequences of lockdowns and other efforts to stem disease spread should also consider place inequalities and differential vulnerabilities.Additional file 1.


Background: The clinical outcomes of antiretroviral drugs may be modified through drug interactions; thus, it is important to update the drug interactions in people living with HIV (PLHIV). Aim: To update clinically relevant drug interactions in PLHIV on antiretroviral therapy with novel drug interactions published from 2017 to 2022. Methods: A systematic review in Medline/PubMed database from July 2017 to December 2022 using the Mesh terms antiretroviral agents and drug interactions or herb–drug interactions or food–drug interactions. Publications with drug interactions in humans, in English or Spanish, and with full-text access were retrieved. The clinical relevance of drug interactions was grouped into five levels according to the gravity and probability of occurrence. Results: A total of 366 articles were identified, with 219 (including 87 citation lists) were included, which allowed for the identification of 471 drug interaction pairs; among them, 291 were systematically reported for the first time. In total 42 (14.4%) and 137 (47.1%) were level one and two, respectively, and 233 (80.1%) pairs were explained with the pharmacokinetic mechanism. Among these 291 pairs, protease inhibitors (PIs) and ritonavir/cobicistat-boosted PIs, as well as integrase strand transfer inhibitors (InSTIs), with 70 (24.1%) and 65 (22.3%) drug interaction pairs of levels one and two, respectively, were more frequent. Conclusions: In PLHIV on antiretroviral therapy, we identify 291 drug interaction pairs systematically reported for the first time, with 179 (61.5%) being assessed as clinically relevant (levels one and two). The pharmacokinetic mechanism was the most frequently identified. PIs, ritonavir/cobicistat-boosted PIs, and InSTIs were the antiretroviral groups with the highest number of clinically relevant drug interaction pairs (levels one and two). Human immunodeficiency virus (HIV) is one of the main public health problems. According to the World Health Organization (WHO), globally, 39.0 million (33.1–45.7 million) people were living with HIV at the end of 2022; additionally, during 2022, 630,000  people died from HIV-related causes and 1.3 million (1.0–1.7 million) persons acquired HIV [Currently, in PLHIV, initial ARV therapy generally consists of two nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) combined with a third active ARV drug, which may be an integrase strand transfer inhibitor (InSTI), a non-nucleoside reverse transcriptase inhibitor (NNRTI), or a protease inhibitor (PI) boosted with cobicistat (COBI) or ritonavir (RTV). InSTIs such as bictegravir (BIC) or dolutegravir (DTG) are the preferred third ARV drug, mainly due to being associated with a lower risk for drug resistance and for drug–drug interactions . AdditioA drug interaction is an undesirable modification that is quantifiable in the magnitude or duration of effects related to the simultaneous or previous administration of other drugs, phytotherapeutics, foods, or due to pathophysiological  conditions of the patient . The ide®) was developed [® and InterApp ARV, used as a graphic reference the free software developed by the University of Liverpool (https://www.hiv-druginteractions.org/ accessed on 25 July 2023), is considered as the most used online source of DDI in HIV [Regarding clinically relevant drug interactions in persons with HIV, from 1995 to 2017, we identified four previously published reviews, which focused on identifying drug interactions between ARV drugs, phytotherapeutics, and foods ,7,8. Theeveloped . The devI in HIV . In thisSimilar to previously published reviews, a systematic review was conducted in the Medline/PubMed database from 1 July 2017 to 31 December 2022 using the Mesh terms antiretroviral agents AND drug interactions OR herb–drug interactions OR food–drug interactions. Articles published in English or Spanish and with full-text access were identified.Inclusion criteria: We included all articles containing clinically relevant information on drug interactions in humans using antiretroviral agents for the treatment of persons living with HIV/AIDS. Additionally, other studies were identified from the reference list of retrieved articles.Exclusion criteria: We excluded the following types of articles: (a) preclinical or in vitro studies; (b) with theoretical concepts regarding drug interactions; (c) without specific ARV drug interactions; (d) not related to HIV; and (e) without full-text availability.To ensure a systematic approach, three researchers reviewed the studies identified according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) flow chart via a predetermined eligibility criteria . The titThe drug interaction pairs of identified ARV agent–drug interactions were classified into five levels according to the gravity  and probability of occurrence (type of study that supports the interaction), following the combination of options, as shown in Possible: The drug interaction pair was documented with results from less than three case reports or by expert consensus.Probable: The drug interaction pair was documented with results from at least one observational study (cohort or case–control study) or at least three case reports.Defined: The drug interaction pair was documented with results from at least one meta-analysis, systematic review, or randomized or nonrandomized clinical trial.The probability was determined and classified according to the kind of study that supported the interaction found for each pair of drug interactions :PossibleIn the cases of the reviews, including systematic reviews or meta-analyses, the reference list was reviewed and the drug interaction had to be support with a clinical study. In addition, if the study  was identified for the first time, it was included. Therefore, in the current update, the drug interaction pair probability, due to bringing together all the references that supported it, could be (a) systematically identified for the first time (the references identified for the first time generated the