Right-sided endocarditis (RSE) accounts for 5%–10% of all cases of infective endocarditis (IE) and frequently has different etiological, pathogenetic, and clinical presentations compared with left-sided endocarditis (LSE). The aims of this study were to evaluate the epidemiologic and clinical characteristics and prognosis of RSE patients and to compare them with those of LSE patients. This study’s importance relates to the local understanding of RSE and LSE, since Israeli demographics are different compared to the Unites States and Europe with regard to intravenous drug abuse and rheumatic valvular disease prevalence.A retrospective cohort study of 215 patients with infective endocarditis was performed. The primary outcome was in-hospital mortality. The secondary outcomes were duration of hospitalization, recurrent hospitalization, recurrent infective endocarditis, and one-year mortality.P<0.001). The most common pathogen in both groups was Staphylococcus aureus, which occurred more in the RSE group (51%) versus the LSE group (19%). In-hospital mortality was lower among patients with RSE .Of the 215 patients in the study, 176 had LSE and 39 had RSE. The RSE patients were younger than the LSE patients , although less common in Southern Israel. The etiological and clinical differences between RSE and LSE are noteworthy. Patients with RSE have a better prognosis than those with LSE. Right-sided endocarditis (RSE) accounts for 5%–10% of all cases of infective endocarditis (IE) and most frequently involves the tricuspid valve.7Patients with RSE may be classified into three groups: (1) IVDU; (2) cardiac device carriers; and (3) no left-sided endocarditis (LSE), no IVDU, and no cardiac device. Each group can be considered as independent entities due to the relevant epidemiologic, clinical, microbiological, echocardiographic, and prognostic differences among them.8Staphylococcus aureus, among both IVDU and the rest of the patient population.16The most common pathogenic cause of RSE is The clinical presentation of RSE often involves fever accompanied by respiratory signs and symptoms secondary to septic emboli to the lungs.20The aims of this study were to evaluate the epidemiologic, clinical, and laboratory characteristics of RSE with regard to patients, etiology, and pathogenesis, as compared with LSE, and to evaluate and compare the patient outcomes for RSE versus LSE.Since Israeli demographics are quite different from those of the Unites States and Europe with regard to intravenous drug abuse and rheumatic valvular disease prevalence, this study has potential importance for the treatment of RSE and LSE patients in Israel.The study focused on IE patients admitted to Soroka University Medical Center (SUMC). The center is the only tertiary hospital for a population of 1.1 million, geographically spread out through an area half the size of the State of Israel.Institutional Review Board approval was obtained prior initiation of the study. A retrospective cohort study was performed of all adult patients with RSE hospitalized in SUMC between 2003 and 2013, since all medical records were computerized in 2003, making the data easily accessible.Discharge diagnoses (ICD-9) were used to identify subjects with infective endocarditis according to ICD-9 codes: 112.81, 397, 421.0-421.9, 424, 424.2, 424.9.All IE cases were reviewed by two investigators  according to the modified Duke criteria for IE diagnosis.20The patients’ demographic characteristics, ICD-9 diagnoses, medications, and clinical and laboratory data were obtained from a comprehensive medical chart review and from the computerized hospital database.Patients with RSE were compared to patients with LSE. In-hospital mortality (primary outcome), duration of hospitalization, recurrent hospitalization, recurrent infective endocarditis, and one-year mortality (secondary outcomes) were obtained.t test, chi-square, and non-parametric tests. Survival curves were calculated by the Kaplan–Meier method, and comparison between patient groups was performed by log-rank test. A two-sided P value <0.05 was considered as statistically significant.Data were expressed as mean ± standard deviation (SD), median ± interquartile range (IQR), or number and percentage. Comparison of RSE and LSE patient characteristics was performed using The study included 215 patients diagnosed with IE based on the modified Duke criteria. Of these, 176 had LSE and 39 had RSE.P<0.001).Patient demographic and clinical characteristics are detailed in P<0.001) and more patients with a prior IE episode . More LSE patients suffered from cardiac arrhythmia , whereas more RSE patients suffered from chronic liver diseases .Among the RSE patients there were more IVDU .There were no statistically significant differences between the two groups in most laboratory parameters, except for an elevated C-reactive protein (CRP) in the RSE group . However, there were more cases of inflammatory reactions after cardiac device, prosthetic valve, and grafts in the LSE group .With regard to the reason for hospital admission, more RSE patients were admitted due to an infected pacemaker pocket  as compared to the LSE group (19%).The etiologic factors for RSE and LSE are presented in There were no statistically significant differences in the pathologic findings of either group on transesophageal echocardiography .P<0.037), as shown in In-hospital mortality rates were lower among patients with RSE (2.6% versus 17%, Right-sided endocarditis is less common than LSE. In this study, 18.1% of patients with IE presented with RSE, which was comparable to historical data.According to a previous publication, RSE patients are younger as compared to LSE patients.The pathogeneses of RSE and LSE are known to be different.It is not surprising that for RSE patients, the majority of whom are IVDU, the percentage of patients with chronic liver diseases is higher, perhaps reflecting the higher rates of hepatitis B and hepatitis C infections and alcohol abuse in this population.Staphylococcus aureus, consistent with previous data.The most common pathogen in both groups of patients in our study was The in-hospital mortality in our study was significantly lower in RSE patients as compared to LSE patients. One-year mortality was also lower in RSE groups compared to LSE groups, but did not reach statistical significance. These results are also similar to previous studies.The results of this study have demonstrated a difference in the characteristics of RSE patients in our study versus previous studies, i.e. a documented higher percentage of patients with pacemaker lead infection and fewer who were IVDU. Indeed, intravenous drug abuse in Israel is less common. Pacemaker lead infection is the leading cause of RSE in Southern Israel. Due to the increased use of these devices, a high index of suspicion is needed so as to diagnose RSE at-risk patients with appropriate clinical presentations.Another interesting finding of our study was that a mass attached to the electrode was just as common in LSE, indicating that sometimes left- and right-sided endocarditis can occur simultaneously.The major limitations of this study are that it was a single-center investigation and that it used ICD codes to identify patients. However, patients were analyzed over a 10-year period.Our study demonstrated an increasing percentage of RSE compared to LSE among patients with IE in Southern Israel. This trend is expected to continue due to the increasing number of patients undergoing device insertion. Pacemaker lead infection has become the leading cause of RSE in Southern Israel; it is much less common to find RSE in IVDU. This study has also demonstrated etiological and clinical differences between RSE and LSE, with the RSE prognosis being better compared to LSE.


