Vitamin D, as an immunomodulator, may be related to the therapeutic effect of asthma patients, but the research in this area is still controversial. The aim of this meta-analysis was to analyze the role of vitamin D supplementation in the treatment of asthma patients.Randomized Controlled Trials (RCTs) of vitamin D supplementation in asthma were searched in PubMed, EMBASE, and the Cochrane library. Primary outcomes were forced expiratory volume in one second (FEV1), asthma exacerbations, Asthma Control Test scores (ACT scores), and fractional exhaled nitric oxide (FENO).P = 0.87), FEV1  and FENO , but reduced the rate of asthma exacerbations , especially in subgroups of children  and follow up time less than 6 months . Additionally, though there was only one study included in the subgroup, it significantly enhanced FEV1 at the last visit for patients whose FEV1 baseline value was less than 70% .A total of 10 RCTs were included, including 1,349 patients. Vitamin D supplementation didn’t affect the ACT scores (SMD = 0.04, 95% CI = −0.13 to 0.21, Vitamin D supplementation can reduce asthma exacerbations, especially in children, and within 6 months of follow up time. In addition, vitamin D has a positive effect on improving FEV1 of patients whose FEV1 baseline value is less than 70%, but more RCTs are still needed to support this conclusion.https://inplasy.com], identifier [10.37766/inplasy20 22.6.0049].[ As one of the most common chronic, non-communicable diseases, asthma is a heterogeneous clinical syndrome affecting approximately 334 million people worldwide . It is dThe existent evidence indicates that asthma is a disease associated with various factors, including environmental factors ) OR (asthma exacerbations [Title/Abstract])} AND (vitamin D [Title/Abstract]) AND (supplementation [Title/Abstract]) AND (RCTs [Title/Abstract]).Randomized Controlled Trials published in English were included, in which vitamin D was prospectively added after the diagnosis of asthma to explore the role of vitamin D supplementation in asthmatics. The intervention group consisted of asthma patients who received any form or dose of vitamin D supplementation in addition to standard treatment, while those who did not receive vitamin D formed the control group. Then, the asthma-related outcomes were analyzed, including lung function (FEV1), FENO, ACT scores, and the rate of asthma exacerbations.Retrospective and observational studies, articles or preprints not published in peer-reviewed journals, articles that did not mention the results included in our study or for which the data were incomplete, and retrospective vitamin D supplementation studies were excluded.All studies selected from the database were filtered by title and abstract to exclude unrelated or duplicate articles. Two authors screened independently, and a third co-author was involved in resolving differences that arose during the literature screening process.Two authors independently extracted the relevant data from the article, including study population , intervention measures (vitamin D administration method and dose), follow-up time and outcomes , and baseline data related to the results .The two authors independently evaluated the methodological quality of the included studies based on Cochrane’s systematic review guidelines and resolved the differences through discussion with the third co-author. The risk of bias was plotted using Review Manager 5.4 and individual quality analysis was performed using the GRADE-PRO method.P < 0.05 was considered statistically significant. When data from three or more studies were available, results were summarized using either the standardized mean difference (SMD) for continuous variables or the risk ratio (RR) for dichotomized variables. Statistical analysis was performed using the Mann-Whitney U test, and a two-sided P-value of <0.05 was considered statistically significant. Using the I2 statistic to evaluate the degree of heterogeneity between included studies. I2 values of 25, 50, and 75% were considered low, medium, and high heterogeneity. In addition, in order to explore the impact and heterogeneity of each outcome, prespecified subgroup analyses were stratified by FEV1 baseline values (less than 70% or greater), age (children or adults), and follow up time. The use of funnel plots failed to demonstrate potential publication bias since each result did not reach 10 studies. Sensitivity analyses were performed to check the robustness of the results by omitting one study and analyzing the remainder in each round.In this meta-analysis, we used risk ratio (RR) and standard error (SMD) as the impact measurement standards, R software version 4.1.1  for statistical analysis and forest mapping. The methodological quality of the study was evaluated using Review Manager Version 5.4 following the Cochrane guidelines. A random effect model was used for statistical analysis due to differences in the mix of interventions and participants. The heterogeneity among studies was assessed by Cochran Q-test, and In this review, we used database search and a comprehensive manual search strategy. A total of 259 studies was found in the initial search, and 49 RCTs were screened out. After manual deletion of duplicate references, the remaining 20 studies were selected by title and abstract. There were 15 eligible articles after excluding irrelevant articles. Among them, studies in which outcome indicators were variation quantity before and after intervention or the outcome indicators which had missing values were excluded. Eventually, 10 studies were included in the review and met the inclusion criteria through evaluating the full text .The characteristics and baseline data of included RCTs were presented in Among the 10 included studies, one RCT  includedThere was significant heterogeneity in the doses of vitamin D used in the intervention groups, with the control group receiving an equal dose of placebo, and both two groups receiving a standardized treatment, inhaled corticosteroid, according to the guidelines. The follow-up time ranged from 1 week  to 12 moTwo RCTs , 82 analBaseline FEV1 values were reported in seven studies in the two groups, six of which were greater than 70% , 80, 82,According to Cochrane system evaluation guidelines, we conducted a risk bias assessment for each study included in this evaluation. A summary chart of bias risk was shown in Grade summary 2 = 0%, P = 0.87; Asthma Control Test (ACT) scores were reported in three studies , 78, 82 2 = 78%, P < 0.01; Forced expiratory volume in one second was reported in six studies –80, 82 i2 = 81%, P < 0.01)], while vitamin D supplementation was associated with a reduction of FEV1 at the last visit in children , while vitamin D supplementation was related to the increase of FEV1 at last visit for patients with FEV1 baseline values less than 70% ] or more than 6 months , while vitamin D supplementation was related to reducing the rate of asthma exacerbations in children , but not with more than 6 months of follow-up  in liver , 94, whi reduced . Vitamin reduced . Oxidati reduced . Althoug reduced , 82, 109 reduced , 78. Hig reduced .Additionally, we further confirmed that it could effectively alleviate the probability of asthma exacerbations in children and when follow-up time was less than 6 months . NoticeaIn conclusion, our meta-analysis demonstrated that there was high heterogeneity in RCTs regarding improvement in exacerbation of asthma and FEV1 with vitamin D supplementation. Vitamin D supplementation led to a reduction of asthma exacerbations, especially in children and with a follow-up period of less than 6 months. In addition, it played an important role in improving FEV1 in patients with FEV1 baseline values below 70%. Though evaluating the ACT scores and FENO, we found that vitamin D worked the same way as a placebo. Based on the results of the GRADE analysis, all major findings were low or very low except for the FEV1 subgroup with baseline values below 70%. Therefore, a larger and well-designed RCT is needed to evaluate the effect of vitamin D in the treatment of asthma, including uniform vitamin D dosing and administration mode, follow-up time, and strict inclusion and exclusion criteria. Furthermore, whether basic asthma treatment should be standardized during follow-up or used as an outcome measure of asthma treatment efficacy still needs to be further explored.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.ML: data selection, data extraction, quality assessm statistical analysis, and writing – original draft. JW: data selection, data extraction, and quality assessment. XS: conceptualization, writing – review, and supervision.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Two of the studies (both concerning gabapentin) had no comparison arm. Conclusions: Treatments including pregabalin, methadone, ketamine, and gabapentin were found to provide pain relief against HNC NP. While there is a plethora of pharmacological treatments available for the management of NP, only a few studies have been conducted regarding the pharmacological management of therapy-related NP in HNC patients. More studies should be conducted regarding the pharmacological approaches in HNC therapy-related NP so that specific treatment algorithms can be developed.Background: Neuropathic pain (NP) in head and neck cancer (HNC) patients represents a treatment challenge. Most studies investigating drugs against NP are conducted in patients suffering with diabetic neuropathy or postherpetic neuralgia, while data are limited in cancer pain management. Additionally, regarding cancer therapy-related NP, most of the studies do not focus on HNC patients. The aim of this review is to identify the studies on systematically administered medication for NP management that included HNC patients under radiotherapy. Methods: A systematic literature search was performed, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, in PubMed, Cochrane Library, Web of Science and ClinicalTrials.gov on 30 October 2021. The medical subject heading (MeSH) terms were (“head and neck cancer” OR “tumor”) AND “neuropathic pain” AND “medication” AND “radiotherapy.” The Cochrane Collaboration tool was used for quality assessment. Results: The search identified 432 articles. Three more articles were identified after searching the reference lists of the retrieved articles. A total of 10 articles met the eligibility inclusion criteria and were included in this review; 6 on gabapentin, 1 on pregabalin, 1 on nortriptyline, 1 on methadone, and 1 on ketamine. Statistically significant results in pain reduction compared to placebo or standard pain medication were found in the studies on pregabalin ( Neuropathic pain (NP) is defined as “pain caused by a lesion or disease of the somatosensory nervous system” , includiIn HNC patients, pain may be nociceptive, but more frequently, it has one or more neuropathic components ,5,6. In NP is a well-recognized problem in HNC patients ,5; treatNP represents a therapeutical challenge in cancer patients as they are already receiving several drugs . RecogniWhile there is a plethora of pharmacological treatments available for the management of neuropathic pain, only a few studies have been conducted regarding the management of NP in HNC patients under RT. The Neuropathic Pain Special Interest Group (NeuPSIG) of the IASP  , and morIn this review, we tried to identify the systematically administered drugs related to NP relief in HNC patients under RT.Full text, Clinical Trial, Meta-Analysis, Randomized Controlled Trial, Review, Systematic Review, Humans, and English and in the Web of Science, Review Articles, Early Access, Open Access, and