probability), (b) increased (the references identified for the first time modified the probability), or conserved .Lack of gravity: There was evidence that the drug interaction did not cause harm to the patient.Minor: The drug interaction did not cause or caused minimum harm to the patient , but generated the need for monitoring the patient’s health.Moderate: The drug interaction generated the need for a closer monitoring of the patient’s health .The gravity attributed to the drug interaction was determined and classified according to the effect on the patient’s health ,4:Lack oFrom the search in the PubMed/Medline database, 366 records were retrieved; among them, 5 were removed before screening. Then, 110 records were excluded due to the screened title and abstract. Thus, 251 articles were assessed for eligibility; among them, 119 were excluded and, consequently, a total of 132 articles were included in the review. In addition, from the citation list, 87 articles were included; thus, 219 articles were used for this review . HoweverA total of 471 drug interaction pairs between antiretroviral agents and other drugs were identified; of them, 291 were interactions systematically reported for the first time, 125 were updates to drug interactions reported previously, and 55 were related to drugs not yet approved or to discontinued drugs in clinal practice . The cliAmong the 291 interactions systematically reported for the first time, 179 (61.5%) were assessed as having a higher risk of causing adverse drug outcomes related to the ineffectiveness or unsafe use of the pharmacotherapy, of which 42 (14.4%) and 137 (47.1%) were assessed as level one and level two, respectively . Table 3Globally, among the 291 interactions systematically reported for the first time, 50 (17.2%) were assessed as being level five; thus, with evidence of the absence of clinically relevant drug interactions, 20 (6.1%) for InSTIs, 14 (4.8%) for NNRTIs, and 9 (3.1%) for PIs and RTV/COBI-boosted PIs were the more frequent . In addi2), with 29, (16.2%) and oral anticoagulants (warfarin and direct-anticoagulants), with 23 , were the non-ARV pharmacologic groups with more drug interaction pairs. Additionally, there were six (3.4%) clinically relevant drug interactions (level two) associated with drug or substance misuse, such as amphetamines or ketamine, mainly due to the concomitant use of boosted PIs and elvitegravir/cobicistat (EVG/COBI). Additionally, six (3.4%) drug interaction pairs with benzodiazepines were identified  were assessed as the most clinically relevant (levels one or two). These figures were lower than reported in the update for 2015–2017 , in whic1.1% wereThe pharmacokinetic mechanism was the most frequent to explain the drug interaction; thus, it was the mechanism to 233 (80.1%) of the 291 pairs systematically reported for the first time. The pharmacokinetics of ARV involve the isoenzymes of the cytochrome P450 enzyme (CYP) family, such as CYP3A4, CYP2B6, and CYP2C9, enzyme of the glucuronidation pathway, such as UGT1A1, as well as uptake transporters, such as OCT2, MATE1, OATP1B1, and export proteins, such as glycoprotein P (P-gp), which increase the probability of pharmacokinetic drug interactions . Some ARIn the current review, the ARV groups with more clinically relevant drug interaction pairs were the PIs and RTV/COBI-boosted PIs, the InSTIs, and the NNRTIs, with 70 (24.1%), 65 (22.3%), and 37(15.9%) drug interaction pairs of levels one and two, respectively, for PIs and RTV/COBI-boosted PIs and NNRTIs, likely due to their metabolism through the CYP450 family , and forDrug substance misuse is an important consideration in PLHIV on ARV therapy, requiring an integrated approach based on evidence . Therefo® software [https://play.google.com/store/apps/details?id=co.com.pypudea.interapparv accessed on 25 July 2023).The method for assessing the clinical relevance of drug interactions used in this review was similar to that used in previous reviews ,6,7,8; tsoftware . The appNeither the current nor the previous reviews included the specific search for pharmacogenetic interactions ,6,7,8, mThe results of this review may have some limitations; therefore, the results should be interpreted and used with caution. In this context, the main limitation was the search restriction to a single database, since the search was performed only in the PubMed/MEDLINE database, which may not have identified other clinically relevant interactions. However, this situation could be minimized with the inclusion of publications identified as relevant in the reference list of the articles included. In addition, the method for assessing and classifying the level of relevance could be considered a subjective scale of “clinical significance”, which was not subject to a validation process. However, the method was proposed in 2007  and updaFrom 2017 to 2022, in the PubMed/Medline database, we identified 219 records, including 87 from citation lists, related to 291 drug interaction pairs in PLHIVs in patients living with HIV on antiretroviral therapy. Thus, the clinical relevance of 471 drug interaction pairs was assessed; of them, 291 were pairs systematically reported for the first time, a figure that was lower than the one reported in the update for 2015–2017. Among the 291 drug interaction pairs systematically reported for the first time, 179 (61.5%) were assessed as level one (42) or level two (137), thus, with a high risk of causing adverse drug outcomes linked to ineffectiveness or unsafety of the pharmacotherapy. Pharmacokinetics is the mechanism most frequently identified to explain drug interactions. In addition, PIs and RTV/COBI-boosted PIs and InSTIs were the ARV drugs with a greater number of clinically relevant interactions. Cation-containing antacids/supplements and iron or zinc products, antiulcer (proton pump inhibitors and anti-H2), and oral anticoagulants were drug groups most frequently with drug interactions with ARV, accounting for 16.2% and 12.8% of cases, respectively. In PLHIVs, clinically relevant drug interactions were associated with drug substance misuse, mainly amphetamines and psychotropic drugs, particularly benzodiazepines.