Results revealed that growth mindset moderated the relation between participants' task performance in the game and the time since their latest refresher NRP course. Specifically, participants who completed the course more recently  made significantly more mistakes in the game than the rest of the participants but only when they endorsed lower levels of growth mindset. Implications of this research include growth mindset interventions and increased screen time in simulation sessions that have the potential to help health-care providers achieve better performance on neonatal resuscitation clinical tasks.This study examines for the first time the moderating role of growth mindset on the association between the time elapsed since participants' last refresher neonatal resuscitation program (NRP) course and their performance on neonatal resuscitation tasks in the RETAIN computer game training simulation. Participants were  The delivery room is a stressful environment where decisions are made quickly and resuscitators must have good cognitive, psychomotor, and communication skills to recognize, analyze, and integrate a large amount of data into useful information under intense time pressure. Several studies reported that the complexity of these tasks leads to deviations from the Neonatal Resuscitation Program (NRP) algorithm, human errors, and poor patient outcomes during simulated neonatal resuscitation –7. StudiOne of the main causes of human error in neonatal resuscitation stems from a lack of practical learning experiences , 11 highEducational games foster higher-order thinking, such as analysis, synthesis and evaluation skills necessary during HALO events by enabling active-learning experiences , 18. FurIn previous research, we developed a complementary tool to the physical SBME to improve knowledge retention during neonatal resuscitation in the delivery room. Specifically, we developed a neonatal resuscitation training computer game simulator, RETAIN, depicted in Figure However, there is little research on the relation between simulation-based training and performance for neonatal resuscitation. Additionally, there may be many factors  that could explain the decline in performance over time after training. Growth mindset, an incremental theory of intelligence, is defined as the belief that ability can be improved with learning and effort –40. In cThe study was performed at the simulation lab at the Centre for the Studies of Asphyxia and Resuscitation, Edmonton, Canada. The Centre for the Studies of Asphyxia and Resuscitation is integrated within the Neonatal Intensive Care Unit at the Royal Alexandra Hospital, Edmonton, a tertiary perinatal center admitting more than 350 infants with a birth weight of < 1,500 g to the neonatal nursery annually. HCPs trained in NRP, including registered nurses, respiratory therapists, neonatal nurse practitioners, neonatal consultants, and neonatal fellows, were recruited from the Royal Alexandra Hospital. The study was approved by the Human Research Ethics Board at the University of Alberta (Pro00064234), and consent was obtained from all HCPs prior to participation. All participants willing to participate were included in the study . Participants had no prior experience with the RETAIN computer game.Each participant was asked to complete a pre-game questionnaire to obtain demographic information  and a post-game questionnaire. Each participant played the RETAIN game, which started with a tutorial followed by three levels, each presenting a resuscitation scenario : Outcome Variable: Number of Tries measures the number of steps it took a participant to complete the game. It sums the number of tries on each of the three levels, and it ranges from 32 to 39. On each round, participants were assigned one point for each correct step. The minimum value of 32 represents a perfect performance score  on all three game rounds.Predictor: Last NRP Course measures the number of months since the participants' latest NRP course. It ranges from 1 to 24 months. Other potential predictors considered in this study are Years of Experience (ranging from 0.08 to 32 years) and Level of Education, which represents a participant's highest level of education . In this sample, there were 17 participants with diploma, certificate, or other professional programs, 29 participants with a Bachelor's degree, two with after degrees, and two with MD degrees.Moderator: Growth Mindset measures the belief that intelligence can be improved with learning and effort  technique to determine the regions of significance for simple slopes in the context of interactions in multiple linear regressions with continuous variables , providing a more detailed account of the moderation  effect  effect –48. In cWRS2 package . However, the residuals were normally distributed, as shown in the quantile-comparison plot of Figure p = 0.54]. Multicollinearity tests yielded Variance Inflation Factor (VIF) values of 1.0, indicating that multicollinearity was not problematic.Residuals are leftover of the outcome variable after fitting a model  to data and they could reveal how well a model represents data. The Shapiro-Wilk normality test revealed that the outcome variable was not normally distributed (SD = 8.66) min to complete the game. The means and standard deviations of the outcome , predictor (last NRP course), and moderator variables (growth mindset) are shown in Table We recruited 50  HCP who were all NRP-trained and had completed an NRP refresher course within the last 24 months of the current study. Participants needed a mean of 8.47  across all continuous values of Growth Mindset (x axis). The region of significance is determined by the locations where the upper and lower bounds of the 95% confidence interval intersect zero . The confidence band crosses zero at m* = 0.03 in Figure 4, with a vertical dotted line marking the boundary between regions of significance and non-significance. Thus, the region to the left of the vertical dotted line represents the region of significance.The relation between time elapsed since participants' latest refresher NRP course and their game performance was explored from the lens of their theories of intelligence . A robust multiple linear regression was conducted to explore whether participants' growth mindset moderated the relation between the time elapsed since their latest NRP course and their performance on the neonatal resuscitation tasks presented in the RETAIN game. Figure b = 0.09, SE = 0.04, beta = 0.32, t = 2.25, p = 0.03). This means that every time a person's Growth Mindset score increases by 1, the adjusted effect of Last NRP Course on Number of Tries  is outside the  interval . Also, the effect of Last NRP Course on the Number of Tries only exists when Growth Mindset is lower than 0.03, in which case the conditional slope of the Last NRP Course is statistically significantly different than zero, as shown in Figure p = 0.04. When the growth mindset is −0.91 , the estimated slope of Last NRP Course is −0.162, S.E. = 0.05, p = 0.004. Finally, the slope is not significant when growth mindset is 0.91 , with the estimated slope of Last NRP Course being 0.01, S.E. = 0.05, p = 0.81. The Figure The Figure F = 3.62, Adjusted R-squared = 0.14, p < 0.05] with an interaction  but no main effect for Level of Education  and no main effect for Growth Mindset . The Johnson-Neymar technique identified two regions of significance illustrated as the light blue areas in Figure p < 0.05 when Growth Mindset (x axis) is outside the  interval. This means that, when Growth Mindset is lower than −1.05 standard deviations from its mean or higher than 0.16 standard deviations from its mean, every time a person's Growth Mindset score increases by 1, the adjusted positive effect of Level of Education on Number of Tries  is not significant. Also, when the Growth Mindset is −0.91 , the estimated slope of Level of Education  is not significant. Finally, the slope is significant when Growth Mindset is 0.91 , with the estimated slope of Level of Education being 1.47, SE = 0.52, p < 0.05.The model using Level of Education and Growth Mindset to predict Number of Tries was also significant  with no interaction , no main effect for Years of Experience , and no main effect for Growth Mindset .Similar analyses using Years of Experience instead of Last NRP Course yielded a non-significant model [Current neonatal resuscitation training is performed on a mannequin in a specialized facility  where participants are trained by instructors specialized in SBME. Consequently, SBME in its current form is time and cost intensive and, therefore, not offered routinely, regularly, or in all health-care facilities . The curThe results of the current study suggest that Growth Mindset is a moderator of the relation between Last NRP Course and performance in a computer game training simulator, which could help explain temporal differences in the effectiveness of NRP training that were not detected by correlation analyses alone. Participants who took the NRP course within the past 8 or 9 months made significantly more mistakes in a training simulation game than the rest of the participants, but only when they endorsed lower levels of growth mindset. This result echoes other studies showing a significant deterioration of resuscitation knowledge and skills at 6–8 months after the completion of the NRP course . Growth It is possible that the observed differences in performance depend on individual differences and variables not currently measured, such as age, stress, mood, anxiety, test fatigue, motivation at work, or job performance. This limitation will be addressed in part in a follow-up study that aims to collect age information and a range of biometric data from the participants. It is also possible that participants did not take too seriously the low-stakes environment of a training simulation computer game and they did not exhibit maximal  behaviors. Finally, other variables we measured, such as clinical role  and the number of years of clinical experience in neonatal resuscitation, did not yield any significant influences on performance or on the relation between NRP timeline and performance.These results are in accord with the NRP program caution that completion of the course does not equate proficiency in infant resuscitation in a clinical environment. Specifically, the NRP course is necessary, but not sufficient in achieving high performance. Perhaps participants who completed the course up to 8 or 9 months before the study need more time and deliberate practice opportunities to consolidate their knowledge through intensive practice sessions. As the bridging between program completion and clinical competence is still a matter of research and evaluation, simulation computer games constitute a promissory avenue for consolidating the skills acquired in NRP training. In the future, we also plan to augment the RETAIN game with more collaborative features that would simulate more intentionally the diversity of skills and richness of communication present in neonatal resuscitation teams.The current study examines empirically the relation between health-care providers' task performance and the time elapsed since their latest NRP course and found that growth mindset moderates this relation. Specifically, the participants who took the NRP course within the past 8 or 9 months made more mistakes in a training simulation computer game than the rest of the participants but only when they endorsed lower levels of growth mindset. To our knowledge, this is a first demonstration that mindset moderates the relation between NRP training and performance. This study constitutes a first step in clarifying the relation between NRP courses and performance, and more research is needed to examine other possible factors that could moderate this relation. Recently, brief social-psychological interventions have been gaining increased attention as approaches for increasing motivation for persistence , performGS, MC, and MB: conception and design; CF, GS, MB, and MC: collection and assembly of data; MC, GS: analysis and interpretation of the data; MC, GS, MB, and CF: drafting of the article; MC, GS, MB, and CF: critical revision of the article for important intellectual content; GS, MC, MB, and CF: final approval of the article.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.


