Barley is the fifth most important food crop in Ethiopia. The genetic relationship and population structure studies of barley are limited to gene bank collections. Therefore, this study fills a gap by investigating the selection, consumption, economic value, genetic diversity, and population structure of farm-collected barley from the Gumer district of the Gurage Zone, which has received little attention. The information on the use of barley in the study area was collected using semi-structured interviews and questionnaires. 124 households of 11 kebeles, the smallest community unit, were interviewed. Barley landraces collected were compared with those collected from Japan, the United States (USA), and other Ethiopian locations. Illumina iSelect (50K genotyping platform) was used to identify single nucleotide polymorphisms (SNP) . Thirty landraces were found in Gumer. Burdaenadenber had the highest on-farm Shannon index estimate (2.0), followed by Aselecha (1.97) and Enjefo (1.95). Aselecha and Fetazer had the highest (44%) and the lowest (29%) richness values, respectively. High and low Simpson index values were found in Aselecha (84%) and Wulbaragenateretero (79%), respectively. The neighbor-joining tree revealed that Gumer landraces formed a separate subcluster with a common ancestral node; a sister subcluster contained barley landraces from Japan. According to the population structure analysis, barley landraces from Gumer differed from Japan and the United States. The principal component analysis revealed that US barley was the most distant group from Gumer barley. The markers’ allele frequencies ranged from 0.10 to 0.50, with an average value of 0.28. The mean values of Nei’s gene diversity (0.38) and the polymorphic information content (0.30) indicated the presence of high genetic diversity in the samples. The clustering of accessions was not based on geographic origin. Significant genetic diversity calls for additional research and analysis of local barley diversity because the selection and use of barley in Ethiopia would have been affected by the preference of ethnic groups. Hordeum vulgare ssp. Vulgare) was domesticated from its wild ancestor H. vulgare ssp. Spontanum [Barley  [Bmy1) at positions 115, 165, 233, 347, and 430, which allows adaptation and selection based on the preference for climate, and food [Recent studies suggest that barley landraces from multiple locations differentiated into genetically defined populations . AlthougPpd-H1) –20. Six and food –23. Furtand food –16.Single nucleotide polymorphism (SNP) of Illumina iSelect genotyping platforms used to examine barley landraces from the Gumer district, Ethiopia. The objectives of this study were 1) to determine the on-farm diversity of barley in the Gumer district. 2) to determine the genetic diversity and population structure of barley landraces from the Gumer district using SNP markers on the nuclear genome. 3) to compare the pattern of genetic diversity from the United States, Japan, and other Ethiopian barley accessions.Ensete spp., potatoes, kale, garlic, and barley; with the latter being the major cash crop for farmers in this area. The annual rainfall pattern is bimodal, and mean annual temperatures range from 10°C to 21°C [The Gumer highlands in the Gurage mountain range  rise out to 21°C . The stuThe study area is ethnically and linguistically homogeneous, representing the Gurage people and language. The ethnic group has several clans, which are all active in managing society. There is an accessible asphalt road, but most farmers in the study area have little or no road access. Small-scale subsistence agriculture dominates the landscape. The smallest unit of the community is called a ‘kebele’ and comprises 100–500 farmers.Eleven kebeles representing the highlands of Gumer were selected for interviews and collection of their barley landraces. The kebeles were selected based on their potential barley cultivation of landraces from the Gumer highlands. Eleven to 12 farmers were randomly selected from each kebeles for a total of 124 farmers .There is no rule for obtaining ethical approval for plant-related research projects in Ethiopia. To collect barley seed samples and interview farmers, a letter of support was obtained from the Hawassa University, Research and Technology Transfer Vice President Office, which was addressed to the Gumer district in the Gurage Zone, and a copy was provided to the administration of each of the eleven kebeles. The vice president of Hawassa University’s Research and Technology Transfer Office granted permission to interview and collect barley seeds from the farmer . ConsentA cross-sectional research design focused on selected kebeles within a district was identified after following a rapid preliminary informal survey and discussions with the zonal administration. Data were collected