Patients with hematological malignancies have an increased risk of arterial thrombosis (ATE). Data about incidence and risk factors for ATE development in patients with acute myeloid leukemia (AML) are missing. Out of 626 AML patients, 18 (2.9%) patients developed ATE in the median time of 3 months. Our study showed that the risk of ATE was increased in AML patients with cardiovascular comorbidities, previous thrombosis, adverse cytogenetic risk as well as BMI > 30.p = 0.000, odds ratio [OR] 20.488, 95% CI: 6.581–63.780), prior history of TE , presence of comorbidities , presence of cardiovascular comorbidities  and cytogenetic risk score . Conclusions: Our study showed that patients with AML are at increased risk of ATE. The risk was increased in patients with cardiovascular comorbidities, previous thrombosis, adverse cytogenetic risk as well as BMI > 30.Background: Patients with hematological malignancies have an increased risk of arterial thrombotic events (ATEs) after diagnosis, compared to matched controls without cancer. However, data about incidence and risk factors for ATE development in patients with acute myeloid leukemia (AML) are missing. Aim: The objectives of this study were to determine the incidence of ATE in non-promyelocytic-AML patients and to define the potential risk factors for ATE development. Methods: We conducted a retrospective cohort study of adult patients with newly diagnosed AML. The primary outcome was the occurrence of confirmed ATE, defined as myocardial infarction, stroke or critical limb ischemia. Results: Out of 626 eligible AML patients, 18 (2.9%) patients developed ATE in the median time of 3 (range: 0.23–6) months. Half of these patients died due to ATE complications. Five parameters were predictors of ATE: BMI > 30 ( Thromboembolism is an important cause of mortality and morbidity in cancer patients ,2,3. WhiPatients with hematological malignancies have an increased risk of ATE within 6-months  and 12-months  after cancer diagnosis, compared to matched controls without cancer . HoweverUnlike patients with solid tumors, patients with AML are often thrombocytopenic at the time of diagnosis and during the treatment course. Therefore, the prevalence of ATE among those patients was expected to be lower than in those with solid tumors. However, it looks like the prevalence of ATE in AML is as high as in other cancers ,14. DataTherefore, the objectives of this study were to determine the incidence of ATE in non-promyelocytic-AML patients and to define the potential risk factors for ATE development.A retrospective cohort study was conducted in the Clinic of Hematology, University Clinical Center of Serbia. Adult patients (≥18 years of age) with newly diagnosed non-promyelocytic AML between January 2009 and December 2021 were enrolled in the study. The retrieval of information and publication of these results were approved by the Institutional Review Board of the University Clinical Center of Serbia (protocol number III 41004).AML diagnoses were confirmed by cytological, flow-cytometry, and cytogenetic findings according to the World Health Organization (WHO) and European Leukemia Net criteria ,16. Part9/L accounts for 0 points, a number between 50–100 × 109/L for 1 point and a platelet count < 50 × 109/L for 2 points. Prothrombin time, given in seconds of PT prolongation, results in 0 points when prolongation < 3 s, 1 point when 3–6 s and 2 points when >6 s. Fibrinogen levels > 100 mg/dL result in 0 points, <100 mg/dL in 1 point. No increase in D-dimer levels accounts for 0 points, moderate increase levels for 2 points, and a severe increase accounts for 3 points. A sum score of ≥5 is defined as an overt DIC-2001 score  20.488, 95% CI: 6.581–63.780), prior history of TE , presence of comorbidities , presence of cardiovascular comorbidities  and cytogenetic risk score . Comparisons of patient and disease parameters are shown in Among the 38 tested parameters, five were predictors of arterial thrombosis: BMI > 30  is in line with previously published data for AML (2.3%) and cancer patients 2–7%) [% [7,8,9,% is in lOur study investigated the predictive value of 38 patient-, disease- and therapy-related parameters for ATE development. The risk factors identified as predictive in our study are consistent with previous published data for cancer patients ,10,11,12With the exception of patient-related cardiovascular risk factors, previous studies identified a few cancer-related risk factors for ATE, including: cancer type, regional and distant disease , chemotherapy, radiotherapy or surgery (vs. no therapy) ,11,12,13Our findings raise the question of whether patients with newly diagnosed AML, particularly those with advanced cytogenetic and cardiovascular comorbidities and high BMI, should be considered for primary prevention of cardiovascular disease. A phase I trial evaluating the efficacy of aspirin with or without statins in thrombosis prevention in solid tumor patients at a high or intermediate risk for ATE might provide us with answers to the question on the rational use of antiplatelet drugs for primary ATE prevention  . HoweverThis study had limitations. First, this study used a retrospective analysis, and the underlying bias could not be avoided. However, we included all consecutive patients diagnosed at our center, thus reducing the risk of selection bias. Due to the retrospective nature of the study data, parameters are missing for some patients. Secondly, our hospital is an academic center, mainly treating patients qualified for intensive therapy, and thus our population probably does not reflect the full spectrum of patients with AML. Furthermore, the presented data are driven from the relatively small Serbian population, which lacks diversity in view of race and ethnicity. Finally, since the number of ATE events was small, multivariate analyses with a predictive model development could not be driven from these data.Our study showed that patients with AML are at an increased risk of arterial thromboembolic events, including myocardial infarction and stroke. The risk of ATE was increased in patients with BMI > 30, cardiovascular comorbidities, previous thrombosis and adverse cytogenetic risk. In conclusion, there is a growing need for dedicated primary thromboprophylaxis trials in patients with acute leukemia in a risk-adapted manner.