English. In the Cochrane Library, the search was limited to title, abstract, and key words. ClinicalTrials.gov was also searched, where the “condition or disease” was “head and neck cancer,” the “other terms” was “pain medication”, and the filters applied were “with results” and “completed”. The reference lists of the articles that met the eligibility criteria were further screened to identify additional eligible studies.A systematic literature search, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines , was perOnly studies involving human subjects and published in English were selected. The aim of this review was to identify studies including HNC patients treated with RT and investigating the management of NP. All articles reporting NP or NP management as outcomes, as well as the ones reporting the use of adjuvant medication known for the management of NP or neuropathy were included. Articles that did not include HNC patients, did not refer to NP or medication related to NP, were not original studies, and nonpharmacological studies were excluded.After the removal of duplicates, all article titles and abstracts were screened by two authors . Any differences of opinion were resolved by a third author (AV). All articles appearing to be eligible were assessed again as full texts by two authors , and disagreements were settled by a third one (AV).The seven domains of the Cochrane Collaboration risk of bias framework  were assFollowing the identification of the eligible papers, the relevant data were extracted from each article. The included information were: study-related data ; study characteristics ; and outcome-related data .In this review, the studies are descriptively presented, based on the used drug. Due to the significant heterogeneity, it was not possible to use a meta-analytical method. Thus, it was preferred to use the “vote counting” method to draw conclusions. This method is one of the simplest ways to combine the results of many studies . Each stAs this article is based on data from previously published research and does not involve any human enrollment, ethics committee approval was not required.The research identified 432 articles. After duplicate removal, 413 of them were screened based on title and abstract, and 359 were removed because they were not consistent with the purpose of this review. Four articles were not retrieved as a full text. Forty-three articles were excluded after reading the full text; 29 of them because they did not concern HNC patients. Three articles were identified after searching the reference lists of the retrieved articles. A total of 10 articles were included in this review .Out of the 10 articles included: 3 were prospective, randomized pilot studies ,27,28; 2On the first domain “random sequence generation”, six of the ten studies had a low risk of bias ,29,30,33Pain was assessed using various scales such as VAS , the Likert scale, NRS , a 4-point scale  or opioids analgesia necessity. In the context of multidimensional, questionnaires such as OMWQ-HN , EORTC QLQ-H&N35 , VHNSSv2 (Vanderbilt Head and Neck Symptom Severity Survey version 2.0), BPI-SF (Brief Pain Inventory—Short Form), and the McGill PQ (McGill Pain Questionnaire) were used. OMWQ-HN and EORTC QLQ-H&N35 provide the responses of patients on domains related to mouth and throat soreness and pain. Neuropathic pain was assessed using DN4 (Douleur Neuropathique 4) as well as LANSSQ (the Leeds Assessment of Neuropathic Symptoms and Signs questionnaire) .The time points of pain assessment and recording varied between studies. It was either a fixed time point after the first radiotherapy session or when patients reported a specific pain score or if analgesia with used analgesics was not acceptable .The outcomes and the adverse effects of the drugs included in the review are summarized in Six out of the ten included studies explored the efficacy of gabapentin in HNC patients treated with radiotherapy ,31,32,34p = 0.002).Hermann et al.  performep = 0.004). By week 7, the median pain score in the gabapentin group was below the 0.25 quantile of the control group.Another prospective, randomized pilot trial included 79 patients . Thirty-p = 0.552). In addition, there was no statistical difference between groups either in VAS scores from baseline to 4 weeks after the treatment, at each time point between two arms or in the number of days until the use of additional analgesics.Kataoka et al. , in an op = 0.0003). Additionally, the gabapentin group had shorter overall pain duration compared to the controls . The 13% of the patients receiving gabapentin did not require additional analgesics, while, in the control group, all patients required opioids, and 70% of them required multiple opioid therapy.Starmer et al.  comparedA retrospective cohort study included 29 patients during radiotherapy treatment and receiving a median dose of gabapentin of 2700 mg per day at weeks 3, 4, 5, and 6 . Only 10In another retrospective cohort study on 42 patients, a median dose of gabapentin of 2700 mg per day at weeks 2, 3, 4, and the last week of radiotherapy was used . The patA small number of patients experienced mild side effects in all studies, ranging from 5% to 33% of the patients. The described adverse events were dizziness, nausea, vomiting, follicular skin rash/allergic skin reaction, somnolence, vertigo, headache, drowsiness, and fatigue. In one of the studies , 3% of tp = 0.003). Around 30.0% (19/64) of patients receiving pregabalin compared to 7.8% (5/64) receiving the placebo achieved pain relief of 50% (p = 0.003). At the same time, there was also a significantly greater reduction of the mean Brief Pain Inventory interference total score in the pregabalin group (13.4) compared to the placebo group (8.6) (p = 0.001). Moreover, the proportion of patients receiving pregabalin and having a reduction in pain intensity of 30% or more at week 16 was also larger compared to the placebo group (59.4% (38/64) and 32.8% (21/64), respectively, p = 0.006).A randomized, double-blind, placebo-controlled trial included 128 patients divided in two groups  . EligiblIn this study, patients experienced at least one adverse event in both the pregabalin and placebo groups . Dizziness, somnolence, facial edema, increased pain, headache, diarrhea, and peripheral edema were described as adverse events. One patient in the pregabalin group discontinued treatment because of facial edema, and two patients in the placebo group discontinued the treatment because of hospitalization for increased pain.p = 0.007 and p = 0.04, respectively). No significant changes in pain were observed within groups from baseline to 1 and 2 weeks after randomization. The Likert pain scale scores showed a nonsignificant trend toward higher pain scores in the nortriptyline group compared to the morphine group at baseline and 1 week after randomization.This study compared nortriptyline (19 patients) to oral morphine (20 patients) in a randomized trial . PatientNausea, vomiting, constipation, and CNS symptoms in 14 patients in each of the nortriptyline and control groups were reported as adverse events. In the nortriptyline group, cardiac arrhythmia was reported.p = 0.011) and 3 (p = 0.03). Improvement >50% at 1 week was higher in the methadone group compared to the fentanyl group .A randomized, controlled trial was performed on 52 patients reporting pain scores NRS > 4 and DN4 > 4 . The patXerostomia was the most common side effect in both groups , with no significant difference between the groups. Moreover, sleepiness, dizziness, nausea, vomiting, constipation, somnolence, and drowsiness were also reported. There were no serious side-effects or drop outs due to intolerable side effects.bis in die (BID) to 2.0 mg BID for technical reasons. There are also no indications on the amount of rescue medication used by the two randomized groups. Moreover, the analgesia after 5 weeks was not significantly different.This study has several limitations, e.g., the initial dosage of fentanyl was low (12.5 µg/h), and during the study, the dosage of methadone was changed from 2.5 mg Oral ketamine was evaluated as an adjuvant to oral morphine in cancer patients experiencing neuropathic pain . Out of Among the four HNC patients, three developed sedation, one vomiting, one anorexia, one nausea, three drowsiness, and one tiredness. The sedation score gradually improved despite continuing medication in all patients.This systematic review aimed to identify the successful analgesia in HNC patients under RT suffering with NP. It highlighted that despite the plethora of scientific publications on different pharmacologic therapies available for the management of NP ,21, onlyOut of the 432 articles which emerged through the database search, only 10 publications ,34,35 meGabapentin, originally an anticonvulsant, is recommended for the treatment of several neuropathic pain conditions . Pain rePregabalin is also recommended for several chronic neuropathic pain conditions . Jiang eNortriptyline, a tricyclic antidepressant, has been found to have analgesic properties and is used for management of NP, but the study included in this review did not demonstrate a better pain relief compared to opioids . NortripMethadone is a strong opioid also used for the treatment of NP as it has an action on the N-methyl D-aspartate (NMDA) receptor . HaumannKetamine, a NMDA receptor antagonist, was suggested as an adjuvant in acute pain treatment . MoreoveOur review aimed to provide a therapeutic approach for this complex pain entity. A useful algorithm for a pain clinician would be to trial a combination of an opioid with an anticonvulsant/tricyclic antidepressant agent or/and NMDA antagonist (either ketamine or action embedded within the opioid itself—methadone). A previous review by Lefebvre et al.  also appOne of the strengths of this study is that it includes the most recent publications. The database search also identified a randomized study of the team of McMenamin where the authors investigated the role of pregabalin , 300 mg This systematic review has some limitations. The literature search was not performed in all existing databases. Therefore, it is possible that some studies that support a range of potentially important pain control measures may be missed. For the 10 studies in this review, a relatively small number of patients  contributed data creating low statistical power to detect the real effects. Moreover, it was not possible to perform a meta-analysis because of the heterogeneity of the parameters reported in the studies: different pain evaluation tools, and different time points of therapies and pain assessment. A further limitation was the relatively low quality of most of the studies included, which would not make the generalizability of the findings possible.Based on the results of the examined studies, it is not possible to provide specific recommendations. Further studies, using better standardized parameters , and new potential therapies for neuropathic pain  are neceThe prompt diagnosis and treatment of NP is an important and largely unmet medical need in the HNC patient population. While there is a plethora of possible pharmacologic treatments available, only a few studies have been conducted regarding the management of therapy-related NP in HNC patients. Gabapentin, pregabalin, methadone, and ketamine were found to provide some analgesia, with good evidence only in two studies on gabapentin and one on pregabalin. Future studies looking into different pharmacological approaches in patients with HNC treated with RT with NP are necessary as patients should receive the most effective and tolerable treatment for their individual needs.