Diabetes mellitus (DM) is the seventh leading cause of death in the United States and the leading cause of death in the U.S. American Indian/Alaskan Natives (AI/ANs), who comprise only 2% of the total population. The AI/AN population has a high prevalence of DM in adults aged 20 years or older and is developing DM at a younger age than the general U.S. population. DM is a major risk factor for cardiovascular disease (CVD), and mortality from CVD is higher in AI/ANs than the general population, as is the prevalence of stroke and 1-year poststroke mortality for both genders when compared to non-Hispanic whites. A genome-wide scan found a number of chromosome linkages in the AI/AN population that suggest that genetic factors may contribute to their high risk of DM and CVD. Importantly, studies also suggest that in addition to race/ethnicity, cultural norms and historic conditions play important roles in the prevalence of DM and CVD in this population. Therefore, multiple factors should be taken into consideration when establishing prevention programs to decrease the prevalence of obesity, diabetes, and CVD incidence among adults and children in the AI/AN population. Prevention programs should focus on behavioral risk factors and lifestyle changes like encouraging smoking cessation, healthy diet, and increased physical activity while taking into consideration cultural, economic, and geographic factors. Diabetes mellitus (DM) is the seventh leading cause of death in the United States. According to the 2017 National Diabetes Statistic report, 9.4% (30.3 million people) of the U.S. population are affected by diabetes and 33% of U.S. adults aged 18 years and older have prediabetes [Although diabetes affects all races, the Centers for Disease Control and Prevention (CDC) report on DM indicates that the American Indian/Alaskan Native (AI/AN) populations, who comprise only 2% of the U.S. population, have a higher prevalence of DM in those aged 20 years or older, with a prevalence more than two times that of the general population . DM is tTo date, there have been very few comprehensive reviews of the literature on the prevalence of DM and DM-related CVD complications among the AI/AN population. In the current review, we summarize findings on the prevalence of DM and CVD, analyze the risk factors contributing to the high prevalence of these diseases in the AI/AN population, discuss strategies for disease prevention, and address the existing health disparities.The prevalence of DM is consistently high in AI/AN populations of all ages and genders –17 and iRegional variations in DM control and morbidity among AI/AN populations have also been noted. For instance, 27% of DM patients under age 45 have plasma hemoglobin A1c levels greater than 9.0 in the Alaskan region, versus 56% in the Southwest AI population . VariatiHeart disease is the leading cause of death among AI/AN populations, with CVD resulting in 1813 deaths in 2009  and 3288The Strong Heart Study (SHS), supported by the National Heart, Lung, and Blood Institute (NHLBI), is the largest epidemiological study yet conducted to have examined cardiovascular risk factors in the AI population . The SHSIt has been well documented that type 2 diabetes (T2D) patients have a greater risk for cardiovascular morbidity and mortality in the general population . Recent It has been shown that systemic hypertension (SH) increases the risk of CVD in diabetic patients . DM and CHD and stroke share several risk factors such as hypertension, smoking, diabetes, physical inactivity, and obesity. Patients with CAD have an increased risk of developing stroke. Recent studies suggest that subclinical episodes of atrial fibrillation (AF) occurred frequently in T2D patients and are associated with an increased risk of silent cerebral infarct (SCI) and the development of stroke in T2D patients who are younger than 60 years of age . AdditioWhen compared to the non-Hispanic white population, the prevalence of stroke in AI/ANs was higher , with a concomitantly higher risk ratios than whites for all three stroke subtypes . Those Shttps://strongheartstudy.org/Research/ResearchDesign.aspx). A genome-wide scan found chromosome linkages for a number of pathological conditions that are more prevalent in the AI/AN population. For example, the scan identified significant linkage of a locus on chromosome 4q35 to weight and BMI for 963 individuals from 58 families from Arizona, Oklahoma, and North and South Dakota [Genetic factors and heritability may play an important role in the high prevalence of CVD observed in the AI/AN population. To explore this possibility, SHS initiated a genetic epidemiology study and a full family study to explore the potential impact of genetic factors and heritability on the prevalence of these disorders in the AI/AN population , 61. Theh Dakota . Furtherh Dakota . Genome-h Dakota , 65.In several studies, North et al. have found evidence for the effect of heritability on the prevalence of DM and CVD in the AI/AN population. For instance, significant heritability of diabetes status , as wellEvidence suggests that several risk factors, such as tobacco abuse, DM, hypertension, and elevated cholesterol levels, contribute to the increased incidence of CVD in the AI/AN population , 35. AnaPhysical inactivity, obesity, and hypertension are known major risk factors for DM and CVD. Among these, physical inactivity is modifiable and obesity is a controllable risk factor. DM and CVD are preventable by controlling physical activity and obesity. It is well recognized that exercise and weight loss reduce blood pressure, increase insulin sensitivity, prevent or delay the onset of T2D, lower CVD risk, and reduce the risk for heart attack and stroke . SuccessSubstantial variations in the prevalence of DM and CVD among the AI/AN population when compared to the general population have been identified. This fact suggests that race, ethnicity, cultural norms, and historic conditions play an important role in the prevalence of DM and CVD. Recognizing these disparities and incorporating the health issues specific to each community into health promotion programs and policies are a critical step in overcoming the disproportionate toll these illnesses take on a population . Food inIn order to address the diabetes epidemic among the AI/AN population, congress initiated the Special Diabetes Program for Indians (SDPI) in 1997 to provide funds for DM prevention and treatment and to increase access to quality diabetes care with a focus on effective evidence-based intervention strategies. The SDPI diabetes best practices' program focuses on screening and monitoring glycemic control, blood pressure, cardiovascular complications, retinopathy, gum and tooth diseases, depression, tobacco use, nutrition, and physical activity education . The SDPThe SDPI has had a positive impact on prevention and control of diabetes among AI/AN populations (presented in the SDPI 2014 Report to Congress). The increase in diabetes prevalence among AI/AN adults has slowed and has not increased in AI youth, suggesting that key diabetic clinical parameters are under control and more importantly, the incidence of end-stage renal disease in people with diabetes is decreasing –86.Medical mistrust is defined as a patient feeling uncomfortable, fearful, or suspicious in a health care setting and has been found to be significantly higher in AI/AN populations when compared to whites . Health In conclusion, the incidence and prevalence of DM and CVD are much higher in the AI/AN population when compared to any other racial or ethnic groups in the U.S. The high risk of developing DM and CVD complications is also disproportionately higher irrespective of age, gender, or geographical location. Multiple risk factors should be considered when establishing prevention programs to decrease the prevalence of obesity, diabetes, and CVD among adults and children in the AI/AN population. Prevention programs should focus on behavioral risk factors and lifestyle changes such as encouraging smoking cessation, eating a healthy diet, and increasing physical activity. In addition, cultural norms, historical conditions, and individual health issues among AI/AN communities should be acknowledged and integrated into all prevention programs.


ACE) gene is indispensable for endothelial control and vascular tone regulatory systems, usually affected in Systemic Lupus Erythematosus (SLE). ACE insertion/deletion (I/D) polymorphism may influence the progress of SLE. Earlier studies have investigated this association without any consistency in results. We performed this meta-analysis to evaluate the precise association between ACE I/D polymorphism and SLE susceptibility. The relevant studies were searched until December, 2017 using Medline (PubMed), Google-Scholar and EMBASE search engines. Twenty-five published studies involving 3,308 cases and 4,235 controls were included in this meta-analysis. Statistically significant increased risk was found for allelic , homozygous , dominant , and recessive  genetic models. Subgroup analysis stratified by Asian ethnicity revealed significant risk of SLE in allelic  and marginal risk in dominant  models; whereas, no association was observed for Caucasian and African population. Publication bias was absent. In conclusion, ACE I/D polymorphism has significant role in overall SLE risk and it can be exploited as a prognostic marker for early SLE predisposition.Angiotensin-converting enzyme ( Systemic lupus erythematosus (SLE) is an autoimmune disease often involving multiple organ inflammation. The clinical consequences of SLE are extremely heterogeneous and generally characterized by pathogenic autoantibody formation against the host's nuclear antigens, immune complex deposition, and end-organ damage  or deletion (D) of a 287-bp fragment on intron 16  is a zinc metalloproteinase converting angiotensin I (Ang I) into angiotensin II (Ang II), an octapeptide acting as a potent vasopressor and stimulator of aldosterone. Ang II also acts as a growth factor, particularly in kidneys, inducing remodeling of tissue, and fibrosis. Contraction of smooth muscle cells and their proliferation is also known to be induced by Ang II, including adhesion of monocytes and platelets  for their quality score. Trial Sequential Analysis (TSA) was used to minimize type-I statistical errors like publication bias and random errors, caused generally by sparse data, in order to quantify the statistical reliability of the included data in the meta-analysis with statistical significance threshold.A meta-analysis, as a statistical tool, can overcome these limitations of single studies with small sample sizes. It combines multiple studies on the same alleles of genes to enhance the statistical power of the analysis and derive more precise and reliable results of the genetic effects. Therefore, we performed this meta-analysis by pooling all the eligible published studies to determine a comprehensive picture of the above said genetic association and understand the role of ACE I/D gene polymorphism and its association with SLE susceptibility was conducted in PubMed (Medline), Google Scholar and EMBASE. An update limit of December 2017 was applied. The search terms were as follows: “ACE” “angiotensin converting enzyme” OR “ACE” (polymorphism OR mutation OR variant) in combination with “systemic lupus erythematosus” OR “SLE” (susceptibility OR risk). The focus of the search was human studies only. The titles and abstracts of the all the searched articles were read for initial evaluation, and only studies fulfilling the eligibility criteria were retrieved and used in this meta-analysis. The reference lists of the selected studies was also inspected manually for other pertinent articles.A thorough search of studies on the ACE I/D gene polymorphism and SLE susceptibility, (b) the study must have a case-control design, (c) the study must have enrolled well diagnosed SLE patients and normal healthy controls, (d) the study must have genotypic frequency data available for both patients and controls, (e) the study must be published in English. In case the data for same patient population was reported in more than one publication, the most recent and complete publication was considered for this meta-analysis. The exclusion criteria for the studies were: studies with overlapping data; studies reporting data for patient population only; studies where genotypic frequency data was not available; and review articles. All information regarding selection of the studies is depicted as PRISMA 2009 Flow-Diagram  the study must be an evaluation of the association between m Figure .Two investigators (RKM & SAD), independently, extracted and summarized the data from each retrieved study by following the standard procedure. The data collection form was designed and used to collect the data to ensure accuracy while following stringent inclusion/exclusion criteria as described above. The attributes extracted and summarized from the selected articles were: first author's name; publication year; origin country; total number of patients and controls included; study type; association status; genotyping method used; and genotype frequency of patients and controls. Discrepancy, if observed, in the data collected from the selected studies by the two investigators was settled by open discussion in presence of SH (an adjudicator) in order to reach a final consensus.The NOS criteria Stang,  was usedp < 0.05 was considered as statistically significant. All the p-values were two sided. Crude odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were computed to assess the association intensity between the ACE I/D gene polymorphism and SLE susceptibility. The allele contrast, log-additive, dominant, and recessive model pooled ORs were estimated  V2 software program . The d Woolf, . Chi-squd Woolf, , and hethttp://www.ctu.dk/tsa/) was used for TSA analysis.In an attempt to include all the eligible trials in this meta-analysis, and to minimize the systematic errors (bias) or random errors by chance, we used a novel statistical TSA tool from Copenhagen Trial Unit, Center for Clinical Intervention Research, Denmark. TSA estimates the required information size and adjusts statistical significance thresholds, and also estimates the power of conclusion  statistics for each of the (29) cases considered in our study. CA trend test is the most popular association analysis for determining genetic associations Sasieni, .CA trend test statistic (T) is given by the following equationWhereM1 = 0; M2 = 1;M3 = 2.For a codominant or additive model, M1 = 0; M2 = 1; M3 = 1.For a Dominant Model, M1 = 0; M2 = 1; M3 = 2.For a Recessive model, Ny is the total number of controls, Nx is the total number of cases, Xi and Yi represents the number of cases and controls for each of the three  genotypes.Here, During the study search the full-texts of all the articles deemed potentially eligible were retrieved. The study eligibility for inclusion was determined by reviewing the full text of all the articles by the first investigator. The second investigator randomly selected 10% of the articles and reviewed them by the same procedure, independently. A complete agreement was observed between the two investigators regarding inclusion and exclusion of the studies. Following the identification of the final set of the eligible articles, one investigator extracted the relevant data from all the studies, and the other investigator independently re-extracted the data from all the included studies to cross-check this step. Table p < 0.05 was fixed for the significant publication bias in the present meta-analysis. All the comparison genetic models showed absence of publication bias (p > 0.05)  Table .Q-test and I2 statistics among the included studies. Four genetic models showed heterogeneity, so the data was synthesized by applying the random effect model , homozygous , dominant  and recessive   genetic model did not show any SLE risk  genetic model. Similarly, dominant  genetic model also showed marginal significant risk. But, other genetic models, i.e., homozygous , heterozygous  and recessive  genetic models did not show any increased or decreased risk of SLE , homozygous , heterozygous , dominant  and recessive  genetic models , homozygous , heterozygous , dominant  and recessive  genetic models  was reached. The dominant model was taken as an example in the TSA analysis, which indicated that d Figure . Subgroud Figure .p-values can be referred from the attached Excel Sheet: A comparison of the results obtained from OR and CA trend test is shown in Table Earlier studies have reported that individual's SLE susceptibility often present a variety of symptoms that pose difficulty in the disease diagnosis by the physicians, leading to a consequent delay in the onset of the treatment. Host factors, including genetic polymorphisms implicated in autoimmune diseases, might have interpreted this divergence. Thus, there is an urgent need of the identification of the genetic biomarkers that are responsible for the onset and progress of SLE. Nowadays, the current research focus is based on the role of genetic susceptibility in autoimmune disease progression or development.ACE plays an important role in SLE etiology by affecting the immune responses and vascular changes. Angiotensin II converted by ACE is a potent pro-inflammatory modulator for immune responses in the renal tissues and shows robust potential in mediating the development and progression of renal disease during SLE  genotype/allele might confer susceptibility in SLE patients. Individual studies generally have low statistical power to detect the risk, owing to their small sample sizes. Therefore, it is more judicious to estimate the precise relationship of ACE I/D gene polymorphism to understand the contribution of this polymorphism in overall SLE risk.Renin—angiotensin system (RAS) regulates the arterial blood pressure at both levels—systemic and tissue, and contributes to the immunological responses arising during various phases of nephropathy evolution Egido, . The majACE I/D polymorphism with an increased SLE risk. These results confirm that ACE I/D genetic variant may interfere with its expression level and plays a pivotal role in the progression of SLE. Earlier studies have reported that circulating ACE levels vary greatly between individuals and is extremely determined genetically. ACE I/D polymorphism could alter the circulation of ACE levels. It has been found that individuals carrying DD genotype had 2-folds higher circulating ACE levels and lowest among the II genotype carrying individuals  was further confirmed by the TSA and comparison with CA trend test statistics, which authenticated the association of Above studies have reported higher serum ACE levels in SLE patients. However, the interruption of the renin angiotensin with ACE inhibitors or angiotensin receptor blockers (ARBs) is recommended as first line adjuvant therapy for the patients with lupus nephritis for proteinuria  for increased statistical power and robust conclusion; well exploration of the methodological issues generally occurring in pooled analysis  which further confirmed the reliability and validity of the present study; and reduction of type I error rate by Trial sequential analysis.In comparison with the previously published meta-analyses , this study also suffers with several limitations, which must be stated and addressed in the future studies. First, the result of overall population may be biased, perhaps owing to slight over-representation of Asian population. Second, the result of subgroup analysis especially for Caucasian and African, it may be possible that the observed result could be partly due to modest number of studies included. Third, there was a significant heterogeneity in some of the pooled analysis, which may affect the meta-analysis outcome. Fourth, unadjusted estimates form the basis of this meta-analysis and studies published in English language only were included. Unpublished data and ongoing studies were not searched and included. Further, studies reporting negative findings are less likely to be published, hence causing publication bias thereby bringing increase of the associations. Fifth, due to lack of sufficient data, we were not able to study lupus nephritis individually in relationship with ACE I/D gene polymorphism and SLE susceptibility. Individuals carrying allele “D” of the ACE I/D polymorphism had greater risk of SLE. The findings will advance our understanding of the role of ACE I/D genetic variant and assist in identifying the “at-risk” individuals. Our results also provide a solid foundation for future genetics studies to focus on ACE related phenotypes and integrative network modules analysis to clarify the potential role of ACE genetic variants in SLE risk. Moreover, more meta-analysis with larger sample size should also be encouraged in future to understand the molecular mechanism of ACE gene with SLE development and to verify the current findings reported in this manuscript.In conclusion, the pooled results of independent association studies by meta-analysis confirmed statistically significant association between SK, SD, RM, MW, AJ, AP, ML BM, NA, and SH conceived and designed the study and experiments. SD, SK, RM, MW, AP, NA, and SH performed the experiments. SD, SK, RM, AJ, AP, ML, BM, and NA analyzed the data. AJ, MW, AP, BM, ML, NA, SD, and SH contributed reagents, materials, analysis tools. SD, SK, RM, AP, and SH wrote the paper. All authors reviewed and approved the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Aedes aegypti infestation index data, extracted from multiple databases. Spatial time “ecological” analysis on the number of arboviruses transmitted by Aedes mosquitoes in Brazil show that the distribution of dengue and Zika was widespread in the whole country, with higher incidence in the West-Central region. However, reported chikungunya cases were higher in the Northeast, the region also with the highest number of microcephaly cases registered. Social economic factors (human development index and poverty index) and environmental management (water supply/storage and solid waste management) pointed the Northeast as the less wealthy region. The Northeast is also the region with the highest risk of Aedes aegypti house infestation due to the man-made larval habitats. In summary, the results of our ecological analysis support the hypothesis that the unusual distribution of microcephaly might not be due to Zika infection alone and could be accentuated by