Conclusion: The proportion of depression and anxiety is relatively high in the MHD patients during the regular prevention and control stage of COVID-19.Objective: To investigate the incidence of depression and anxiety among maintenance hemodialysis (MHD) patients during the regular prevention and control stage of COVID-19 in China as well as the influencing factors. Methods: A cross-sectional study including 180 patients under the treatment of hemodialysis was conducted in the hemodialysis center of the 8th Affiliated Hospital of Sun Yat-Sen University. The questionnaire regarding the subject’s general information, Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) was completed by the patients, and the laboratory test results were recorded. Results: The incidences of anxiety and depression were 35.6% and 38.9%, respectively, and the average scores of SAS and SDS were (48.03 ± 5.02) and (48.12 ± 5.42), respectively, in the subjects. The results showed that age, monthly income, vascular access of dialysis, feeling of pain and itching (within a week), worried about being infected by COVID-19, whether having health insurance and the levels of hemoglobin, parathyroid hormone, and phosphorus were the impact factors of both anxiety and depression in the MHD patients ( Since the outbreak of the epidemic in 2019, the psychological status of various groups, including the general population, isolated groups, medical staff and patients, has been affected to various degrees. Many studies have been conducted on the mental health problems in these groups. For example, several studies ,4 have bPrevious studies have revealed the impact of COVID-19 on anxiety, depressive, fear, denial, insensitivity, and poor sleep quality depending on individual pre-existing psychological problems and sociodemographic factors ,6. PreviSimilarly, chronic kidney disease (CKD) is one of the most common chronic diseases, and the patients with CKD are often accompanied by varied degrees of anxiety, depression and other psychological problems due to the long duration of dialysis and various complications. During the epidemic, patients with CKD need to continue the regular dialysis. It is difficult for them to avoid taking public transportation and staying in public areas, so the patients often worry about being infected by the virus during the trip between home and hospital and the period of dialysis, which can exacerbate mental health problems such as anxiety and depression. Depression and anxiety are often comorbid with the end-stage renal disease (ESRD), and they are associated with poor adherence to the treatment and low quality of life in the patients under dialysis . At presThis study was a cross-sectional survey. The subjects were the patients who underwent long-term hemodialysis from February 2019 to June 2022 in the 8th Affiliated Hospital, Sun Yat-Sen University. A structured questionnaire was used to assess the mental health status of the patients during the regular prevention and control stage of COVID-19. The survey was conducted from 23 to 30 June 2022. To prevent the spreading of COVID-19, the preventive and control policies were set up based on the risk level at different regions in China. The local government imposed restrictions on hospitals with dialysis patients, including a series of measures for hemodialysis centers, such as forming an expert group setting to handle the patient treatment and increasing dialysis shifts and dialysis isolation wards to meet dialysis needs. Inclusion criteria for the study subjects: (1) were MHD patients; (2) agreed to participate in the research; (3) were able to read or understand the content of the questionnaire and communicate orally or in writing. Exclusion criteria: (1) had history of mental and neurological diseases, long-term alcohol or drug abuse, long-term use of opioids or tranquillizers; (2) had cognitive impairment or severe visual impairment; (3) had complications that affect the patient answering the questionnaire; (4) had critical disease. This study was approved by the ethics committee of the 8th Affiliated Hospital, Sun Yat-Sen University. A total of 180 patients were included in the study and signed informed consent.The self-designed questionnaire for collecting general demographic data included information on gender, age, monthly income, whether having healthcare insurance, feeling of pain, skin itching, duration of dialysis, vascular access of dialysis, and worried about being infected by COVID-19.Self-rating anxiety scale: The Self-Rating Anxiety Scale (SAS) created by Zung  was usedSelf-rating depression scale: The Self-Rating Depression Scale (SDS) created by Zung  was usedEach participant completed the questionnaire on We Chat, which is a widely used social media APP in China, including SAS, SDS and questionnaires for general demographic information. The questionnaire was anonymous to ensure the confidentiality and reliability of the data.p < 0.05 (two-tailed).All data were analyzed by using SPSS 22.0 . Continuous variables were presented as mean ± SD. Categorical variables were expressed as number and percentages (%). Differences between groups were compared using one-way ANOVA and Chi-square test. Spearman’s correlation coefficient (r) was used to assess the association between laboratory test data and levels of anxiety and depression. Statistically significant variables were further analyzed through multivariate logistic regression. Estimates of association strength were demonstrated by odds ratios (ORs) with 95% confidence intervals (CIs). Significant levels were set as +) was 4.82 ± 0.68 mmol/L, and β2 microglobulin was 25.56 ± 7.95 mg/L.Among the 180 participants, there were 96 men (53.3%) and 84 women (46.7%), 113 patients were ≥50 years old (62.8%), 84 patients had lower than 10,000.0 RMB (46.70%) monthly income, 89 patients (49.4%) underwent dialysis over three years, 105 patients were (58.3%) worried about being infected by COVID-19, 87 patients (48.3%) felt localized pain, 130 patients (72.2%) had healthcare insurance, 127 patients (70.6%) were using arteriovenous fistula (AVF) as their vascular access of dialysis, of which there were 53 cases (29.4%) with catheters and artificial blood vessels. The average hemoglobin (Hb) was 111.49 ± 15.58 g/L, albumin (Alb) was 38.06 ± 4.13 g/L, serum ferritin (SF) was 129.94 ± 167.46 ng/mL, blood calcium (Ca) was 2.26 ± 0.21 mmol/L, parathyroid hormone (PTH) was 243.73 ± 190.62 pg/mL, blood phosphorus (P) was 1.98 ± 0.64 mmol/L, serum potassium  and 70 (38.9%) cases of anxiety and depression, respectively, of which the majority  consisted of mild anxiety and depression, respectively.p < 0.05). Possession of medical insurance and age (<50 years) also significantly varied between depression and non-depression groups . For details, please refer to The general information and laboratory tests of the MHD patients were divided into groups according to whether they were anxious or depressed. The differences of monthly incomes, vascular access of dialysis, duration of dialysis, feeling of pain, worried about being infected by COVID-19, skin itching, and levels of Hb, PTH, and P were significant between the anxiety and non-anxiety groups as well as depression and non-depression groups , but they were negatively correlated with Hb (p < 0.05), as shown in The Pearson correlation analysis results showed that the SAS and SDS scores of MHD patients were positively correlated with PTH and P . In the MHD patients, for the risk of anxiety, the number of individuals with higher income  was 0.284 times that of those with lower income    , and thep < 0.05). Among the MHD patients, for the risk of depression, the longer duration of dialysis (≥3 years) was 2.668 times the shorter