Background: Piriformis syndrome (PS) is a painful musculoskeletal condition characterized by a deep gluteal pain that may radiate to the posterior thigh and leg. This study was designed to compare the effectiveness of ozone and BTX to lidocaine injection in treating piriformis syndrome that was resistant to medication and/or physical therapy. Study design: Between November 2018 and August 2019, we involved eighty-four subjects diagnosed with piriformis syndrome in a double-blinded, prospective, randomized comparative study to receive an ultrasound-guided injection of lidocaine (control group), botulinum toxin A, or local ozone (28 patients each group) in the belly of the piriformis muscle. Pain condition evaluated by the visual analog score (VAS) was used as a primary outcome, and the Oswestry Disability Index (ODI) as a secondary outcome, before, at one month, two months, three months, and six months following the injection. Results: The majority (58.3%) of patients were male, while (41.7%) were female. At one month, a highly significant decrease occurred in VAS and ODI in the lidocaine and ozone groups compared to the botulinum toxin group (p < 0.001). At six months, there was a highly significant decrease in VAS and ODI in the botulinum toxin group compared to the lidocaine and ozone groups (p < 0.001). Conclusion: Botulinum toxin may assist in the medium- and long-term management of piriformis syndrome, while lidocaine injection and ozone therapy may help short-term treatment in patients not responding to conservative treatment and physiotherapy. A lesser-known cause of extra-spinal sciatica is piriformis syndrome (PS), in which a number of conditions affecting the piriformis muscle or its vicinity may irritate the nearby sciatic nerve and cause unilateral deep gluteal pain radiating to the ipsilateral thigh. This pain may be worsened by actions that increase piriformis muscle tension, such as rotation of the hip in flexion or knee extension, in addition to sitting intolerance, tenderness over the sciatic notch, and limitation of straight leg raising. These signs are consistent with morphological changes in the piriformis muscle and sciatic nerve ,2. PirifWith a wide range of therapeutic alternatives, conservative treatment for PS significantly reduces pain and enhances function. Non-steroidal anti-inflammatory drugs, muscle relaxants, and neuropathic pain medications are among the pharmacological treatments included, along with physiotherapy, psychotherapy, lifestyle changes, and local injection procedures . The pirOzone is a soluble allotropic form of oxygen produced by a direct exposure of oxygen to the electric current in ozone generators, and it has excellent oxidizing activity in biological tissues producing reactive oxygen species and lipid oxidation products. These molecules function as biochemical regulators of inflammation through the downregulation of the tumor necrosis factor, as well as tumor necrosis factor receptor 2 . Ozone tFurthermore, due to its distinct mechanism of preventing the release of acetylcholine at the muscle plaque level, botulinum toxin (BTX) has been widely used in numerous sectors of medicine to treat focal hypertonia, muscle spasticity, dystonia, and other diseases ,9. The cHowever, piriformis syndrome frequently develops into a chronic condition; thus, pharmaceutical treatment is only advised for a short time . In ordeThis prospective comparative study was conducted between November 2018 and August 2019 at Al-Azhar University Hospitals  after local and institutional ethics committee approval. The study included 84 patients, all of whom gave their written informed consent to participate. The research followed the rules of the Declaration of Helsinki regarding human research. We included patients diagnosed with primary piriformis syndrome by history, physical examination, external gluteal tenderness near the sciatic notch, and clinical tests: Freiberg, Pace, and Fair ,17,18. T®, FUJIFILM Sonosite, Bothell, DC, USA), according to the patient’s build. The transducer was parallel to the piriformis muscle (PM), with the medial side directed to the sacrum and the lateral side towards the great trochanter  was advanced under direct ultrasound guidance in an in-plane orientation, traversing the skin, subcutaneous fat, and gluteus maximus, and passing from lateral to medial through the piriformis sheath and into the muscle belly itself  diluted to 3 mL, with 0.9% sodium chloride, a mixture of 3 mL of oxygen-ozone (O2-O3) with an ozone concentration of 20 μg/mL , or 3 mL of 1% lidocaine , according to the group. All patients were evaluated for pain intensity and disability before the intervention, and then at one month, two months, three months, and six months after the intervention.The intervention area  was sterilized with chlorhexidine and draped. After local infiltration anesthesia, a 22-gauge needle , which is a self and subjective expression of the extent of disability and is composed of ten questions, each with six choices. The questions cover the pain intensity; ability to work, stand, sit, lift, and perform personal care; travel; sleep pattern; and sexual life. A score of 0–5 is given to each question to sum it and present the sum as a percentage of 100 .Regarding sample size calculation, we planned a study of a continuous response variable from independent control and interventional subjects with one control(s) per interventional subject. In a previous study , each su−2. All patients completed the study. The average age of all patients was 39.5 ± 8.58 years, and the average body mass index was 29.5 ± 2.9 kg mMost patients were male , with a mean symptoms’ duration of 10.9 ± 2.5 months, a VAS score of 8 ± 0.92, and an ODI score of 45.6 ± 9.9. The demographic data in each group are shown in .No significant statistical difference was seen between the three groups for all demographic data. . RegardiOverall, the values of VAS and ODI decreased after one month  and then remained almost stable, with a general trend of slight progressive increase in the second month , third month , and sixth month after injection . The comparative analysis between the three groups showed a highly significant decrease in the first and second month, in both VAS and ODI, in the LD and OZ groups, compared to the BTX group, with the inter-group differences demonstrated in After two months, both VAS and ODI scores remained almost stable for the OZ group, while we noted a progressive increase in the LD group; the reduction in both scores started to occur in the BTX group after two months . From thNearly all patients in the three study groups experienced success with the US-guided technique, and no problems or adverse effects were noticed.This study shows promising options for chronic cases of PS after the failure of conservative therapy. By injecting lidocaine, ozone, or BTX, we can significantly improve both short- and long-term pain and disability scores. Nearly all patients involved in the three study groups experienced success with the US-guided injection technique, with no adverse events noticed.A significant portion of PS cases remain undiagnosed even though the incidence ranges from 5% to 36% ,21,22. TInjections into the peri-sciatic nerve, the medial aspect of the muscle, or the side, are just a few of the different injection strategies discussed in the treatment of PS . However−2. Regarding the gender of the studied patients, the majority (58.3%) were male, while 41.7% were female. As the female: male ratio in PS was reported to be 6:1, these results did not accord with those previously recommended in the literature. Additionally, Shah et al.’s [The recruited patients’ average age was 39.5 ± 8.58 years, and the average BMI was 29.5 ± 2.9 kg mp < 0.001), which concurred with the finding of Kongsagul et al. [After 1 and 2 months of follow-up, our study showed that VAS and Oswestry Disability scores in the lidocaine and ozone groups significantly decreased compared to the BTX group . This result is supported by a placebo-controlled trial on 145 myofascial pain patients, which revealed that BTX is valuable for controlling pain severity and duration in myofascial pain syndrome for 4–6 weeks after the injection [The results from our comparative study among the three groups at 3 and 6 months also showed a highly significant decrease in VAS and Oswestry Disability scores in the BTX group compared with the lidocaine and ozone groups (njection . Moreovenjection . Moreovenjection . They innjection .P < 0.05) or the physical performance when compared to sodium chloride at 0.9% or bupivacaine at 0.25% in 27 patients complaining of low back pain [In contrast, some studies claimed that BTX did not improve the VAS (20% at 15 days and 30 days, and 22% at 90 days after treatment, ack pain . The samack pain  and Ojalack pain  in patieack pain  also repack pain . Additioack pain . Our finack pain . It has ack pain ,13. Acetack pain .Thus came the significance of ultrasound-guided BTX or ozone injections, as preferred to electromyography, fluoroscopy, CT, or MRI-guided injection procedures, which have been utilized to increase the accuracy of needle placement into the PM for the treatment of chronic resistant cases of PS. However, it was shown that these methods were not adequate for determining the needle depth required to reach the PM . AdditioWhile lidocaine and ozone therapies may aid short-term treatment in patients who are not responsive to conservative treatment and physical therapy, BTX may help with the medium- and long-term management for PS patients. The precise mechanism of BTX and ozone therapy on various chemical and inflammatory mediators, as well as their impact on reducing pain and functional disability in chronic resistant PS cases, requires further study with a large sample size.