poverty and previous or co-infection with other pathogens. Our study reinforces the link between poverty and the risk of disease and the need to understand the effect on pathogenesis of sequential exposure to arboviruses and co-viral infections. Comprehensive large-scale cohort studies are required to corroborate our findings. We recommend that the list of infectious diseases screened, particularly during pregnancy, be regularly updated to include and effectively differentiate all viruses from ongoing outbreaks.Zika virus infections can cause a range of neurologic disorders including congenital microcephaly. However, while Zika infections have been notified across all regions in Brazil, there has been an unusual number of congenital microcephaly case notifications concentrated in the Northeast of the country. To address this observation, we investigated epidemiological data (2014–2016) on arbovirus co-distribution, environmental and socio-economic factors for each region in Brazil. Data on arbovirus reported cases and microcephaly were collected from several Brazilian Ministry of Health databases for each Federal unit. These were complemented by environmental management, social economic and  Aedes. The co-circulation of these viruses in Brazil, sharing the same vectors and causing similar symptoms, represents a major public health challenge. Dengue fever is the most important re-emerging mosquito-borne viral disease worldwide. In Brazil, the incidence of dengue has been frequently high, with 1.49 million cases reported in 2016 [Zika, dengue and chikungunya are arboviral diseases transmitted by mosquitoes from the genus  in 2016 . The fir in 2016 , mainly The outbreak of Zika infection in Brazil has exposed the high risk this arbovirus imposes during pregnancy to the fetus. Brazil experienced an approximately 20-fold increase in the total number of congenital microcephaly cases from 2014 to 2015, following the confirmation of autochthonous Zika virus transmission . In DeceBefore the Brazilian outbreak, no microcephaly-Zika related cases have previously been reported. Zika virus was firstly isolated from a Rhesus monkey in the Zika Forest of Uganda, in 1947 . The firRecently, Colombia faced the world’s second largest Zika outbreak, leading to a four-fold increase in the overall microcephaly cases compared to the previous year. However, the relative increase of reported cases  was far fewer than in Brazil, where a nine-fold increase was reported . This obHere we aim to provide insights into the unusual pattern of microcephaly distribution in Brazil. By analysing the number of cases reported and co-distribution of dengue, chikungunya and Zika virus, their vectors, as well as socioeconomic and environmental data, we sought to investigate whether co-acting risk factors might be contributing to the Zika microcephaly cases in the Brazil Northeast region.Togaviridae) from 2010, including cases of co-infections. The search terms used were: “Outbreak”, “Zika”, “Chikungunya”,”Dengue”, “Brazil”, and “Co-infections”. Maps of arbovirus incidence  per Brazilian Federal Unit were constructed using the package tmap in R software [To better understand the co-distribution of dengue, chikungunya and Zika virus in Brazil we collated data on reported cases  for all three pathogens from 2014 to 2016. Data including the total number of cases per year and per state for each virus were obtained from epidemiological Bulletins from the Brazilian Ministry of Health database,  , confirmsoftware .http://portalsaude.saude.gov.br/) and from the epidemiological Bulletins  available at the Brazilian Ministry of Health database [Registro de Eventos em Saúde Pública”  [Protocol on Surveillance and Response to Occurrence of Microcephaly and/or Central Nervous System” [Microcephaly is a congenital malformation where babies are born with a skull size smaller than expected when compared to those of the same sex and age . Specifidatabase . Additiodatabase , the “Recefalia) . It incl System” .Data on the cumulative incidence of microcephaly from 2015 to 2016 are based on cases that fulfilled the previous definition of cephalic perimeter (33 cm), in addition to the new definitions adopted in the Surveillance Protocol 2015, that defined the 32 cm for boys and 31.5 cm for girls, born with 37 or more weeks of gestation. Notified cases in fetuses, abortions, stillbirths or newborns were confirmed positive for microcephaly by Zika or other undetermined infectious diseases when: a) typical alterations indicative of congenital infection were found, such as cerebral calcifications, ventricular and posterior fossa alterations among other signs observed by an imaging method, or/and b) when confirmed by laboratory-based Zika virus identification. Data are presented per state.Human development index , which considers education (average years of studies), longevity (population life expectancy) and gross domestic product per capita; (ii) Poverty index , which considers health , education (school attendance) and living standards . Environmental management data considers: Garbage accumulation index (number of houses with accumulated and uncollected garbage) and rainwater storage (number of houses with storage of rainwater in containers). Data are presented per year and per state.Demographic, socioeconomic, and environmental management data were obtained from the national census performed by the Brazilian Institute of Geography and Statistics (IBGE) . Data foAedes aegypti infestation levels in Brazil in 2016, was obtained from the Aedes aegypti Infestation Index Rapid Survey (LIRAa), performed every year by the Federal Government. This house infestation index measures the percentage of searched buildings with the presence of larvae of A. aegypti. The average house infestation index (HII) of each municipality is calculated and classified in different risk levels  [ HII> 4) .Aedes aegytpi infestation index were assessed using Spearman’s and Pearson’s correlations and regression models.All the data were merged within the R statistical software. We performed an ecological analysis where pairwise relationships between microcephaly, virus infection, social economic factors, arbovirus and During the period from 2010–2014, Brazil registered an average of 156 cases of microcephaly per year. Surprisingly, by the end of 2015, the number of cases was 20 times higher . PernambIt was also in the Northeast region that the first cases of Zika infection were reported in May 2015 . However2 ≤ 0.25; P ≥ 0.212). During the same period Brazil experienced simultaneous transmission of dengue and chikungunya. During January-September 2016, Brazil recorded 200,465 Zika cases, 236,287 chikungunya cases and 1,438,624 dengue cases [2 ≥ 0.57; P ≤ 0.002). There have been reports that associated chikungunya infection with an increase in neurologic manifestations, including Guillain-Barre syndrome and encephalitis, encephalopathy and microcephaly [Although it is now established that Zika virus is the cause of severe fetal complications in pregnancy, including microcephaly, the distribution of reported Zika cases and infection-related microcephaly do not overlap . In factue cases . It is pue cases . In Brazue cases , 27, 41.ocephaly –48. An iocephaly . It has ocephaly .2 ≤ 0.22, P ≥ 0.272)  and the poverty index calculated in 2010. The HDI values range from 0.6 to 0.8 across the country. The Northeast and North regions concentrate the Federal Units with the lowest HDI (= 0.6) .To evaluate the potential effect of socioeconomic factors on the incidence of Zika-suspected microcephaly, as suggested by others –23, 53,  (= 0.6) . The hig (= 0.6) , the epi (= 0.6)   was introduced in Brazil aiming to assist the implementation of measures for vector population control. The 2016 Ae. aegypti house infestation index classified most of the regions in the Northeast region  or in the North (Para) . It is important to consider that arboviral epidemics are most likely determined by multiple factors including environmental conditions, host status and herd immunity and virus genetic mutations that might cause changes in virulence, or vector competence [In the Americas, the domestic behavior of an areas , 56. A sh (Para) , as beint region . We did  or Zika   were not investigated. Future studies of the genomic epidemiology of these viruses can assist with improving an understanding of the biology, disease phenotypes and transmission, and support the design of diagnostic and vaccine strategies to control the next epidemics.It is important to consider that the findings in this study are subject to at least six limitations. Firstly, the cases of infection-related microcephaly reported in the databases include congenital microcephaly caused by Zika virus or other infectious agents. Therefore, it is not known if the distribution of microcephaly cases is caused by laboratory confirmed Zika virus infection. Secondly, cases of co-infections  were not investigated or not reported. Third, the ascertainment of birth defects generally does not capture infants or fetuses whose birth defects are not apparent prenatally or at delivery, but rather are identified several months after birth. Fourth, there was no report on Overall, we analysed a set of robustly collected and curated data on epidemiological, environmental and socio economic factors of all regions in Brazil. Our results support the hypothesis that the high rates of microcephaly in the Northeast state in Brazil might not be due to Zika infection alone. Our study reinforces the need for comprehensive large-scale cohort studies, as well as public-health measures and guidance to better inform the population under the higher risk of infection-related microcephaly in Northeast of Brazil.The unusual distribution of microcephaly-Zika associated cases in Brazil is likely to be caused by a combination of epidemiological, environmental and socio economic factors. Our work highlights the overlap between the distribution of chikungunya infection with the co-incidence of infection-related microcephaly in the Northeast region. It emphasizes the link between poverty and the risk of disease, and the impact that poor environments can have on human health and the spread of infections. To understand the impact of co-infection on disease outcomes, we recommend that the list of infectious diseases screened during epidemics, particularly for pregnant woman, is updated to include and effective differentiate arboviruses from ongoing outbreaks or epidemics.S1 Fig(JPG)Click here for additional data file.S2 FigPearson’s correlation test and linear regression was used to investigate the association between infection-related microcephaly and incidence of: Zika in 2015 (A) and 2016 (D); chikungunya in 2015 (B) and 2016 (E); dengue in 2015 (C) and 2016 (F); all per region of Brazil, and results were considered significant for P<0.05.(JPG)Click here for additional data file.S3 FigMicrocephaly versus poverty index. Results were considered significant when P<0.05.(JPG)Click here for additional data file.S4 FigA. aegypti infestation, per Brazil Federal Unit, versus incidence of dengue (A), chikungunya (B) and Zika (C). Linear correlation was considered significant when P<0.05.The number of municipalities at high risk of (JPG)Click here for additional data file.