duration (<3 years) , older age (≥50 years) was 0.276 times more frequent than younger age (<50 years), , feeling pain was 5.286 times more frequent than non-feeling , worried about being infected by COVID-19 was 4.423 times more frequent than not feeling worried , not using AVF as vascular access of dialysis was 3.014 times more frequent than using AVF . For details, please refer to Analysis of depression among MHD patients with laboratory tests showed that age, duration of dialysis, vascular access of dialysis, feeling of pain, worried about being infected by COVID-19, Hb, PTH, and P were the factors that influenced depression  is a global health problem characterized by high morbidity, complications, disability and mortality. The rapid increase in the number of patients with CKD and end-stage renal disease has caused a heavy social and economic burden. The prevalence of CKD in China has exceeded 10%, meaning that at least 1 in 10 people has CKD, and CKD is predicted to become the fifth leading cause of death worldwide by 2040.The MHD patients have many psychological problems even under general circumstances. Before the COVID-19, 20% of the MHD patients suffered from mental health problems ,11. The A meta-analysis from Ko et al.  showed tLevin’s  previousOur current study showed that the feeling of pain was significantly associated with the risk of depression and anxiety. Pain is a common symptom in CKD patients. No matter whether being treated with dialysis or other treatment, pain occurs in more than 58% of patients with CKD and about 49% with moderate to severe pain . On one This study demonstrated that patients who worried about being infected by COVID-19 had a high risk of anxiety and depression compared with those did not worry about it. This might be explained as patients needing to maintain life and undergo regular hemodialysis. Most of the hemodialysis patients are middle-aged or elderly people, often with chronic diseases such as hypertension and diabetes, and they might have poor immune defense capacity ,21,22,23Vascular access is essential for maintaining hemodialysis in MHD patients. Vascular access among hemodialysis patients mainly includes: autogenous arteriovenous fistula (AVF), arteriovenous graft (AVG) and central vein catheter (CVC). Many studies have confirmed ,25,26 thZhang et al.  studied Moreover, patients’ monthly income was negatively correlated with the incidence of anxiety. Kidney transplantation is far from sufficient for the treatment of ESRD patients due to the scarcity of renal donors, and hemodialysis is one of the main treatments during the waiting period of kidney transplantation. The patients with CKD need to receive regular dialysis every week to maintain relatively normal metabolism, but the medical costs of hemodialysis are huge. Although hemodialysis could improve symptoms, long-term MHD patients are prone to cardiovascular and cerebrovascular diseases, malnutrition, renal bone disease and other complications. High costs and low income (mainly due to absence from duty) create a double economic burden for the MHD patients, which seriously affects the quality of life and mental health of the patients. Good economic status not only helps patients have good health insurance and social support but also ensures them being able to afford other expenses, such as medicine, transportation, nutritive foods, and emergency expenses. Therefore, patients with lower income might have more concerns and fears about the treatment and prognosis of the disease.The study showed that the longer duration of dialysis (>3 years) was associated with depression in the MHD patients. Sumida  conducteThe 2017 KDIGO guidelines suggested that the target level of Hb should be between 110 and 120 g/L. In the current study, only 78.2% of the patients reached this target. Some studies ,33 have Studies have shown that the prevalence of hyperphosphatemia in MHD patients in China is as high as 76%, but the compliance rate is only 38.5% .The patiMultivariate logistic regression analysis also found that PTH was positively associated with the incidence of anxiety and depression in the MHD patients. PTH acts on multiple organs and systems of the human body, high serum PTH levels not only cause skeletal system lesions but also increase cardiovascular events, affect immune system function and impact the nutritional status in MHD patients . The resThe incidence of anxiety and depression in MHD patients is high even during the period of regular prevention and control of COVID-19 in China. Age, monthly income, feeling of pain, worried about being infected by COVID-19, vascular access of dialysis, blood phosphorus, PTH, and Hb are the factors related to developing anxiety and depression in the MHD patients. The related sectors should pay attention to the mental health status and influencing factors of the patients as well as provide appropriate psychological counseling and intervention to them. Good nutritional support and adjusting the disorder of metabolism, especially the blood concentrations of calcium and phosphorus, is crucial for the MHD patients. The patients with low income and longer duration of dialysis should be paid even great attention in preventing anxiety and depression to improve their prognosis and hopefully enhance their quality of life. Finally, the appropriate assessment and adequate psychological support should be provided to the dialysis patients, especially the MHD patients.There are several limitations in this research. First, this was a cross-sectional study, which could not provide a direct cause-and-effect risk association. Second, a cross-sectional study had no follow up information; therefore, there are no longitudinal data available regarding the long-term development of depression/anxiety during the period of regular prevention and control of COVID-19. Finally, the sample size was not large enough, and the subjects were selected from a single dialysis center, which might have created bias regarding the sampling.


The purpose of this study was to investigate the effect of a 1% brinzolamide and 0.1% brimonidine fixed combination (BBFC) on ONH blood flow (BF) in rabbits.A crossover study was conducted on pigmented rabbits; a physiological saline solution, brinzolamide, or BBFC was administered for eight days. ONH BF, intraocular pressure (IOP) and systemic parameters were measured before the eighth day’s first dose and at 6, 9, 12, and 14 hours after the dose. ONH BF was assessed using laser speckle flowgraphy, and mean blur rate (MBR) values were calculated. The percentage against baseline of each parameter was calculated, and intergroup comparisons were performed at each time point.There were no significant differences in the percentage change in systemic parameters. At 6 hours after administration, the BBFC group showed a significantly higher percentage change in large vessel area-MBR (%MV) compared to the control group . On the other hand, the brinzolamide group did not show a significant difference. Both the brinzolamide and BBFC groups had significantly lower percentage change in IOP (%IOP) compared to the control group .BBFC effectively reduces IOP and mitigates diurnal fluctuation-induced decreases in ONH BF. Glaucoma, the second most common worldwide contributor to blindness , is defiOne of the limitations of these past studies were that they were primarily conducted in clinical settings with human subjects, leaving diurnal variations and nighttime changes in ocular BF largely unexplored. In fact, previous research has reported substantial nocturnal decline in ocular BF in eyes with primary OAG ,18, suggSeveral studies have reported a positive effect on ocular BF after the administration of either brinzolamide –21 or