There is little recent information about the prevalence of symptomatology of mental health disorders in representative population samples in Mexico. To determine the prevalence of mental health symptoms in Mexico and its comorbidity with tobacco, alcohol, and drug use disorder (SUD), we used the 2016–17 National Survey of Drug, Alcohol, and Tobacco Use . The data were collected from households using a cross-sectional, stratified, multistage design, with a confidence level of 90% and a response rate of 73.6%. The final sample included 56,877 completed interviews of individuals aged 12–65, with a subsample of 13,130 who answered the section on mental health. Symptoms of mania and hypomania (7.9%), depression (6.4%), and post-traumatic stress (5.7%) were the three main problems reported. Of this subsample, 56.7% reported using a legal or illegal drug without SUD, 5.4% reported SUD at one time on alcohol, 0.8% on tobacco, and 1.3% on medical or illegal drugs, 15.9% reported symptoms related to mental health, and 2.9% comorbidity. The prevalence found is consistent with those reported in previous studies, except for an increase in post-traumatic stress, which is consistent with the country’s increase in trauma. Mental health disorders are among the health problems associated with the greatest levels of disability . Mood diSurveys from various countries, including Mexico, show a lifetime prevalence of mental disorders according to DSM-IV criteria, with range of 47.4% and 12.0% in the U.S. and Nigeria, respectively. The extremes for the prevalence of anxiety and depression disorders are in the U.S.  and China . Disorders of impulse control are highest in the U.S. (25%) and the lowest in Nigeria (0.3%) [Auerbach et al. 2018) evaluated the prevalence of mental illness in 19 universities in eight countries, including Mexico, and estimated that 35% of those surveyed suffered from at least one disorder such as major depression, mania/hypomania, generalized anxiety disorder, panic disorder, alcohol use disorder, or substance use disorder . In Mexi018 evaluBenjet et al. (2009) found that the prevalence is lower in adolescents, but that the more common disorders were specific phobias and social phobia. In women, the more common disorders were phobias, major depression, oppositional defiant disorder, agoraphobia without panic disorder, and separation anxiety; in men, they were oppositional defiant disorder, alcohol abuse, and conduct disorder. In general, women presented a greater number of disorders and a greater prevalence of each . It is iDespite various efforts, there has been no more recent study in Mexico of the state of the mental health of the population, but updated data are important for the improvement of care and treatment. The objective of this study is, thus, to determine the prevalence of mental illness symptomatology in Mexico and its comorbidity with the use of tobacco, alcohol, and drugs, obtained through the 2016–17 National Survey of Drugs, Alcohol, and Tobacco Use .The study was carried out on a subsample of the National Survey of Drug, Alcohol, and Tobacco Use, administered in 2016 to participants aged 12–65 in urban and rural Mexican households [The second administration of the survey included a subsample of 13,130 respondents who agreed to give a saliva sample for DNA analysis, to be used in analyzing the relationship of mental health, addiction, and genetics. This sample was weighted according to selection probability to be representative on the national level. Mental health symptomatology for these individuals was evaluated using the Diagnostic Interview for Psychosis and Affective Disorders (DI-PAD) using the operational criteria for psychotic disorders (OPCRIT v. 4.0), administered by interviewers trained in its use. This scale has shown a high level of consensus among interviewers (kappa = 0.8), with the best consensus for estimations of the presence of disorders during the lifetime of the interviewee . The anaRespondents were asked if they had a religious affiliation, and if so, which the variable used for the analysis was dichotomous, with 1 = yes  and 2 = no.Educational level was assessed with four possible responses: 1 = none or only elementary school (0–6 years), 2 = junior high school (7–9 years), 3 = high school (10–12 years), and 4 = undergraduate or graduate studies (13 or more years).An indicator was constructed using socioeconomic data, following the method of Gutiérrez et al. (2015), which considered ownership of goods  and access to services . The index included five levels based on percentile distribution, classified into three groups: 1 = low and low-medium, 2 = medium and high-medium, and 3 = high .A positive response was defined as having been diagnosed with bipolar disorder or meeting the following two criteria: (1) having felt unusually happy, irritable, energetic, or hyperactive for three days or more, and (2) not having needed much sleep, without feeling tired, or having more energy than normal.A positive response was defined as having been diagnosed with schizophrenia or meeting the following two criteria: (1) having experienced a period of hearing voices when no one was present or having visions or seeing things that others could not see, and (2) having had ideas or beliefs that others did not share or that turned out not to be true ,9.A positive response was defined as having had the following three symptoms: (1) having experienced a sudden feeling of anxiety or fear; (2) having, as part of that experience, an accelerated heart rate, chest pains, shortness of breath, a choking sensation, nausea, sweating, weakness, or the fear of going crazy or dying; and (3) having these feelings worsen or intensify in the first ten minutes ,9.A positive response was defined as “having ever felt depressed, sad, or discouraged almost every day for two weeks or more” and also meeting one of the following criteria: (1) having ever lost most or all interest in normal activities for two weeks or more, (2) having had feelings of uselessness or guilt during that period, or spent a lot of time with thoughts of death, suicide, or self-harm, or (3) having noted significant changes in appetite during that period, or unexpected gain or loss in weight, changes in normal sleep patterns, or difficulty concentrating ,9.A positive response was defined as having had the following two symptoms: (1) having ever had repetitive thoughts or images, much more exaggerated than ordinary worries, that could not be stopped, and (2) having repeated certain behaviors over and over for an hour or more a day ,9.A positive response was defined as meeting the following two criteria: (1) having experienced a traumatic event that felt life-threatening, and (2) having experienced strong images or memories of traumatic events that return suddenly, such as uncontrollable thoughts or recurrent nightmares ,9.This variable was evaluated with the question: “In the last 12 months, have you tried to take your own life?” The variable was dichotomous, considering that there was a suicide attempt where respondents answered positively.This variable was defined as recurrent and persistent dysfunctional gambling behavior that causes a clinically significant deterioration or illness, where an individual presents four or more symptoms in the previous 12 months, according to the criteria of the DSM-5 ,13. In addition, a variable was created with different groups of interest to this study, based on the presence of certain symptoms or comorbidity. These were:The persons in this group met two criteria. The first was that they had at least one of the symptoms of mental illness: mania/hypomania, psychosis, anxiety, depression, obsession/compulsion, post-traumatic stress, suicide attempt, or pathological gambling. The second was that they had an alcohol, drug, or tobacco use disorder (SUD).Participants in this group presented positive symptomatology for at least one of the previously mentioned mental health symptoms, but not SUD.Participants in this group had none of the mental health symptoms described but did indicate having three or more symptoms of SUD during a single year at some point in their lives, based on the DSM-IV-TR , either Participants in this group included those who had ever in their lives used a legal drug , an illegal drug, or an unprescribed medical drug, but without meeting the criteria for SUD and without presenting any mental illness symptomatology.This category included participants who said they had never used any legal drug , illegal drug , or unprescribed medical drug, and who had never presented any of the mental illness symptomatology described in this section.All the protocols for this study were approved by the Ethics Committees of the Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz  and the Instituto Nacional de Medicina Genómica .Statistical analyses were carried out using the program STATA, version 13. Estimations were obtained of the prevalence of each symptomatology with an analysis of prevalence ratios (PR) based on generalized linear models (GLM) with log-link and binomial distribution. A multinomial logistic regression model was also carried out, where the dependent variable was that defining the substance use and comorbidity groups and the reference group that without symptomatology or use. These procedures allowed for better predictors and control of an important number of variables.The majority of the participant population was aged 18–29 (30.8%) or 40–65 (34.9%), and 91% reported a religious affiliation. Almost half had a low or medium-low socioeconomic index (48.5%), and only 12.7% had an undergraduate education or more.As shown in TUD is associated with mania/hypomania (19.2% with TUD vs. 7.8% without), anxiety (8.5% vs. 3.8%), depression (3.9% vs. 2.2%), and post-traumatic stress (16.6% vs. 5.6%). AUD or DUD are significantly associated with all pathologies analyzed, and AUD is also associated with suicide attempt. Those with TUD present more disorders (38.2% reported one or more) than those without TUD (17.8%); the figures for AUD are 40.2% and 16.7%, respectively, and for DUD 69.5% and 17.3%, respectively .A multiple regression model of prevalence ratios (PR) was carried out using various sociodemographic variables as predictors and different types of mental illness symptomatology as criterion variables  than women (4.7% and 7.7%). Participants who report having no religion have a higher risk of symptoms of obsessive–compulsive disorder , while those with a medium socioeconomic level have a lower risk  than those with a low or medium-low level (2.6%). Young people aged 18–29 have a higher risk of presenting post-traumatic stress disorder  than those aged 12–17 (4.5%).Finally, there are significant differences by sex and educational level for suicide attempt and pathological gambling b. For boA multinomial logistic regression model was carried out to analyze the association of various factors with drug use and comorbidity, using the population that reported no drug use or mental illness symptomatology as the base category . With rePsychiatric or mental health disorders have increased in recent years. Studies have been carried out in Mexico that indicate their prevalence in different populations, such as the general population, adolescents, and university students ,3,16, buBefore proceeding to the discussion of the findings, the limitations of this study should be recognized. The results come from screening scales and not from diagnostic instruments; however, the scale been used has shown its consistency in estimating the frequency of mental illness symptoms in the general population and its utility in identifying those symptoms during the lifetime of those who respond ,9,17. ThThe Survey of Psychiatric Epidemiology  showed that 83% of persons with mental health problems sought help once or twice in their lives. However, only 22% received minimally appropriate care for persons with a diagnosis, which includes at least four visits per year to any type of provider, or at least two visits and any type of medication, or to be in treatment at the moment of the interview. This low figure is due mainly to the lack of access to mental health services. The ENEP found an average of 13 years between diagnosis and treatment of major depression, and 30 years for anxiety disorders , making The information compiled in this study is highly useful for guiding public policy. The results find that 15.9% of respondents report symptoms of a mental health disorder at some time in their lives. The three most common symptoms are mania/hypomania (7.9%), followed by depression 6.4%), and post-traumatic stress (5.7%). The ENEP found a similar prevalence for depression 7.2%), but a lower prevalence for post-traumatic stress, which is to be expected, given that it was estimated before the increase in homicides and other forms of violence that are associated with this disorder . Persons.4%, and %, but a The analysis of risk factors found that women with symptomatology of mental illness more commonly reported having a religion, a lower educational level, and a lower socioeconomic level, as has been reported in other studies ,22. OtheAlso consistent with prior studies carried out in Mexico is the finding that men show greater prevalence of substance use and a greater comorbidity between mental disorders and both alcohol and other substance use and pathological gambling. Women report a greater frequency of suicide attempt, a greater prevalence of mental illness symptomatology, and more depression and anxiety than men ,5,10. ThTelephone and online surveys carried out during the COVID-19 pandemic lockdown found a growth in the symptomatology of mental illness ,25. ThouThe results find that 15.9% of respondents reported symptoms of a mental health disorder at some time in their live. The three most common symptoms were of mania/hypomania (7.9%), followed by depression (6.4%), and post-traumatic stress (5.7%). In addition, people with a high school education had higher risk factors for DUD, SUD, and mental health symptoms comorbid with psychiatric symptoms. Results that despite coming from screening scales, clearly inform us of the mental health of Mexicans.A limitation of the study that we must point out is that the evaluation of psychiatric symptoms was obtained with the DI-PAD screening instrument, which only allows us to know the symptoms and not the diagnosis. So the definition of the comorbidity group is only an approximation and not the exact meaning of it, which is indicated in the