from farmers who cultivate barley landraces. Key information and personal observations were obtained through questionnaires, household interviews, and focus group discussions.A questionnaire was used to collect information from a wide range of sources (respondents) on indigenous knowledge and practices involved in barley landraces and utilization in the study areas. The questionnaire was written in English and translated into the local language “Guragigna". The head of the family was chosen based on the preliminary survey and documents obtained from district agricultural offices.Furthermore, all required age groups and sexes, including the heads of household of elder women, were purposefully included to ensure adequate coverage of the requirements. The mentioned landraces, with their names, use-value, and seeds, were collected during interviews. Each of the 124 barley sample communities was sampled during the main barley growing season in 2020. The total land planted with each crop was recorded for each farm. The SNP diversity was compared between barley from Gumer and collections from Japan, the US, and other locations in Ethiopia  that werIndividual barley samples  from eacSNP genotyping was performed with the Illumina iSelect 50K barley SNP array . Before To understand the diversity among the 11 kebeles, the Shannon-Wiener index, Pielou’s index, Pielou’s evenness, Simpson’s index, and abundance analysis were calculated using the vegan package (version 2.5–7)  with theH’ is the Shannon-Wiener index, J’ is the Pielou index, pi is the proportion of barley landraces, S is the number of barley landraces and λ is Simpson’s index.Where H is the Shannon index, Genetic diversity was assessed for the Gumer collection and compared on the unbiased expected heterozygosity (He) from Ethiopian, Japanese, and USA populations chosen from the world barley panel. Genetic differentiation between populations was estimated with F statistics using the snpReady package (version 0.9.0) . The snpThe spatial genetic structure of landraces was studied with principal component analysis (PCA) performed with the adegenet package (version 1.3–1)  using R The common names assigned to genetic resources based on indigenous knowledge can be indicators of genetic distinctiveness . Names aSeed color, spike length, number of rows, stress tolerance, yield, end-use characteristics, and other significant agronomic features distinguish the landraces. Some landraces are still being cultivated, with varying coverage in various locations. In contrast, Keleme is severely marginalized and on the point of extinction, while Shemeya has already vanished, as indicated by its presence only in one family. Similar findings have emerged from northern and Central Ethiopia, suggesting the rapid extinction of the major historical landrace.P> 0.05, The inter-landrace diversity or landrace richness (R), calculated using the Menhinick index, is summarized in We also found that the diversity estimate (Pilou evenness (J)) was high, except for the Aselecha kebele, which scored 0.36 . The culFarmers in the study districts intentionally preserve landraces to meet their needs . These rGender plays a role in selecting which landrace to plant. Women favor Keleme for its sweet taste, easy dehulling, and medicinal value. But men do not prefer it due to its susceptibility to drought, disease, and low market value . All farFarmers cultivate a diverse range of landraces, each with its maturity, yield potential, stress tolerance, end-use quality, and other agronomic characteristics . This diFifteen land races planted in the study areas are identified, named, and described by Gumer farmers. Since SNP markers differentiated the landraces, vernacular names and farmer descriptions of landraces could be linked to formal scientific classifications. The landraces have been identified as a distinct type using the scientific taxonomic classification system using morphological traits .The selection and decision-making process was based on sets of criteria. This value has an impact on the successful management of the landraces for their cultural and environmental needs. Complexity is expressed in their description of landraces for adaptation, stress tolerance, and yield . SelectiIn the present Gumer barley panel, we identified 20,367 replicable SNP calls of the 44,040 SNP probes available on the array . Of thesWe compared the Gumer barley SNP markers to Japanese, USA, and other Ethiopian landraces. The PIC value range was 0.17 to 0.38, with an average value of 0.30. Nei’s gene diversity score ranged from 0.15 to 0.50, with a mean of 0.38. The MAF ranges from 0.10 to 0.50 with an average value of 0.28, indicating the presence of a great diversity among the barley landraces .The PIC values were 0.25, 0.30, 0.30, and 0.30 for Gumer, Ethiopia, Japan, and the US, respectively. The