brTen male Dutch rabbits weighing 1.93 to 2.48 kilograms were obtained from Kitayama Labes Co, Ltd. . Ten animals were used for the study of diurnal variation, and 9 of the same 10 animals were used for the study of the effectiveness of the eye drops. All rabbits were kept under controlled light/dark conditions, with food and water available ad libitum. The study was designed in accordance with the ARVO Statement Guidelines for the Use of Animals in Ophthalmic and Vision Research, and all rabbits were handled and all experiments were performed following the guidance of the Helsinki Declaration and with the approval of the Institutional Animal Care and Use Committee (IACUC) of our institution .Considering that diurnal variations in IOP and retinal BF have previously been reported ,19,24–26The study was conducted as a complete crossover trial, ensuring at least 7 days of washout for each animal to avoid any bias in the administration schedule. The rabbits were divided into groups, each receiving physiological saline solution, 1% brinzolamide  or a 1% brinzolamide and 0.1% brimonidine fixed combination . Each treatment was administered twice daily, with the first instillation at 9:00 and the second under red light conditions 12 hours after the first instillation. This regimen was followed for 8 days, with repeated instillations in the left eye. On the 8th day of administration, IOP, ONH BF, blood pressure (BP), and pulse rate (PR) were measured before the first administration and 6, 9, 12, and 14 hours after the first administration. diluted 5 times with saline were applied twice (more than 5 minutes before and just before the measurement) to anesthetize the left eye. After the application of an eyelid speculum , IOP in the left eye was measured 3 times, and the average value was used for evaluation.The subject for IOP measurement was the left eye (the treated eye). We used a pneumatonometer  for this purpose. The animals were acclimatized to the restraint and the IOP testing environment for at least 3 days prior to the experiment. The animals were restrained in a restraint, and anesthetic eye drops This study used the LSFG-LITE device  for evaluation of ONH BF. The principles of LSFG have previously been described in detail . In esseFor ONH BF measurements, the left eye  was selected, and this assessment was conducted subsequent to the IOP measurement. The LSFG measurements were taken three times consecutively, and the average value of the three measurements was used for evaluation. For the LSFG imaging, the animals were secured using a restraint, as depicted in For the measurement of BP and PR, we used a BP100D II . Prior to the test, the animals were acclimated to the restraint and BP/PR measurement environment for at least 5 days. The BP/PR measurement was conducted following the LSFG measurement. The animals were restrained with a hanging-type restrainer, and a cuff was wrapped around the forelimb for approximately 5 minutes of quiet resting time. BP/PR measurements were taken 3 times; data measured during times when noise was minimal and the state of the animal was judged to be calm based on the waveform were identified, and the data closest to the measurement point was used.Mean BP (MBP) and mean ocular perfusion pressure (MOPP) were calculated as follows: MBP = diastolic BP (DBP) + 1/3 (systolic BP [SBP]—DBP); MOPP = 2/3 MBP–IOP.All data are shown as the mean ± standard deviation (SD). The percentage against baseline of each parameter was calculated. An analysis of variance (ANOVA) and post-hoc Dunnett’s test were used to analyze the significance of differences in %MBP, %PR, %MOPP, %IOP, %MV, and %MT at each measurement point against the baseline of measurements at 9:00. A one-way ANOVA followed by the Tukey-Kramer test was used to analyze the significance of differences in %IOP, %MOPP, %MV, and %MT in the group comparisons of the evaluation of eye-drop effects at each time point. All statistical analyses were performed with JMP software . The significance level was set at P < 0.05.Firstly, we investigated the diurnal variation of IOP and ONH BF using normal, untreated rabbits. When using the 9:00 measurement as the baseline, the percentage against baseline at 15:00, 21:00, and 23:00 was, respectively, as follows: %IOP , %MV , and %MT . IOP exhibited diurnal variation, peaking at 21:00 , whereasAt all measurement points, no significant differences were observed in the comparisons among groups for %MBP, %PR, and %MOPP  . Six houSix hours after administration, the BBFC-treated group showed significantly higher %MV compared to the control group  , while tAt 6, 9, 12, and 14 hours after administration, both the BBFC-treated group and the brinzolamide monotherapy group tended to have higher %MT compared to the control group, but these differences were not statistically significant  .After administering BBFC to pigmented rabbits twice daily at 12-hour intervals for 8 days, lower %IOP and higher %MV were observed 6 hours after administration compared to the brinzolamide group and the control group.In this study, we examined diurnal variations in IOP and ONH BF and investigated the effect of BBFC on these parameters in rabbit eyes. Untreated healthy rabbits exhibited a higher nocturnal IOP at 21:00 compared to diurnal IOP, while both MV and MT peaked at 9:00 in the morning and decreased gradually until 23:00. Six hours after BBFC administration, a significant reduction in IOP and an amelioration of MV decline, i.e., diurnal fluctuation, were observed, while there were no significant intergroup differences in MBP, MOPP, or PR throughout the day.The diurnal fluctuations in IOP and ONH BF that we observed in this study are consistent with previous studies, which have reported that IOP is higher at night in both healthy individuals and patients with glaucoma –26,32,33On the other hand, we did not observe any differences in %MBP, %PR, and %MOPP between the control, brinzolamide, and BBFC groups. There have been discussions concerning the BP-lowering effect of α2 stimulators , a compoInterestingly, we observed a significant increase in %MV 6 hours after administering BBFC, while brinzolamide alone and %MT failed to produce statistically significant changes, though the trend was similar. The stronger BF improvement effect of BBFC compared to brinzolamide alone suggests the presence of a BF-improving effect in brimonidine as an α2 stimulator ,43–45. WIn this study, both IOP and ONH BF increased only at 6 hours after the first administration of BBFC, while the effects were not evident at other time points, such as 9, 12, and 14 hours after the first instillation. According to previous reports, the peak impact of brimonidine and brinzolamide on IOP or ocular BF is reported to occur within a 3–9-hour range ,22,54,55Our study has several limitations. First, we used normal rabbits; extrapolating the results from this rabbit model directly to human patients with glaucoma might not be straightforward. Second, LSFG cannot directly provide data on blood flow velocity, and the depth at which it measures blood flow remains unclear. Further investigation is needed to clarify these points in the future.In conclusion, this study demonstrated the effects of BBFC in reducing IOP and ameliorating the reduction of ONH BF due to diurnal variation 6 hours after the first instillation. Therefore, BBFC may represent a valuable therapeutic option for glaucoma in terms not only of IOP reduction but also ONH BF change.S1 DataAll relevant data are available in (XLSX)Click here for additional data file.S1 FigPicture showing the use of a restraint to secure the animal during intraocular pressure measurement and laser speckle flowgraphy imaging.(TIF)Click here for additional data file.