The Coronavirus Disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome-coronavirus-2, has claimed 5,587,549 lives worldwide as of January 20, 2022. Fortunately, large-scale vaccination can mitigate the impact of COVID-19 by making the disease milder and less common. Although 75.2% of the United States population has received at least 1 dose of a COVID-19 vaccines thus far, concerns regarding vaccine side effects have contributed to vaccine hesitancy. Furthermore, nearly 50% of adults in the United States are concerned not only about side effects, but about their downstream impact, including missed work.The goal of this cross-sectional study was to investigate the effect of messenger RNA vaccine adverse effects on the propensity to miss work among employees associated with a single, large academic health center.Using Qualtrics, all employees, including faculty, staff, and trainees, of 5 large departments were surveyed to determine whether they received the COVID-19 vaccine and which type, and any symptoms they experienced after receipt of either vaccine dose. We hypothesized that vaccine recipients would be more likely to miss work or feel sick enough to miss work following the second dose.Thirty-seven percent of respondents experienced events severe enough that they needed to miss work from either of the doses, with the majority (27.8%) related to the second dose. These findings are consistent with and expand on the results from the phase 3 trials for Pfizer-BionTech and Moderna, which showed that vaccine side effects were more common after the second dose than after the first dose. Our statistically significant finding was more common among Asians, women, trainees/house staff, and nonphysician clinical employees.With an increasing number of individuals taking the vaccine, employers will need to account for the impact of adverse effects on their employees’ ability to work. These findings will further help organizations better plan for staffing as vaccinations increase to mitigate the spread of COVID-19. The Centers for Disease Control and Prevention reported that anaphylaxis, the most severe side effect reported in the messenger RNA (mRNA) vaccines, occurred in 11.1 and 2.5 cases per million doses of the Pfizer-BionTech and Moderna vaccines, respectively. Although the 2 studies that led to emergency use authorization did not report any episodes of anaphylaxis, less than 2% of the participants who received either vaccine reported severe or life-threatening systemic adverse events. Conversely, moderate side effects (Grade 2 or higher) occurred in 33% of participants who received the Pfizer vaccine, whereas almost 21% of participants who received the Moderna vaccine experienced a related adverse event. In both studies, when side effects occurred, they were more common following the second dose as compared to the first dose.As of January 20, 2022, 75.2% of the total population had received at least 1 dose of a COVID-19 vaccine that received emergency use authorization by the Food and Drug Administration, whereas and 63.1% were considered fully vaccinated.,5 The Cese event.,5 In botMany individuals delay or refuse to take the vaccine due to concerns about the severity of side effects, including almost 20% of US health care workers who are not yet vaccinated, according to a recent survey.The goal of this study was to investigate the relationship between mRNA vaccine adverse effects and the propensity for missing work on account of the symptoms among employees associated with a single, large academic health center. Furthermore, we examined whether the severity of side effects from the first dose was predictive of the severity of the second dose, and whether this would correlate with missed work. We hypothesized that there would be a small frequency of work absenteeism following the first dose, but that this would increase significantly following the second dose. Accordingly, we hypothesized that report of symptom severity would correlate with the need to miss work.2This cross-sectional study obtained data via a Qualtrics survey that was sent out via email to all employees in the departments of Family Medicine, Internal Medicine, Obstetrics and Gynecology, Pediatrics, and Surgery at Robert Wood Johnson Medical School in January and February 2021. These departments were chosen because they have the highest number of faculty and would subsequently yield the most participants. The employees surveyed included residents and fellows in training; paid staff; and paid and volunteer faculty members. To limit recall bias, the survey was emailed to employees during the first release of the vaccines and closed 4 weeks after it was first sent out. The survey included 30 related to the respondent's role in the hospital, history of medical comorbidities associated with worse COVID-19 outcomes, regularity of influenza vaccination, and other general demographics . Additional questions included whether participants had received the COVID-19 vaccine, which vaccine they received, and symptoms they had experienced after they received 1 or both doses of the vaccine. Severity of symptoms experienced after receipt of the vaccine (side effects) was grouped into 4 categories: none, mild, moderate, and severe  and all 2-sided 3A total of 861 survey responses were received, for a response rate of 50%. Among those, 192 (22.3%) respondents provided information about their vaccine-related outcomes after having received only 1 dose and 529 (61.4%) healthcare workers provided vaccine-related outcomes after receiving both vaccination doses, at the time of their survey response. All other respondents had either not received any vaccination doses at the time of survey response or opted not to provide information about their vaccine-related outcomes. Of the 529 respondents, 8.2% were 30 years old or younger, 27.2% were 31 to 45 years old, 31.9% were 46 to 60 years old, and 32.7% were over 60 years old. Approximately 70.3% of the respondents were attending physicians, with trainees/house staff making up 11.7%, nurses accounting for 8.7%, and other more specific clinical and nonclinical roles making up the remaining 9.3%. Females accounted for 54.2% of the sample, 68.4% self-reported as White, 30.1% reported having medical comorbidities that are related to worse COVID-19 outcomes, and 94.1% reported receiving the flu shot every year , 333 (63.0%) did not report needing to miss work after either dose, whereas 16 (3.0%) needed to miss work after dose 1 but not dose 2, 147 (27.8%) needed to miss work after dose 2 but not dose 1, and 33 (6.2%) needed to miss work after both doses (P < .001). Most notably, 12 (17.4%) of the respondents who reported no symptoms after dose 1, reported moderate symptoms after dose 2, and 78 (22.6%) of the respondents who reported minimal symptoms after dose 1, reported moderate or severe symptoms after dose 2. No respondents reported severe symptoms after either dose , among those who had received both doses n = 529), 321 (60.7%) reported having the same level of symptom severity for both doses, whereas 132 (25.0%) and 76 (14.3%) reported having more severe and less severe symptoms for dose 2 vs dose 1, respectively  and moderate (P = .57) symptoms; however, for those who reported no symptoms after their second dose, there was a significant decrease in the likelihood of needing to stay home after dose 2 . For those who did not report needing to miss work after the first dose, there was a significant decrease in needing to miss work after the second dose as well . Additionally, compared to those who self-reported as Black, there was no significant difference for those who self-reported as White  or “Other” , with a trending significant increase for those who self-reported as Asian . Compared to males, females showed a trending significant increase , and compared to faculty, both trainees/house staff  and other specific clinical roles  showed a significant increase in the need to stay home after dose 2  were severe enough to interfere with work. Our results showed that 37% of participants experienced events severe enough that they needed to miss work from either of the doses, with the majority (27.8%) related to the second dose effects. As predicted in our hypothesis, vaccine recipients were significantly more likely to miss work or feel sick enough to miss work following the second dose (34% of respondents) than after the first dose (9.2% of respondents). These findings are consistent with results from the phase 3 trials for Pfizer-BionTech and Moderna, which showed that vaccine side effects were more common after the second dose than after the first dose.Interestingly, additional analysis showed that there was no significant difference in respondents missing work after the first dose of either vaccine but there was a significant difference in respondents missing work or feeling unwell enough to want to miss work after the second dose with both the Pfizer and Moderna vaccines. Additionally, Moderna was associated with a nearly 2-fold increase in second-dose adverse events causing respondents to miss work as compared to Pfizer. This finding is consistent with prior evidence that adverse effects are more frequent in patients who receive the Moderna vaccine than in those receiving the Pfizer vaccine.When applying stepwise regression for demographics, we discovered that females , trainees/house staff (when compared with faculty), and non-attending/non-nursing roles (when compared with faculty) were more likely to need to stay home after dose 2. In terms of gender, this finding is consistent with prior research that has shown that females report more adverse effects from vaccines that do males.Our study had several limitations. First, we surveyed individuals associated with a single institution in New Jersey. Therefore, the results may not be generalizable to other locations in the country or to individuals outside of the medical field. Because our survey collected data at the beginning of 2021 when the Pfizer-BionTech and Moderna vaccines were the only available options, the results do not provide any information about adverse events from other vaccines against COVID-19, nor does it tell us whether the respondents have similar symptoms after receiving other vaccines. Furthermore, we did not collect information about which specific adverse events interfered with respondents’ work attendance. Similarly, because the patients determined the severity of the side effects, there is clear reporting bias involved. However, given that our study examined the symptoms’ impact on participants ability or willingness to work, the participants’ perceived severity is more relevant than what the specific event was. Furthermore, while certain demographics were associated with a need to stay home after vaccine receipt, our survey did not investigate the reasons for these differences. Our study is not generalizable to individuals who receive other COVID-19 vaccines, such as that produced by Johnson & Johnson/Janssen. Furthermore, the results from our study should not be applied to the Pfizer-BionTech and Moderna “booster shots” recently approved.In our literature search, no other studies have looked at the need to stay home after receipt of the mRNA COVID-19 vaccines. Therefore, our study is unique and has significant implications for the public. With an increasing number of individuals taking the vaccine, employers must consider the impact of adverse effects on their employees’ ability to work. Depending on the type of work, employers can consider either staggering vaccination days for the employees (to minimize missed workers) or vaccinate all employees on the same day and give the next day as a planned day off from work. Additionally, with school-aged persons increasingly able to take the vaccines, the effects on school attendance and learning must be taken into consideration. Finally, with the possibility that booster shots may be needed, similar studies are warranted to explore the effect of a third vaccine dose on the workplace.Further research should be directed toward understanding which adverse events are most likely to interfere with recipients’ work attendance. If this information is known, interventions may be explored to prevent such events. Likewise, a greater understanding of why there are racial, gender, and professional differences, may help minimize the effect of vaccine adverse events. Given that our study only surveyed adults, similar studies of adolescents and children should be conducted to understand the potential impact on school attendance. With the increasing use of the Pfizer-BionTech and Moderna “booster shots”, similar studies should also be performed to investigate the effect of these additional vaccinations on work interference.5Over one-third of recipients of either of the 2 COVID-19 mRNA vaccines (Pfizer-BionTech and Moderna) experienced adverse events that were severe enough to cause them to either miss work or wish they would have. This finding was more common among Asians, women, trainees/house staff, and nonphysician clinical employees. Further research is needed to understand the drivers of these findings and how to mitigate such events.Conceptualization: David A Cohen, Patricia Greenberg, Payal Parikh.Data curation: David A Cohen, Patricia Greenberg, Brielle Formanowski.Formal analysis: Patricia Greenberg, Brielle Formanowski.Investigation: David A Cohen, Patricia Greenberg, Brielle Formanowski, Payal Parikh.Methodology: David A Cohen, Patricia Greenberg, Brielle Formanowski.Project administration: David A Cohen.Resources: David A Cohen.Software: Patricia Greenberg, Brielle Formanowski.Supervision: David A Cohen, Patricia Greenberg.Validation: Patricia Greenberg.Visualization: David A Cohen, Payal Parikh.Writing – original draft: David A Cohen.Writing – review & editing: David A Cohen, Patricia Greenberg, Brielle Formanowski, Payal Parikh.