average gene diversity (GD) was 0.31, 0.37, 0.37, and 0.39 for Gumer, Ethiopia, Japan, and the United States, respectively . SimilarP < 0.001), indicating a population of self-pollinating and inbreed in Gumer.The genetically effective size of populations was determined using SNP data . The JapWe determined the most likely population structure for the landraces using two methods. The first technique was a genetic structure-based clustering strategy, which was inferred using the second-order rate of change of the likelihood K . We founWe found that Bayesian model-based stratification and PCA clustering techniques did not group barley collections based on their geographic origin. For example, a variety of Gumer (GM12) clustered along the USA. A higher number of polymorphic SNPs were found in the United States and Japan landraces compared to those in Gumer.A PCA analysis revealed that location on a continental scale is not the most predictor of genetic structure. The geographic origin of the landraces did not confirm the clustering in the first components (PC I), which together explain 26.7% of the variance. PC1 distinguishes Gumer and some Ethiopian barley from the US barley, while PC2 distinguishes the USA and Japan barley from Gumer and some Ethiopian barley .DAPC analysis Figs  and 4 reThe clusters were composed of Gumer, Ethiopia, Japan, and USA samples. Populations were divided according to their collection origin; thus, continuous genetic flow between populations is limited or absent (in the case of Gumer). This was confirmed by the unique structure in the Gumer population, shown by the Structure, DAPC, and PCA analysis. Simultaneously, the use of PCA, Structure, and DAPC in clustering the barley landraces from different geographic regions yielded comparable results, indicating a strong genetic uniqueness of Gumer barley compared to USA and Japan barley Figs –4. The sThe results of AMOVA revealed that the variation accounted for 71%, 50%, and 58% of total genetic variability for Ethiopia, Japan, and the United States, respectively . By contST value was 0.41 (P 0.001). However, the value of FST between Gumer and Ethiopia, Gumer and Japan, Gumer and USA, Ethiopia and USA, and Japan and USA was 0.40, 0.68, 0.74, 0.11, 0.2, and 0.16, respectively  and the geographic origins  in this study. These findings indicate the need for a specific collection site and use of the value of barley to unravel the different human practices in domesticating barley for different use values. When comparing Gumer vs. Ethiopia, FST was 0.40, and Nm was 0.38. Nm between Japan and USA was high, and genetic differentiation based on FST values was significant between the landraces among the different populations, which confirmed the dynamic genetic variation among the collected landraces , 54. TheThe clustering analysis revealed that the SNP data did not classify landraces based on their geographical background, and landraces were jumbled together. For example, cluster I comprised 29 Gumer landraces and 18 landraces from Ethiopia, a landrace from the USA, and Japan. Cluster II comprised 17 landraces from Japan and 10 landraces from the USA, and 4 landraces from Ethiopia. Cluster III included 6 Japanese, 4 American, 1 Gumer, and 18 Ethiopian landraces. Cluster IV contained landraces from the United States, with only six Ethiopian and two Japanese landraces. Cluster V was made up of landraces from the United States, with three from Japan and four from Ethiopia. Cluster VI is composed of 1, and 2 Japanese and Ethiopian landraces .We discovered that the Ethiopian landraces were closer to the Japanese landraces and far from the Gumer landraces, rather than the two groups being closer to each other, using Fst values between populations . The JapSome Ethiopian landraces clustered with Japanese and US landraces, which implies that they share a genetic background . This grGenetic diversity is essential to create a robust food security system capable of responding to repeated biotic and abiotic stresses . In planOur interviews with the farmers showed that most landraces are used for food. These findings provide insight into the observed patterns in the Gumer barley genetic structure. We found little difference in abundance among the kebeles’ collections, likely due to the exchange of landraces among the members in different Kebele. The community uses barley as a food source, animal feed, and a source of income. As a result, the farmers select landraces with higher yields due to their increased adaptation to local farming conditions. These practices, and the importance of barley to the Gumer communities, shed light on the low diversity and genetic structure of barley in Gumer.The 50K barley SNP array is designed to capture the most reliable gene-associated SNP markers available in the barley genome (cv. Morex), but