Overweight and obesity have increased rapidly in the past few decades in China, and less research has focused on the association between the consumption of ultra-processed foods (UPFs) and overweight or obesity in Chinese adults. The objective of this study was to determine the relationship of UPF consumption with the risk of overweight or obesity in Chinese adults. Residents aged 18 years and above who participated in the nationally representative survey Chinese Food Consumption Survey in 2017–2020 were included in this study. Dietary intake data were collected via non-consecutive three-day 24 h dietary recalls and weighing household foods and condiments. According to the NOVA food classification system, UPFs were classified depending on the purpose and extent of food processing. Multiple logistic regression and multivariate-adjusted restricted cubic spline (RCS) regressions were performed to estimate the association between UPF consumption (categorized into quartiles: quartile 1 (Q1), quartile 2 (Q2), quartile 3 (Q3), and quartile 4 (Q4)) and risk of overweight or obesity. A total of 38,658 adults aged 18 years and above participated in the present study. The prevalence of overweight and obesity in adults was 33.0% (95% CI: 32.91–33.10) and 9.6% (95% CI 9.55–9.67), respectively. After a multivariable adjustment, the risk of overweight or obesity was increased by 10% in Q3  compared to Q1 as a reference. Women  and adults living in small and medium-sized cities  with higher UPF consumption had higher odds of overweight or obesity. Nevertheless, the effect of higher UPF consumption on the risk of overweight or obesity was relatively weak for overall adults in China. The top three categories of subgroups consumption of UPFs were 1: sugar-sweetened beverages; 2: sauces, cheeses, spreads, and gravies; and 3: ultra-processed breads and breakfast cereals. These findings provide evidence that higher UPF consumption was positively associated with overweight or obesity, which was defined based on Chinese criteria among women and adults living in small and medium-sized cities in China. Further studies, such as intervention trials, are needed to identify the mechanism of correlation between the consumption of UPFs and health-related outcomes in Chinese adults. From a public health perspective, with the prevalence of overweight and obesity growing and the increase in UPF consumption in Chinese adults, it is necessary to promote healthy food intake and a balanced diet through active nutritional education actions for overweight and obesity prevention and control. Overweight and obesity are defined as abnormal or excessive fat accumulation, which may impair health. With the rapid development of the global economy and social progress, the prevalence of overweight and obesity has risen significantly over the past few decades ,2. In 20Diet, as a determinant for overweight and obesity, plays a key role in the development of overweight and obesity. China is facing a nutrition transition from the traditional Chinese diet to the westernization of dietary patterns . The Chi2; OR: 1.48, 95% CI: 1.25, 1.76) and obesity , respectively [2; OR: 1.45, 95% CI: 1.21, 1.74), according to the data of China Health and Nutrition Survey (CHNS 1997–2011) [Ultra-processed foods are commonly high energy dense and contain added sugar, saturated fat, and salt, but they are low in fiber and micronutrients. Based on the degree of food processing, all foods and food products are classified by the NOVA food classification system, which is a new classification considering the nature and purpose of industrial processing . NOVA clectively . The Braectively . With re97–2011) . HoweverIn view of the increasing prevalence of overweight and obesity and higher UPF consumption in Chinese adults, it is necessary to clarify the correlation between UPF consumption and overweight or obesity so as to put forward measures to prevent overweight and obesity through diet. We performed the present study to explore the association between UPF consumption and overweight or obesity in Chinese adults using nationally representative survey data from the Chinese Food Consumption Survey in 2017–2020 (CFCS 2017–2020). The objective of this study was to come up with a more accurate estimation of the association between UPF consumption and overweight or obesity and provide targeted suggestions and measures for preventing and controlling overweight and obesity through dietary behavior in Chinese adults.The study data were obtained from the Chinese Food Consumption Survey in 2017–2020 (CFCS 2017–2020). The CFCS is a nationally representative cross-sectional study conducted by China National Center for Food Safety Risk Assessment to examine the food consumption status and assess food, nutrient intakes, and food safety risk in the Chinese population. The CFCS was conducted at 126 investigated sites across 23 provinces in 2017–2020. This survey used a multistage stratified cluster random sampling method to collect the sample information, including food consumption and diet, food processing methods, food contact materials, demographic geography, economic development, and physical examination.We excluded the subjects according to the following exclusion criteria: (1) participants with deficiency of dietary and physical measurement data, 814 in total; (2) pregnant or lactating women, 484 in total; and (3) participants with implausible energy intakes , 243 in total. Finally, a total of 38,658 adults aged 18 years or older were included in the present study . The CFCAccording to the NOVA food classification system, food items were categorized into four groups, including MPFs, PCIs, PFs, and UPFs . UPFs inWe used non-consecutive three-day 24 h dietary recalls (including one weekend and two weekdays) for all individuals to collect dietary data. Two 24 h dietary recall days were separated by at least three days. The first and third 24 h dietary recall days were separated by at least nine days. For the consumption of oil and various seasonings, trained investigators weighed food items in the household inventory. Total energy and nutrient intake per day were calculated using the Chinese Food Composition Table ,26.Anthropometric data were collected using standardized protocol by trained health workers with strict quality control during the household investigation. The measurements of weight and height were carried out in accordance with the requirements of WS/T 424-2013 “Anthropometric measurements method in health surveillance.” Weight was measured in kilograms (kg) without shoes and in light clothing to the nearest 0.1 kg using an electronic weight scale (TC-200k). Height was measured in centimeters (cm) without shoes to the nearest 0.1 cm using a portable stadiometer.2). Overweight was defined as 24.0 kg/m2 ≤ BMI < 28.0 kg/m2, and obesity was defined as BMI ≥ 28 kg/m2 in adults.Overweight or obesity was defined based on Chinese criteria . Body maIn this study, multiple covariates were involved, including gender, age, education level, individual annual income, occupation, alcohol drinking status, labor intensity, geographical