Ralstonia, Allorhizobium-Neorhizobium-Pararhizobium-Rhizobium, Pseudomonas, unidentified_Chloroplast and Bacteroides at the genus level. In addition, our findings demonstrated striking changes in the composition of the oral and gut bacterium community in the dogs suffered from CMTs compared to the healthy dogs, with a significant increase of Bacteroides which also was the significant microbial biomarker in the oral and gut bacterium community. It showed that the Bacteroides was shared in the intratumoral, oral and intestinal bacterial microbiomes, confirming that microbiota might travel from the mouth to the intestine and finally to the distant mammary tumor tissue. This study provides a new microbiological idea for the treatment of canine mammary tumors, and also provides a theoretical basis for the study of human breast cancer.Canine mammary tumor (CMT) is the most common tumor in dogs, with 50% of malignant cases, and lacks an effective therapeutic schedule, hence its early diagnosis is of great importance to achieve a good prognosis. Microbiota is believed to play important roles in systemic diseases, including cancers. In this study, 91 tumors, 21 oral and fecal samples in total were collected from dogs with CMTs, and 31 oral and 21 fecal samples from healthy dogs were collected as control. The intratumoral, oral and gut bacterial community of dogs with CMTs and healthy dogs was profiled by 16S rRNA high-throughput sequencing and bioinformatic methods. The predominant intratumoral microbes were  In recent years, more and more domestic pets are raised as the spiritual sustenance of humans, particularly dogs. The morbidities of various diseases have increased with the rise of the dog population and the prolongation of the life span, especially tumors . As the Proteobacteria, Firmicutes and Actinobacteria at phyla [In the past decade, some studies reported that the microbiome could either directly (within the tumor) or indirectly  increase the chances of developing cancers, for example, liver, cervical, colorectal, pancreatic, oral, and breast ,12,13,14at phyla . On the at phyla ,16. Furtat phyla ,18,19,20at phyla . As humaTherefore, based on this background, we hypothesized that the risk of CMTs might be related to the composition and functionality of the mammary tumor, gut or oral microbiota. In this study, we aimed to explore the characterization of the intratumor, gut and oral microbiome in dogs with canine mammary tumors using 16S rRNA high-throughput sequencing, and to reveal whether intratumor microbiota can move from the gastrointestinal tract or oral cavity to the mammary gland on dogs.To characterize the CMT-associated tissue, gut and oral microbiome, the tumor, feces and oral swabs of lateral oral gingival mucosa from dogs with CMTs and its control samples including the normal tissue adjacent to tumors from diseased dogs, feces and oral swabs from healthy dogs were collected and analyzed during September 2020 and July 2021. A total of 147 dogs were collected in this study, which included 95 dogs with CMTs and 52 healthy dogs. Among them, we collected 91, 21 and 21 tumors , feces ap > 0.05) , Firmicutes (17.56%), Bacteroidota (7.35%) and Actinobacteria (6.77%) , Allorhizobium-Neorhizobium-Pararhizobium-Rhizobium (3.77%), Pseudomonas (3.44%), unidentified_Chloroplast (2.78%) and Bacteroides (2.21%)  and canine tumor-adjacent tissues (CAT), we applied high-throughput sequencing to detect the V4 region of the bacterial 16S rRNA gene. As a result, 78,586 raw sequence reads with an average length of 253 bps were produced from all samples. In total, 5200 OTUs were obtained from the sequencing results, which included 121phyla, 271 classes, 585 orders, 876 families, 1883 genera and 1464 species. The results of the ACE index  showed that a decrease in within-sample bacterial richness was observed in those intratumor A, which  > 0.05) B. To cha (6.77%) C, and thAT group . At the  (2.21%) D, which n groups .p < 0.05), of which 32 pathways were upregulated and 43 pathways were downregulated . Particularly, there were six of the 73 pathways involved in the glycan biosynthesis and metabolism, which were peptidoglycan biosynthesis and degradation proteins, peptidoglycan biosynthesis, glycosyltransferases, lipopolysaccharide biosynthesis proteins, lipopolysaccharide biosynthesis, and glycosylphosphatidylinositol (GPI) anchored proteins. Overall, our results present here reveal CMT-associated alterations in the composition and functionality of intratumoral microbiota.With a focus on pathways relevant to microbial metabolism, we found that pathway modules associated with nucleotide metabolism, enzyme families, xenobiotics biodegradation and metabolism, metabolism of other amino acids and metabolism of terpenoids and polyketides were differentially enriched between the CMT and CAT groups  and healthy dogs (ONN group), we applied high-throughput sequencing to detect the V4 region of the bacterial 16S rRNA gene. As a result, 4,363,630 raw sequence reads with an average length of 253 bp were produced from all the oral swabs. In total, 2286 OTUs  were obtained from the sequencing results, which include 58 phyla, 142 classes, 307 orders, 466 families, 777 genera, and 536 species. The Shannon and Chao1 indexes explicitly showed that the differences in oral bacterial community composition existed between the OBC and ONN groups, and two mean values of the OBC group  were both higher than that of the ONN group  A,B. More of 0.09 , which iProteobacteria (32.41%), Bacteroidota (31.31%) and Firmicutes (10.26%), with a less common presence of Spirochaetota (2.89%) on the OBC group (Porphyromonas (18.84%), Fusobacterium (5.07%), Moraxella (4.84%), Ralstonia (3.61%) and Conchiformibius (2.88%), with a slight presence of Bacteroides (1.94%) on the OBC group  was performed to further uncover the remarkable species of oral microbiota that characterize the differences between the OBC and ONN groups  . To sum BC group . At the BC group . Since dBC group D, we souBC group D. We fouN groups E. When tp > 0.05). Moreover, analyses of sample-to-sample differences in microbial community structures (beta diversity) showed that the gut microbiome of the SBC group clustered separately from that of the control ONN group  (Firmicutes (47.65%), Proteobacteria (21.96%), Bacteroidota (11.02%) and Fusobacteriota (7.94%) (Bacteroidota showed a significant difference between groups (Bacteroides (9.08%), Ralstonia (9.19%), Escherichia-Shigella (8.34%) and Fusobacterium (6.33%)  and healthy dogs (SNN group), we applied high-throughput sequencing to detect the V4 region of the bacterial 16S rRNA gene. As a result, 3,797,952 raw sequence reads with an average length of 253 bp were produced from all the oral swabs. In total, 2447 OTUs  were obtained from the sequencing results, which include 63 phyla, 148 classes, 316 orders, 465 families, 900 genera, and 554 species. The alpha diversity showed that there were no significant differences in gut bacterial community composition existed between SBC and SNN groups (= 0.001) A. To cha (7.94%) , and Pron groups . At the  (6.33%) B, which  (6.33%) C. Additi (6.33%) D. When tstridium E.Ralstonia, Bacteroides and Lactobacillus were the predominances of genus among in tumor, gut and oral microbiome. Bacteroides in the tumor, gut and oral microbiome of diseased dogs were higher than these of healthy dogs. That says, the Bacteroidales, Bacteroidaceae and Bacteroides were detected in the tumor, and were also observed in the disordered oral and gut microbiota . At the genus level, we observed significant increases in the abundances of Bacteroides and Blautia in the SBC group compared with the SNN group, with a significant decrease of Ralstonia (p < 0.05). In addition, the LEfSe analysis further revealed Bacteroides were characteristically enriched in the SBC groups . Subsequently, LEfSe analysis further revealed that the significant the microbial biomarker included Bacteroides, Treponema, Acholeplasma, unidentified_Nitrospiraceae and Ralstonia at the genus level on the OBC group. Therefore, we conclude that the high abundance of Treponema and Bacteroides, may stand out as potential specific risk factors for CMTs.Many studies indicated that members of the oral microbiota are involved in intestinal dysbiosis, indirectly affecting the composition of the intestinal microbiota via dissemination into the gut . It was us study ,28. FurtBacteroides, suggesting that Bacteroides might be related to the occurrence and development of CMT. The result was similar to the previous study, but the latter difference was that the Bacteroides fragilis was observed in cancerous breasts, and induced the growth and metastatic progression [Bacteroides which also was the significant microbial biomarker on the oral and gut bacterium community. It can be seen that Bacteroides in the oral and gut microbiota were present in the tumor, indicating that microbiota might travel from the mouth to the intestine and finally to the distant mammary tissue. This result might explain why the risk of breast cancer in patients with periodontitis associated with oral bacterial disorders increased [So far, there was no related research on whether the CMT contained bacteria and its source. This study first reported the bacterial composition of CMT, which contained a high abundance of gression . What’s ncreased . In vetencreased . It furtOur study determined the characteristics of intratumoral microbiota by the 16S rRNA high-throughput sequencing, and confirmed the intestinal and oral dysbacteriosis of diseased dogs with CMTs. Additionally, the presence of common bacteria among three sites of dogs indicated that microbiota might travel from the oral cavity to the intestine and finally to the distant mammary tumor tissue. It was beneficial to develop a new microbiological method for the prevention and treatment of canine mammary tumors, and played a considerable role in other tumors of dogs and human breast cancer studies.Tumoral, fecal and oral samples from the dogs suspected of suffering CMTs and normal tissue adjacent to the suspected tumor, feces and oral swabs from the healthy dogs were collected from the animal hospital in Changchun province, China, between September 2020 and June 2021. The age, breed, gender, somatotype, spayed status and region of healthy dogs were in agreement with that of diseased dogs suffering CMTs . The proFor histological studies, the CMTs were fixed in 10% neutral buffered formalin. After fixation the material was washed in saline phosphate buffer (PBS), followed by dehydration in a series of ethanol in increasing concentrations (from 70 to 100%), followed by diaphanization in xylol and paraffin inclusion. The paraffin blocks were submitted to microtomy  and the cuts of 5 μm made were adhered on histological slides and left in an oven at 60 °C for 12 h. After that, the slices of the glands fragments on the slides underwent a routine of tissue staining techniques using Hematoxylin and Eosin, Masson’s Trichrome and Picrosirius Red. Next, the analysis and photos were made through normal and polarized light on a Leica BX80 Camera Zaiss HRC microscope.The canine mammary gland tissues were interpreted by an expert pathologist and those with CMTs defined by histopathology were considered CMT cases.