N = 25,772) were exposed through a web-based self-administered questionnaire to products from three food categories , with or without FoPLs, and were invited to select the portion they would consume (in size and number). Kruskall-Wallis tests, and mixed ordinal logistic regression models, were used to investigate the effects of FoPLs on portion size selection. Compared to no label, Nutri-Score consistently lowered portion sizes (OR = 0.76 (0.74–0.76)), followed by MTL (OR = 0.83 (0.82–0.84)). For ENL, the effects differed depending on the food group: It lowered portion size selection for cheeses (OR = 0.84 (0.83–0.87)), and increased it for spreads (OR = 1.19 (1.15–1.22)). Nutri-Score followed by MTL appear efficient tools to encourage consumers to decrease their portion size for less healthy products, while ENL appears to have inconsistent effects depending on the food category.In the European Union (EU) three coloured graded Front-of-Pack labels (FoPLs), two endorsed by governments (Nutri-Score and Multiple Traffic Lights (MTL)) and one designed by industry (Evolved Nutrition Label (ENL)) are currently being discussed. This study aimed to investigate the impact of these FoPLs on portion size selection, specifically for less healthy products. In 2018, participants from the French NutriNet-Santé cohort study ( Various Front-of-Pack nutrition labels (FoPLs), varying both in the graphical design and the information they convey, have been implemented in Europe and internationally, in order to provide information on the nutritional quality of food products and to help consumers identify healthier foods . Given tHowever, a consortium of six agro-industry firms recently proposed an interpretive FoP nutrition labelling, the Evolved Nutrition Label (ENL), which is an adaptation of the Multiple Traffic Lights system . MTL areIn France, the Nutri-Score, a summary colour-coded and graded FoP nutrition label, adopted in 2017 by health authorities to be applied on pre-packed food products, indicates the overall nutritional quality of a food product based on 100g ,6. MultiVery few studies have investigated the impact of FoP nutritional labelling on portion size selection ,16,17, wThe objective of the present study was to assess comparatively the effect of the Evolved Nutrition Label, Multiple Traffic Lights and Nutri-Score, on the portion size selection of less healthy food products, compared to a control situation without any FoP nutrition label.N = 25,000 participants from the overall study, in order to achieve a balance between statistical power, with an expected small effect size, and the relevance of observed differences. Participants did not receive any form of incentive or compensation to participate in the online survey. Participants who opened the questionnaire but did not complete and validate it were considered as excluded participants.Participants were recruited from the French NutriNet-Santé cohort, an ongoing web-based cohort of adult volunteers, launched in France in 2009 [Three different FoPLs were tested, including the Evolved Nutrition Label, the Multiple Traffic Lights and the Nutri-Score . In addiThe Nutri-Score is a summary, graded, colour-coded FoPL adopted by health authorities in France in October 2017 to be applied on pre-packaged food products of the French market . This voThe Multiple Traffic Lights is a nutrient-specific FoPL, implemented by the Food Standard Agency in UK since 2004 , and proThe Evolved Nutrition Label, recently proposed by a consortium of five agro-industry firms , is a moFor the present study, the portion size used to compute the numeric information on the MTL and ENL labels was based on portions sizes officially set by the industry taskforce for the ENL . It alloMore details on the computation of the three FoPLs are provided in The four following criteria were taken into account to select the three food categories for the present study: (i) The food categories had to be commonly consumed in the French population, in order to ensure representative observed behaviours and avoid non-responses due to a lack of familiarity with the products; (ii) food categories had to represent different types of eating occasions—breakfast, snacking and meals; and (iii) food categories were predominantly constituted of products with lower overall nutritional quality ; and (iv) a standardised portion was recommended by the ENL taskforce. Thus, sweet biscuits, cheeses and sweet spreads were selected. In each of the food category, four different products were chosen to correspond to foods from D or E categories of the Nutri-Score , with a visible variability in the MTL and ENL labels of the products and in order to be representative of the food offer for the selected food categories.For the three food categories, four photographs of portions sizes were proposed and displayed in increasing order, with a standard difference in grams between portions . Portion sizes selection was based on calibrated photographs, and each photograph corresponded to a standardised portion, depending on the food category. The photographs were calibrated using standard tools  and displayed in usual crockery. The size of the crockery displayed was the same, whatever the category of food. Portion sizes proposed to the participants were based on the distribution of the portions consumed for the selected food categories within the NutriNet-Santé study, and on the portion sizes proposed by the ENL Taskforce.For the category of biscuits, the proposed portion sizes were 1, 2, 3, and 4 biscuits. For cheeses and sweet spreads, consumers were invited to select one of the four photographs corresponding to the following portions: 15 g, 30 g, 45 g and 60 g, containing the recommended portion of ENL (15 g for spreads and 45 g for cheeses).No additional information was provided, in particular the amount in grams corresponding to the photograph was not provided, to not influence consumers’ choice, in particular as the MTL and ENL provide the portion size within the label.After answering questions on shopping grocery involvement , consumption frequency of the tested food categories , self-estimated diet quality on a 4-item scale, and self-estimated nutrition knowledge level on a 4-item scale , participants were invited to complete the portion size task.Each participant was exposed to the three food categories and to a set of four products for each category, resulting in the assessment of 12 products overall. They were exposed to the four labelling conditions  in each set of four products. The order of presentation of the food categories, the order of presentation of the food products and the combination of products*labelling conditions were all randomised, in order to avoid any priming effects. For each food product presented to the subjects, they were invited to select a photograph corresponding to the portion size they would choose to consume, irrespective of their usual consumption. An example of the portion size task is presented in t-test for continuous variables (age), and Chi square or Fischer test for categorical variable . For each of the 12 products, we considered that the final portion size selected by each participant corresponded to the selected photograph of a portion  multiplied by the number of portions the participant would consume. Analyses were carried out using the photographs of the portions as units, and not grams, as the quantity corresponding to each photograph was not communicated to participants. Final portion sizes therefore ranged between 1  and 16 . Final portion sizes between the four labelling conditions were then compared using Kruskall-Wallis tests (PROC NPAR1WAY in SAS software). Finally, associations between FoPLs and the final portion size were analysed using mixed ordinal logistic regression (PROC GENMOD in SAS software), with the labelling exposure as fixed effect, and the subject as random effect—to take into account intra-individual correlations. The modelled probability was the increase of a portion unit. As randomisation led to a balanced distribution of individual factors across labelling conditions, ordinal logistic regressions were not adjusted. Analyses were performed by food category and then on all food categories combined. Sensitivity analyses were conducted taking into account the consumption frequency of the tested food categories: When subjects answered never consuming a food category, their responses for the corresponding category were excluded. Interaction between FoPLs and individual characteristics, including sex, age, educational level, monthly income per household unit, occupational activity, self-estimated diet quality, nutrition knowledge level, and body mass index (BMI) were tested. Interaction between FoPLs and food categories was also tested.All participants who filled and validated the questionnaire were included in the analyses. Sociodemographic and lifestyle characteristics were compared between included and excluded participants, using Student’s p-value of 0.001 was considered significant to take into account multiple testing. Analyses were carried out with SAS software .All tests of significance were two-sided, and a 2. Four percent of included participants estimated having a very unhealthy or unhealthy diet, and 31% being not very knowledgeable or do not know anything about nutrition, and 66% declared being involved in grocery shopping. Individual characteristics between included and excluded participants were globally similar. However included participants tended to be more likely men, with a post-secondary educational level and less from managerial staff, with a higher BMI.For the present study, 27,198 subjects from the NutriNet-Santé cohort opened the online questionnaire, and 25,772 participants filled and validated their questionnaire, and were then included in the analyses. Individual characteristics of the participants are presented in p-value < 0.0001). For sweet biscuits and cheeses, Nutri-Score followed by MTL significantly led to lower portion sizes compared to no label. The effect of ENL to decrease the portion size was significant for cheeses only (OR = 0.84 (0.83–0.87), p-value < 0.0001). However, for sweet spreads results were contrasted according to the FoPL. Indeed, the final portion selected was 1.79 (1.56) for Nutri-Score, followed by MTL (1.91 (1.73)), no label (1.94 (1.70)), and then ENL (2.05 (1.78)). Therefore, compared to no label, Nutri-Score led to the lowest portion size (OR = 0.79 (0.77–0.82), p-value < 0.0001), followed by the MTL (OR = 0.94 (0.91–0.97), p-value = 0.0001). In contrast, the ENL was associated with a significant increase of the portion size with an OR = 1.19 (1.15–1.22) , compared to no label.Results of selected final portion size by labelling condition are displayed in p-value < 0.0001). Compared to no label, the Nutri-Score led to the lowest portion size overall (OR = 0.76 (0.74–0.76), p-value < 0.0001), followed by MTL (OR = 0.83 (0.82–0.84), p-value < 0.0001), and ENL (OR = 0.99 (0.98–1.00), p-value = 0.2).Overall, the mean (SD) final portion size was 1.99 (1.66) portions for the Nutri-Score, followed by MTL (2.05 (1.71)), ENL (2.16 (1.76)) and no label condition (2.17 (1.76)) .No significant interaction between any individual characteristics and FoPLs was found  appears to help consumers select an appropriate amount to eat ,24,25, tThe difference in the performance between the MTL and ENL is likely attributable to the modification of the colour allocation for the ENL , which appears to lead to somewhat misleading interpretations of the appropriate portion size. Indeed, for some food categories, we observed a limited to no effect for the ENL compared to other labels or no label, to choose the lower portion size of less healthy foods. For spreads, the ENL appeared to be associated to the larger portion size selected by consumers compared to no label and other FoPLs. This could be explained by the colour attribution for the ENL, using less strict threshold compared to MTL and on