location, total energy intake, protein, fat, carbohydrate, dietary vitamin A, dietary vitamin C, dietary calcium, and dietary sodium. Age was divided into three groups . Education level was divided into three groups . Individual annual income was divided into five groups . Occupation was separated into six groups . Alcohol drinking status over the past month was divided into two groups (yes and no). Labor intensity was divided into three groups . Residence was separated into three groups . The regions were divided into the eastern , central , and western .2 test. Continuous variables were described using mean and standard deviation and compared using the Kruskal–Wallis test. Multiple logistic regression analysis was used to quantify the association between UPF consumption  and the risk of overweight or obesity. We used the median value of each quartile of UPF consumption as a continuous variable to test the linear trends between UPF consumption and the risk of overweight or obesity. For the sensitivity analyses, we performed a stratified analysis using multiple covariates and an interaction analysis to estimate the effect of stratification factors on the association between UPF consumption and the risk of overweight or obesity. To explore the nonlinear relationship between UPF consumption and ORs of overweight or obesity, multivariate-adjusted restricted cubic spline (RCS) regressions were performed in the primary analysis. Statistical analyses were conducted using SAS 9.4 , and the plot was generated in R (version 4.1.0). All statistical tests were two-tailed and considered significant at p < 0.05.Categorical variables were described by n, percentage (%), and compared using the χp < 0.01). Among the highest quartile of UPF consumption groups, more adults were 18–44 years old with college or above education levels and CNY 40,000–99,999 individual annual income and worked in technical or business services (p < 0.001).As shown in p trend: 0.690), with the lowest quartile (Q1) as a reference. With further adjustment based on total energy, protein, fat, carbohydrate, vitamin A, vitamin C, calcium, and sodium intake (Model 3), only quartile 2 (Q2) and quartile 3 (Q3) had increased risk of overweight or obesity  compared to Q1. The risk of overweight or obesity was increased by 3% in the highest quartile (Q4) of UPF consumption  with no statistical significance.After the adjustment for confounding factors, including gender, age, education level, individual annual income, occupation, drinking past month, labor intensity, and place and region of residence (Model 2), the risk of overweight or obesity was increased by 8% in the highest quartile (Q4) with UPF consumption . For Model 3, no correlation was observed between the highest quartile (Q4) UPF consumption and overweight  compared with the lowest quartile (Q1) consumption. For the associations of UPF consumption with obesity, compared to Q1, no correlation was observed between the highest quartile (Q4) UPF consumption and obesity .For the associations of UPF consumption with overweight, after adjusting for covariates (Model 2), the risk of overweight was increased by 7% .p non-linearity < 0.001). Furthermore, there is no clear linear trend between the risk of UPF consumption and overweight or obesity.We used RCS to model and visualize the relationship between UPF consumption and ORs of overweight or obesity . The ploThe findings of this study demonstrate the association between UPF consumption and overweight or obesity among Chinese adults aged 18 years and above through nationwide population-based data from CFCS from 2017–2020. As the consumption of UPFs increased, higher UPF consumption was found to be positively correlated with overweight or obesity among women and adults living in small and medium-sized cities after adjusting for potential confounders. The highest UPF consumptions were associated with 10% and 13% significant increases in the risk of overweight or obesity in women and adults living in small and medium-sized cities, respectively. Nevertheless, the effect of higher UPF consumption on the risk of overweight or obesity was relatively weak for overall adults. The top three categories of subgroups’ consumption of UPFs were 1: sugar-sweetened beverages; 2: sauces, cheeses, spreads, and gravies; and 3: ultra-processed breads and breakfast cereals.Multiple similar cross-sectional studies have been conducted in several countries, including the UK , Brazil Several potential mechanisms may explain the association between higher UPF consumption and overweight or obesity. Firstly, an obvious feature of UPFs is that UPFs have higher energy density compared to a traditional diet . In addi2; OR: 1.51, 95% CI: 1.14, 1.99), while no association was found in men [2 higher BMI among women , but only 0.79 kg/m2 higher BMI among men , according to NHANES 2005–2014 [In the present study, we found that higher UPF consumption was more associated with women, not men, after adjusting for potential confounders. The observed gender-based differences in our study were consistent with the results of some previous studies. In a nationally representative cross-sectional study of Korean adults aged 19–64 years from the Korea National Health and Nutrition Examination Survey (KNHANES), 2016–2018, women with the highest consumption of UPFs had higher odds of being obese (BMI > 25 kg/md in men . Filippa005–2014 . Another005–2014 . Previou005–2014 . On the 005–2014 ,49. As a005–2014 . The speWe also found that the association was more pronounced among adults living in small and medium-sized cities compared to metropolis and rural areas. In the past two decades, society and the economy have developed rapidly, and the urbanicity rate has been on the rise in China . IndividTo the best of our knowledge, this study is the first nationally representative cross-sectional study to demonstrate the association between UPF consumption and the risk of overweight or obesity defined based on Chinese criteria in Chinese adults. Of note, detailed dietary data were collected through previously validated weighing of foods and condiments in household inventories of non-consecutive three-day 24 h dietary recall, which could contain more accurate and various food types . In addiIn conclusion, the present study found that higher UPF consumption was positively associated with overweight or obesity defined based on Chinese criteria among women and adults living in small and medium-sized cities. Nevertheless, the effect of higher UPF consumption on the risk of overweight or obesity was relatively weak for overall adults in China. Further studies, such as intervention trials and longitudinal studies, are needed to identify the mechanisms of correlation between consumption of UPFs and health-related outcomes in Chinese adults. From a public health perspective, with the prevalence of overweight and obesity growing and increased UPF consumption in Chinese residents, it is necessary to promote healthy food intake and a balanced diet through active nutritional education actions for overweight and obesity prevention and control.