® Gigh-Fidelity PCR Mastere Mix GC Budder 2× , 10 μL the extracted gDNA template (1 ng/μL), 3 μL H2O and 2 μL of 2 μM 16S rRNA V4 (515F/806R) barcoded primer mix which was consisted of equimolar forward (515F: 5′-GTGCCAGCMGCCGCGGTAA-3′) and reverse (806R: 5′-GGACTACHVGGGTWTCTAAT-3′) primer pairs [Genomic DNA was extracted from each sample using DNA Miniprep Kit  according to the manufacturer’s instructions, and then were used as the templates for PCR amplification of the V4 region of the 16S rRNA gene. PCR was conducted in a 30 μL volume mixture including in 15 μL Phusioner pairs . The cycer pairs .Due to the presence of dirty data, the merging, quality filtering and removal of chimeric reads were performed in raw data which was obtained after sequencing using the QIIME 2 pipeline  to acquiFunctional composition of metagenomes was predicted from 16S rRNA data by the PICRUSt software , the pipFor isolating tumoral bacteria, tumor tissues were placed in 75% ethanol solution for 3 min to disinfect the surface, and then vortexed multiple times in the sterile PBS buffer to encourage the removal of any bacteria on the tissue surface. Subsequently, the epidermis of tumors was removed using a new blade and sterile cell culture to obtain the tissues within the tumorous. Finally, these acquired internal tumor tissues were divided into two sections. One treated tumor was incubated in solid medium plates with 5% sterile defibrinated sheep blood, including brain heart infusion (BHI) and columbia agar base medium, for 3–5d at a 37 °C incubator under anaerobic conditions . A singlThe isolated tumoral bacteria were identified based on their characterization of the colonies, morphological observation and 16S rRNA gene sequencing. The purified bacteria were serially diluted with sterile saline solution, and coated on blood agar plates followed by incubation at 37 °C for 3d under the anaerobic condition to observe the characterization of the colonies. The morphology of the isolated strains was observed by Gram staining. Subsequently, the turbid broth medium was sent to Comate Bioscience Co., Ltd . for sequencing, and the obtained sequences were aligned to the GenBank database using NCBI BLAST.t-test. The discrimination in community composition between diseased and normal groups was determined by analysis of similarities of UniFrac parameters using 999 permutations in each test. Significant changes in the phylum and genus relative abundance of the microbiome were analyzed by Student’s t-test and adjusted by Benjamini-Hochberg correction. Statistically significant biomarkers at the OTU level were identified by the linear discriminant analysis of effect size analysis [p value was less than 0.05.Shannon, Simpson, ACE and Chao1 indexes between canine mammary tumors and normal tissues adjacent to suspected tumors were compared by using Student’s analysis . It was Bacteroides was shared in the intratumoral, oral and intestinal bacterial microbiomes, confirming that microbiota might travel from the mouth to the intestine and finally to the distant mammary tumor tissue. This study provides a new microbiological idea for the treatment of canine mammary tumors, and also provides a theoretical basis for the study of human breast cancer.In summary, we first systematically described the characteristics of intratumoral bacterium composition in the canine mammary tumor, and analyzed the oral and gut bacterial microbiome composition and differences between the dogs with CMTs and healthy dogs. The result showed that the


Lc3, Bcln1, P150, Ulk, and Atg5) and apoptosis . Transcripts related to autophagy were reduced in the hypothalamus, pituitary, and adrenals after TBI, however, this was not reflected in autophagy-related protein levels. In contrast, protein markers related to apoptosis increased in the adrenals during the acute phase and in the pituitary during the chronic phase. TBI stresses induce a variation of autophagy-related transcripts without modifying the levels of their proteins in the HPA axis. In contrast, protein markers related to apoptosis are increased in the acute phase in the adrenals, which could lead to impaired communication via the hypothalamus, pituitary, and adrenals. This may then explain the permanent pituitary damage with increased apoptosis and inflammation in the chronic phase. These results contribute to the elucidation of the mechanisms underlying endocrine dysfunctions such as pituitary and adrenal insufficiency that occur after TBI. Although the adrenals are not directly affected by TBI, we suggest that the role of the adrenals along with the hypothalamus and pituitary should not be ignored in the acute phase after TBI.Traumatic brain injury (TBI) is a major health problem affecting millions of people worldwide and leading to death or permanent damage. TBI affects the hypothalamic–pituitary–adrenal (HPA) axis either by primary injury to the hypothalamic–hypophyseal region or by secondary vascular damage, brain, and/or pituitary edema, vasospasm, and inflammation. Neuroendocrine dysfunctions after TBI have been clinically described in all hypothalamic–pituitary axes. We established a mild TBI (mTBI) in rats by using the controlled cortical impact (CCI) model. The hypothalamus, pituitary, and adrenals were collected in the acute (24 h) and chronic (30 days) groups after TBI, and we investigated transcripts and protein-related autophagy ( The brain can be temporarily or permanently altered after a traumatic brain injury (TBI). First, a primary injury is defined as direct damage to the brain, including tissue shear and vascular damage ,2,3. A sThe mechanism(s) of pituitary dysfunction, which can be seen in 27% of the survivors (6-36 months) after moderate to severe TBI, has/have not yet been fully elucidated . The pitApoptosis and autophagy are important molecular processes that maintain the homeostasis of the organism and the cell, respectively. Although apoptosis fulfills its role by dismantling damaged or unwanted cells, autophagy maintains cellular homeostasis through recycling organelles and selective intracellular molecules. Apoptosis is defined as programmed cell death, and active cleaved caspase-3 has been shown to stimulate apoptosis in numerous studies of the process of apoptosis in mammals ,17,18. BThe controlled cortical impact (CCI) causes long-term dysregulation of the neuroendocrine stress response in the animal model and is mainly used to mimic human head trauma with different severity for developing preventative measures and reducing the impact of various types of primary injury . It is already known that TNF-α increases in serum after TBI, and studies in animal models have focused on different regions of the brain . ImportaTBI was generated in rats by using the controlled cortical impact (CCI) model. The hypothalamus, pituitary, and adrenal tissues were removed in the acute (24 h) and chronic phase (30 days). Generally, TNF-α protein levels are measured from the sera to detect inflammation in the HPA axis . The HPA in the hypothalamus, pituitary, and adrenal glands in the acute (24 h) and chronic (30 days) phases after TBI. Among the five transcripts, P150  and Atg5  were significantly decreased from the acute phase and further decreased in the chronic phase after TBI in the hypothalamus  and chronic  phases of TBI than the control group  and chronic phases  of TBI , which was not maintained during the chronic phase   of TBI A; howeve > 0.99) B. Bcln1 was the only transcript to increase in the adrenals of the chronic group compared to the acute group of TBI and the control group   were significantly decreased compared to the control group in the acute phase of TBI   (= 0.007) C. Three = 0.023) C. The le= 0.023) C. When autophagy is induced, cytosolic Lc3-I is transformed to Lc3-II and localized in autophagosome membranes by the addition of PE. As a result, Lc3-II expression is widely considered to be a sign of autophagy induction . When auTo evaluate the occurrence of apoptosis after TBI, in the acute and chronic phases, we assessed the expression of total caspase-3 and levels of Clv-caspase-3 (the active form of caspase 3) by using Western blot analysis in the HPA axis-related tissues. There was no detectable level of Clv-caspase-3 protein in the hypothalamus in the acute and chronic phases after TBI A. We fouEndocrine dysfunctions after TBI have been