a per portion basis, which leads to labels without any red for the less healthy products tested in this survey. This is in direct contrast to the Nutri-Score and MTL where scores of “E” and red colour coding were presented to participants for the same products. Thus, with the ENL, consumers are potentially misled about the real nutritional quality of the product and would feel less restraint, resulting in the selection of larger portion sizes, which contradicts the initial objective of the ENL. These results can be considered in the light of studies which found that food labels, which may, sometimes artificially, increase healthiness perception , could lead to larger portion size selection of less healthy foods ,28. HoweFurthermore, participants from the present study have selected much larger portions for spreads than the portions considered for the ENL computation , suggesting that such standardised portion sizes are not necessarily realistic compared to current dietary practices. This indicates that presenting nutritional information on a per portion basis is unlikely to contribute to consumers choosing a healthier portion size and may in fact encourage excess consumption in some cases. As such, our results advocate for the presentation of nutritional information per 100 g to help consumers limit overconsumption of less healthy foods. More generally, this study highlights the challenges associated with portion size definition, as they rely on somewhat subjective decisions, with a compromise between defining a ‘recommended’ portion size  and an ‘actual’ portion size .th percentile of the distribution) were carried out and estimates of FoPLs effects remained similar. However, some limitations should be acknowledged. Firstly, caution is required, regarding the extrapolation of these results to the general French population, since this study included volunteers motivated to participate to nutrition study with probably more health-conscious behaviours and higher socio-professional and educational level overall. Participants of the study were also more likely to have a higher educational level compared to the entire cohort. In addition, repeating the study in the UK or Ireland (where the MTL is well-known among consumers), might produce slightly different results. Secondly, the present study focused on self-reported selection of fictitious portion sizes rather than actual consumption behaviour. Moreover, results might be subject to desirability bias, with subjects selecting purposefully lower portions sizes than their actual consumption. However, participants were blinded to the study outcome, and assessed different foods for each label and the no label condition, which may have limited this bias. Thirdly, some participants, who declared consuming frequently some of the food categories, may have been influenced by their actual usual consumption habits, that could have underestimated the effect of FoPLs. However, given that all participants were exposed to all labelling conditions, this did not impact the difference between FoPLs. Fourthly, the study focused on products with small portions, for which a difference between ENL and MTL would be apparent, but did not compare the FoPLs effects on products with large portion size. Finally, displaying images on an ordinal scale may prompt some subjects to avoid extremes, therefore leading to an over-selection of pictures in the ‘middle range’ . Moreover, the limited number of photographs shown to the participants may have increased this bias. However, given that the food products tested in the study are usually consumed in small portions, differences between portions on the four photographs had to be realistic and sufficiently perceivable, limiting us on the number of photographs. Therefore, the results of this study should be interpreted with caution, and be complemented by experimental or in real-life condition studies investigating consumption of real foods and not fictitious products, associated with various FoPLs.Strengths of this study pertained in its large sample size, the selection of different food categories corresponding to various eating occasions, and a variety of food products for each category. In addition, to prevent potential bias of label’s order, a randomised design was used, and to control for a potential bias of food products, all combinations between products and FoPLs were tested and randomised also. Moreover, analyses excluding outliers (i.e., participants who selected a portion size over the 90To conclude, FoP nutrition labels appear to influence portion size selection for less healthy foods, though the magnitude and direction of effects may vary depending on the type of label. The Nutri-Score, and to a lower extent the MTL, appear as efficient tools to decrease the portion size selected by consumers for less healthy products, and therefore help limiting over-consumption of these products. In contrast, the ENL seems to be confusing and misleading on the nutritional quality of products, and may encourage larger portion size selection for some less healthy products, such as sweet spreads. The difference in performance between the MTL and the ENL indicates that the modification/change in boundary for colour coding, which results in fewer reds and more ambers, had a direct impact on portion size perceptions. These findings contradict the hypothesis of the food companies supporting ENL, concerning its potential effect to decrease consumed portion sizes for less healthy products.


P > 0.05), there was no evidence of significant publication bias. Moreover, our DR analysis indicated that the risk of NHL grew by 26% for each additional microgram of nitrite consumed in the diet per day . Through subset analysis of the nitrite studies, data from the high-quality studies indicated that consumption was positively associated with carcinogenicity, leading to NHL  and positively correlated with the development of diffuse large B-cell lymphoma , but not other NHL subtypes. In addition, the data suggested that females  and high levels of nitrite intake  had a higher risk of NHL. Our meta-analysis supports the hypothesis that nitrite intake, but not that of nitrate, raises the risk of developing NHL. In the future, better designed prospective research studies should be conducted to confirm our findings, clarify potential biological mechanisms and instruct clinicians about NHL prophylaxis.Epidemiologic studies of the relationship between nitrite or nitrate consumption and risk of non-Hodgkin lymphoma (NHL) remain controversial. The current meta-analysis aimed to reexamine the evidence and quantitatively evaluate that relationship. Manuscripts were retrieved from the Web of Science, Chinese National Knowledge Infrastructure and PubMed databases up to May 2019. From the studies included in the review, results were combined and presented as odds ratios (OR). To conduct a dose-response (DR) analysis, studies presenting risk estimates over a series of categories of exposure were selected. Our data indicate that the consumption of nitrite was linked to a significantly increased hazard of NHL , rather than nitrate . According to Egger’s and Begg’s tests ( According to the 2018 global cancer statistics, NHL ranks as the 8th most common carcinoma in males and 10th in females2. In the USA, it has been estimated that 74,680 new cases of NHL  and 19,910 deaths  occurred in 20183. Despite the diagnostic and therapeutic progress in the recent decades7, the 5-year survival rate for all NHL forms combined is 72% (https://seer.cancer.gov/statfacts/html/nhl.html). It is well-known that NHL patients, particularly for high-risk subtypes , continue to receive adverse prognoses. Hence, to increase precautions against and reduce the prevalence of NHL, further exploration of its risk and deeper understanding of its epidemiology are essential.Non-Hodgkin lymphoma (NHL) is a heterogeneous group of hematologic malignancies, developing from cells contained in the lymphoid tissue or from lymph glands. In recent decades, NHL has been categorized into more than 40 forms based on pathological and histological features by the World Health Organization8. In epidemiological studies, the potential relationship between nitrate or nitrite consumption and risk of development of tumors has been investigated. Positive associations have been detected in adult glioma 9, thyroid neoplasm 10, and gastric carcinoma 11, etc. Moreover, Xie et al.12 and Song et al.13 further confirmed these correlations by conducting meta-analyses. During the past decades, the relationship between risk of NHL and nitrate or nitrite consumption have been investigated in several epidemiological publications, yet the results are contradictory. Some surveys failed to show positive or negative associations21, while others have revealed significant correlations25. When no specific trend can be ascertained from any individual investigation, combining a number of independent studies can reveal hidden associations through meta-analysis. Therefore, we conducted the present meta-analysis to discover latent connections between nitrate or nitrite consumption with the etiology of NHL, and so aimed to: (1) evaluate the epidemiological evidence about the relationship between nitrate or nitrite consumption from water or diet and risk of NHL; (2) consider a possible dose response (DR) relationship between nitrate or nitrite consumption and the risk of NHL; and (3) assess the quality of evidence and the statistical significance of the results.Nitrate and nitrite are crucial precursors of N-nitroso compounds (NOCs), a group of genotoxic composites that are highly carcinogenic and which act systemically25.Figure 25. In each study included in the review, at least two different pathologists were involved in the diagnosis of NHL. Every NHL case was categorized by the Working Formulation criteria of the Lymphoma Study Group or using the World Health Organization (WHO) classification criteria27. The quality of each study was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS). Scores ranged from 4 to 8 with a mean value of 6   , with both Egger’s and Begg’s tests indicating that no evidence of publication bias existed   and risk of NHL is illustrated in Fig. 83) Fig. . No evidly) Fig. . Furtherly) Fig. . Conversly) Fig. . No signly) Fig. . Similarly) Fig. .Figure 2Subset analyses were subsequently conducted, based on study design or quality, gender, source of nitrate, geographical region, NHL subtypes or levels of nitrite or nitrate Tables  and 3. IBecause a heightened risk of NHL caused by the intake of nitrites, but not nitrates, was found, a DR analysis was further conducted to assess the dose-response interrelationship for the risk of NHL and nitrite consumption. A 26% greater risk of NHL was linked to an increase of 1 microgram of nitrite per day  , but not studies of nitrate  . Furthermore, the overall association was more robust . As displayed in Table et al., as can be seen from the Galbraith plot . The pooled OR remained not significant . As shown in Table In order to assess heterogeneity in the studies of this meta-analysis, the lot Fig. . After eet al.24 and the research by Ward et al.25, respectively. For nitrate intake and risk of NHL, the ORs of the eleven studies varied from a high of 1.02 (0.95–1.11) to a low of 1.00 (0.91–1.09) after omitting the studies of Ward et al.25 and Chang et al.20, respectively.The influence of each study on overall estimate of risk was measured by repeating the meta-analysis after omitting each study in turn so as to conduct an analysis of sensitivity. As shown in Supplementary Fig. etc.), nitrites and nitrates may be adjuncts that maintain the color of meat products and reduce microbial spoilage. However, excessive intake of processed meat is associated with an elevated risk of carcinomas, including NHL28. In recent years, the association between risk of NHL and nitrate or nitrite intake have been explored in a number of epidemiological studies. However, the relationship remains uncertain. Therefore, all available studies that have explored these relationships were integrated into this meta-analysis in an attempt to clarify these possible associations.Globally, nitrates and nitrites are present within many typical diets. For example, in processed meats . In summary, the results suggest that nitrite intake, but not nitrate, is an important factor in the occurrence of NHL and that increased nitrite intake appears to raise the risk of NHL in a dose-dependent manner.29. In fact, this meta-analysis was in agreement with previous studies, the results of which indicate that nitrate consumption was not linked to increased risk of NHL. Moreover, in subtype analysis where study quality or design, geographical area, source of nitrate, NHL subtypes, levels of nitrate in water and gender were considered, the risk of NHL was not increased as a result of nitrate consumption. Indeed, in representative exposure models, several studies have provided strong evidence that nitrate cannot be a carcinogen for humans or animals31. Notably, Palli et al., Rogers et al. and Ward et al. separately demonstrated that high nitrate consumption protected against esophageal cancer, gastric cancer and renal cell carcinoma34. However, high nitrate intake was deemed to be from the consumption of vegetables, which are also rich in various anti-cancer substances  declared, as early as 2010, that there was no conclusive evidence that nitrates were carcinogenset al. observed that nitrite intake promoted lymphomas in rats in a dose-dependent manner35. In agreement with this study, our results indicated a significant positive relationship was found between NHL and high levels of nitrite intake , but not for low levels of nitrite intake . However, the mechanisms by which nitrites could influence the pathogenesis of NHL require clarification. A number of potential mechanisms could be responsible for nitrites being a risk factor for NHL. Previous studies have reported that nitrites can be converted into NOCs in the stomachs and intestines of both humans and animals through nitrosation with amides and amines. It is generally believed that NOCs are among the strongest known carcinogens, including N-nitrosodiethylamine (NDEA), N-nitrosopiperidine (NPIP), N-nitrosopyrollidine (NPYR), N-nitrosodimethylamine (NDMA) and N-Nitrosodibutylamine (NDBA), etc36. They are considered genotoxic procarcinogens associated with driving tumorigenesis in a variety of tissues in more than 40 species, even senior primates38. In agreement with previously published reports, Storer et al.39 found that NDEA was able to effectively increase the frequency of malignant lymphoma in Eμ-pim-1 transgenic mice. Additionally, through the interplay of superoxides and NO production nitrites are able to form peroxynitrites which have powerful oxidative capability that causes damage to DNA through cellular oxidation, closely associated with carcinogenesis41. In vitro, Ustyugova et al.42 demonstrated that nitrites could inhibit Th1 cytokine formation, including interferon-γ, tumor necrosis factor-β and interleukin-2. Interestingly, Saberi et al. confirmed that such a change in concentration of these cytokines, at least partly, contributes to the increased risk of developing NHL43. In our study, a significant positive relationship was showed between the risk of NHL and nitrite consumption for female , but not for male . The different hormone and cytokine levels in female and male might be a possible reason for raising the risk of NHL. A greater number of basic studies are urgently required in order to clarify the biological mechanisms in carcinogenesis induced by nitrites in NHL.In 1979, Newberne The present meta-analysis is the largest study to date in which the relationship between nitrate and nitrite consumption from diet or drinking water has been studied in relation to the risk of NHL, including 8,067 NHL cases in total. Based on the studies included in this review, it was possible for us to investigate the relationship in various subgroups using meta-analysis methods. Nevertheless, the meta-analysis had some limitations, due to data originating from previously published observational studies. Firstly, our analysis assembled together published studies in Chinese or English but did not attempt to uncover unpublished data, which may have led to publication bias. However, the Begg’s and Egger’s tests did not suggest any apparent evidence for recall bias. Secondly, in this meta-analysis, the results were principally derived from case-control studies, which could lead to the potential for publication bias, owing to the data for case-control studies being retrospective. Thirdly, due to a number of the subgroup analyses being conducted on tiny datasets, a high degree of confidence should not be placed on their conclusions. Fourthly, although we found a positive relationship between nitrite consumption and DLBCL, we did not obtain sufficient data to compute odds ratios for other particular histopathological subclasses of NHL from the studies included in this meta-analysis. Therefore, we were not able to explore the relationship between nitrate or nitrite consumption and the risk of suffering additional subclasses of NHL. Fifthly, when exploring the relationship between nitrate intake and the risk of NHL, we combined the data for nitrate consumption from diet and drinking water. However, the metrics for nitrate in diet or drinking water was different and we could not find an accurate method for combining them, which would affect the reliability of this meta-analysis. Additionally, a wide range of values for the cutoff points for the highest and lowest level of the consumption of nitrate and nitrite was found in the involved studies, which could led to the possible bias. Finally, the accuracy of the conclusions of this meta-analysis will have been influenced by the threshold values of the highest and lowest categorizations of nitrate or nitrite consumption being distinct in the various studies. Hence, a greater number of well-designed, multi-center, large-sample epidemiological studies are essential for better elucidating the association between the risk of NHL and nitrate or nitrite consumption.To summarize, the results suggest that nitrite intake is linked to increased risk of NHL. In the future, to acknowledge our conclusions and to ensure precautions against NHL, additional and more stringent systematic studies are required.45.A systematic and comprehensive article retrieval strategy that provided a general impression of the risk of NHL due to nitrate or nitrite consumption was conducted. The Web of Science, the Chinese National Knowledge Infrastructure (CNKI) and PubMed databases were searched for articles of follow-up, cohort or case-control studies assessing the relationship between the risk of NHL and nitrate or nitrite consumption from drinking water or diet, from inception of each database until May 31th, 2019. Few relevant articles were obtained by searching for the terms ‘nitrate’ or ‘nitrite’ and ‘non-Hodgkin lymphoma’. Identification of more relevant articles was accomplished by combing the keywords in a more detailed retrieval strategy, as follow: (N-nitroso compounds OR nitrite OR nitrate) AND (NHL OR non-Hodgkin’s lymphoma OR non-Hodgkin lymphoma OR lymphoma). In addition, a manual search of the references of relevant articles was performed to locate additional studies not identified in the initial search. The current analysis was performed with due consideration to the quality criteria for meta-analysesAll relevant articles were included if they fulfilled the following criteria: (1) a follow-up study or the study had a case-control design; (2) the study investigated the possible relationship between risk of NHL and nitrate or nitrite intake from diet or drinking water; (3) outcomes included relative risk (RR) or odds ratio (OR), or provided sufficient data to perform calculations; (4) the study was published before May 2019 and reported in Chinese or English. If the same samples were reported in different articles, only the manuscript reporting the largest sample size was selected. If an article provided inadequate details or reported overlapping material, it was precluded.The following data were retrieved from each article: article title (including publication year and first author’s name), study location of origin, judgment of risk factors, numbers of cases and controls, study design, adjustment factors and patient country of origin. Because non-Hodgkin lymphoma is an uncommon disorder, it is believed that the RR is commensurate with the OR. Thus, OR was adopted to assess any potential association between risk of NHL and nitrate or nitrite consumption. And OR was calculated by comparing the highest level of nitrate or nitrite consumption with the lowest. Two researchers (C.H. and M.X.Y.) independently conducted data collection via a structured questionnaire. A third researcher was consulted in order to reach a consensus, if required.46. In the event of disagreement between the two investigators, a third reviewer arbitrated. The NOS is a tool that permits appraisal of follow-up, population selection, exposure and comparability of included studies. It was then possible to quantitatively assess the quality of each article according to the four aspects above. For each study, the points total varied from 9 to 0. Scores ≥7 represented articles considered high-quality, while scores <7 were considered of low quality.Two investigators independently evaluated the quality of the articles included in the review through application of the nine-star Newcastle-Ottawa Scale (NOS)47. Conversely, the DerSimonian and Laird method was used to evaluate a random-effects model48. In order to calculate levels of heterogeneity, the I2 statistic  and the Q test were adopted49. To detect sources of heterogeneity, we also conducted subgroup analyses, using source of nitrate, study design or quality, geographical area, gender, NHL subtype and levels of nitrate in water. In addition, a Galbraith plot and meta-regression analysis were also performed to explore the potential origins of heterogeneity50.The relationship between risk of NHL and nitrate or nitrite intake was evaluated using pooled ORs and their 95% confidence intervals (CIs). The choice of random or fixed-effects model was dependent on heterogeneity between studies. Where significant heterogeneity was absent, a Mantel-Haenszel test was utilized to compute pooled ORs in a fixed-effects modelet al.51 and Greenland et al.52, we repeated the meta-analysis to re-assess risk. The mean value of every categorization range for nitrate or nitrite intake was used in the DR analysis. If the upper boundary of the highest category or the lower boundary of the lowest category was not provided in a particular study, the equivalent interval was assumed according to the next highest or lowest category53. The potential DR relationship of risk of NHL to nitrate or nitrite intake was estimated in two stages51. In the first, a limited cubic spline model with 4 knots at the percentages: 5%, 35%, 65% and 95% of the allocated exposure consumption was calculated, then three regression moduli (4 knots minus 1) were computed. Secondly, the covariance from every study was integrated.For DR analysis, articles were included if they provided the number of controls and cases in addition to reporting at least 3 levels of nitrate or nitrite intake for every exposure classification. Using a method proposed by Orsini 54, which indicated the magnitude of influence of all studies allocated normally around the center of a funnel plot. In addition, latent publication bias was also evaluated using an Egger’s test (linear regression method)55 and a Begg’s test (rank correlation method)56. STATA 11.0 software  was used to conduct the meta-analysis. P values less than 0.05 were considered significant.In order to assess underlying publication bias, we executed a trim-and-fill testsupplementary information.