clinically described in all hypothalamic–pituitary axes. In addition, hypopituitarism was detected in 27% of survivors (6–36 months) after moderate to severe TBI. The HPA axis is responsible for providing an adequate cortisol level to maintain organisms’ homeostasis in the face of stress responses . Based on the knowledge gained so far, it is tempting to assume that chronic inflammation plays a role in the development of long-term endocrine dysfunctions after TBI, especially in people with an inherited predisposition ,13,25,26Previous studies have demonstrated that autophagy is activated after TBI, and researchers have hypothesized that inhibition of the autophagic pathway may ameliorate neurological deficits ,28,29. HTherefore, we investigated whether autophagy or apoptosis was involved in the regulation of cellular functions in the hypothalamic, pituitary, and adrenal tissues of rats after a mild controlled cortical impact (CCI) model and focused on transcription and protein markers associated with autophagy and apoptosis. The present study revealed the increased apoptosis ratio in the acute phase of TBI in the adrenal glands ,31. RemaAccording to our results, although transcription levels of autophagic markers showed significant changes in the hypothalamus, pituitary, and adrenal glands in acute and chronic phases after TBI, these changes were not reflected in protein levels of autophagy-related such as Lc3 and Beclin-1. Although transcript levels of autophagic markers were significantly lower in all tissues after TBI, especially during the chronic phase, these changes did not translate to tissue protein levels of these transcripts. The decrease in autophagic transcripts could indicate more general changes in levels either of pre- or posttranscriptional RNA regulation in the HPA axis after TBI. An in-depth study of the regulation of total transcripts during these phases should be planned soon.The trauma-induced inflammatory response is a major component of TBI. This secondary injury after TBI occurs hours or weeks after injury and causes biochemical changes in proximal and distant tissues. The trauma not only causes neuroinflammation in the brain but also leads to a systemic inflammatory response. Proinflammatory cytokines play an important role in maintaining normal brain function and repair after TBI. However, the extreme and uncontrolled release of these cytokines, particularly interleukin (IL)-1β, IL-6, and TNF-α, can also cause a large amount of damage outside of the brain. Levels of these cytokines may increase thousands of times more than physiologically expected levels in the brain; however, that may not be reflected in the serum levels. TNF-α is an important inflammatory mediator that occurs after TBI . As a reChronic inflammation is one of the most important triggers of apoptosis, defined as programmed cell death. Cleaved caspase-3 activates and stimulates apoptosis in many apoptotic processes in mammals. First, caspase-3 is synthesized as a 32 kilo Dalton (kDa) proenzyme, then it is cleaved into 12 and 17 k Da subunits. Two subunits (12 k Da and two 17 k Da) join to create the functionally active cleaved-caspase-3 enzyme. After the formation of the active cleaved caspase-3 enzyme, effector caspases, which include caspase-3, -6, and -7, initiate the degradation of many important cellular proteins. Finally, after degradation, the chromatin condenses and fragments the DNA ,17,18.(Bcln1) and microtubule-associated light chain-3 (LC3), play a major role and are frequently accepted as potential markers of autophagic activity [Basal levels of autophagy ensure the removal of abnormal proteins and aged or damaged organelles within the cell in the normal state. However, when the autophagy mechanism is over-activated, it can trigger apoptosis. Autophagy-related (Atg) genes/proteins, including Beclin-1 activity ,33. Beclactivity ,35. P150activity ,37.At this point, increased apoptotic or autophagic activity associated with increased neuroinflammation in tissues associated with the HPA axis after TBI may lead to loss of secretory or regulatory cells, which may be the cause of pituitary deficiency occurring after TBI. There are no studies in the literature showing how autophagy or apoptosis mechanisms play a role in the HPA axis after TBI to date. This knowledge could help in the development of new targeted treatment strategies.In 2011, Chen et al. created TBI in rats by using the fluid percussion injury model and found that the rate of apoptosis increased in the hypothalamus and pituitary in the 7 and 14 days after TBI . Tan et Finally, our results suggest that adrenal glands in the acute phase after TBI may play an important role in the mechanism of post-TBI-emergent endocrine dysfunctions, particularly pituitary insufficiency. We suggest that increased apoptosis of the adrenal glands in the acute phase can also impair communication along the HPA axis, and disruption of communication leads to permanent damage to the pituitary in the chronic phase. In addition to all this, these results show that the adrenal glands may play an important role in the mechanism of diseases other than pituitary insufficiency that occurs after TBI. Although the adrenal glands are not directly affected by TBI, we suggest that adrenal glands contribute to the endocrine dysfunctions occurring after TBI.A total of 42 healthy eight-week-old adult male Sprague–Dawley rats weighing 250–300 g, were used in this study. These rats were housed under a 12 h light/dark cycle at 23 °C and allowed ad libitum access to food and Erciyes University, Genome and Stem Cell Center (GenKok), Transgenic Department, Kayseri, Turkey. The male rats were randomly divided into three groups, and each group included 14 rats. TBI was generated in rats by using the CCI model ,39,40. T2, 2.0 mL/min flow rate) and put in a stereotaxic frame with the head in a horizontal plane about the interaural line. The spontaneous respiration of the rats was not suppressed during the experiment. Depth of anesthesia was monitored by the chin and skeletal muscle tone. Every surgical procedure was carried out in an aseptic environment. In this method, a craniotomy is performed, and head trauma is created in the area of interest with a computerized pneumatic system at the desired speed, depth, and duration. After anesthesia, the scalp of the rat, which was fixed in the prone position with a standard nailed frame, was shaved, and the area was cleaned with 10% povidone-iodine, and the periosteum was dissected by cutting the skin and fascia with a 10-mm median linear incision. The skin and galea were fixed to the laterals with a bulldog clip to provide an adequate visual field. Then, in the left parasagittal region, a craniectomy defect was produced by drilling the cranium with a 3-mm diameter dental drill 2 mm lateral to the sagittal suture and 2 mm posterior to the bregma. By varying the velocity with which the exposed dura was struck and the depth of tissue compression, a mild injury was induced. The TBI model had the following parameters: high pressure of 200 Kpa, and depth of 1.0 mm. This model is referred to as a mild-TBI model in the literature [The CCI techniques, parameters, and postoperative care have all been thoroughly reported previously ,39,40. Rterature . Finallyterature ,40.Ulk, P150, Atg5, and Bcln1 genes in the hypothalamus–pituitary–adrenal of all groups were determined. The Actb gene was used as a housekeeping gene. All PCR experiments were repeated twice. The Ct values were normalized by using the Total RNA isolation was made from tissues using Trizol , and cDNA was synthesized from the RNA samples by using an Evo Script cDNA synthesis kit . The cDNA procedure was conducted according to the manufacturer’s protocol and samples were quantified by using a Roche 480 real-time PCR . Transcript levels of t method ,42.https://www.cellsignal.com/about-us/cst-antibody-validation-principles) (accessed 7 December 2022) [Standard procedures were used to extract total proteins from dissected hypothalamus, pituitary, and adrenal glands ,44. A deer 2022) ,46,47.The compliance of the data to normal distribution was evaluated by the histogram, q-q graphs, and Shapiro–Wilk test. For determination of the differences in gene expression data, independent samples were analyzed by ordinary one-way ANOVA or by Kruskal–Wallis test according to their distribution. If samples had normal distribution, parametric ordinary one-way ANOVA test was used with Tukey post-hoc test. If samples did not have normal distribution non-parametric Kruskal–Wallis test with Dunnett’s post hoc test was used. Differences in protein expression were analyzed by unpaired Student t-test or by Mann–Whitney-U test according to their distribution. If samples had normal distribution, a parametric unpaired Student t-test was used. If samples did not have normal distribution, a nonparametric Mann–Whitney-U test was used. p values <0.05 were considered statistically significant. All data are expressed as the mean with SD. The sample size was calculated with power analysis, the amount of Type I error  was 0.05, the power of the test (1-beta) was 0.95, and the effect size was 0.82 while using the independent samples one-way ANOVA test for minimum sample size required a significant difference of nine for each group; a total of 27 male rat was used for G-power (v3.1) power analysis.Graph-Pad Prism 8 packages were used for statistical analysis. Results with In this study, we sought to determine which, where, and when the autophagy or apoptosis mechanisms in the HPA axis of neuroinflammation occur after TBI trigger and its relationship with endocrine dysfunctions that occur after TBI. Although the adrenal glands are not directly affected by TBI, we suggest that adrenal glands contribute to the endocrine dysfunctions occurring after TBI.