it is not sufficient to discover novel loci from Gumer landraces. The fact that we found fewer replicable SNPs on the array than the original Morex allele panel suggests the presence of new alleles. Subsequent research would benefit from hybridization and sequencing techniques to offer a more comprehensive description of the Ethiopian barley genome.in situ landrace populations must not have changed systematically over time. Alternatively, the genetic diversity in Gumer landraces could arise from factors such as adaptation to wider agroecology, natural crossings caused by cultivating different genotypes in a field, and the use of diversified agricultural methods.Our findings demonstrated that the barley landraces gathered from Gumer had lower diversity indices than those gathered from other regions in Ethiopia. This suggests that the occurrence of variability between the Ethiopian and Gumer landraces may have been caused by the usage of farmer landraces that are stored and employed for every season of farming. This study’s genetic diversity and structure could be attributable to genetic drift that occurred during the rejuvenation cycles. Several conditions must be met for this to be a persuasive explanation. For instance, the initial samples used to create the early landraces must have been large enough to capture a significant amount of the genetic diversity prevalent in today’s landrace populations in Gumer. In addition, the genetic diversity of We identified two barley subpopulations using a genetic stratification approach based on a Bayesian clustering model. A discriminant analysis using the BIC suggested that fewer than six clusters would be preferable. Both methods showed successful clustering of Gumer barely separate from USA, Japan, and other Ethiopia landraces.Another group used barley from gene banks and found , 60 geogHowever, our study found that there was limited admixture between the current barley collection from Gumer and barley from Japan, the USA, and other regions of Ethiopia. Instead, Gumer barley formed a separate structure and cluster, at least from Japan, and USA landraces, demonstrating a unique genetic makeup; therefore, the landraces now represent a unique genome structure of barley.We collected 30 barley landraces from Gumer in this work and compared them to landraces from Ethiopia, Japan, and the USA, using a high-density 50K barley SNP array. The research assesses the genetic diversity and population structure within landraces. Our results revealed a moderate polymorphism in the investigated Gumer barely. The molecular analysis in the tested landraces from Ethiopia, Japan, and the USA showed a high level of SNP variability. Based on the results of AMOVA, genetic diversity observed within Gumer is less than that found among samples from Ethiopia, Japan, and the USA. The result suggests that local landraces have less genetic differentiation. In addition, based on obtained results, the SNP array can distinguish the Gumer barley from Ethiopia, Japan, and the USA. However, many SNP lines were not recognized from the Gumer genome, indicating that a reference genome for Ethiopian barley germplasm is an alternative method to unravel the domestication process of Ethiopian barley. This study highlights the value of farmer-based agroecology in efforts to quantify diversity in barley. As a result, DNA genotyping of barley collection using a large number of landraces and SNP markers tightly linked to known genes associated with plant adaptation to different environments can help breeding programs based on the deployment of specifically selected DNA markers spread across the entire genome. The creation of sets for these chosen SNP markers of adaptation-related genes and their use in breeding programs could speed up the production of new competitive barley cultivars.S1 Table(XLSX)Click here for additional data file.S2 Table(XLSX)Click here for additional data file.S3 Tableo: heterozygosity within a population; Hs: genetic diversity within a population; Ht: overall gene diversity; Http: corrected Ht; Dst: gene diversity among samples; Dstp: corrected Dst; Fst: fixation index; Fstp: corrected Fst; Fis: inbreeding coefficient per overall loci; Dest: a measure of population differentiation. Significant deviation from Hardy–Weinberg equilibrium at *P < 0.05, **P < 0.01, and ***P < 0.001, respectively.Summary statistics of genetic variation existing in barley based on 20368 SNP among 182 landraces. H(XLSX)Click here for additional data file.S4 TableThe results are based on allele frequencies for 20368 SNP markers in 182 barley landraces.(DOCX)Click here for additional data file.S1 Text(PDF)Click here for additional data file.


Improved efficiency is one overall goal in WHO’s Health Systems Framework. Efficiency is an important dimension of health system performance assessment (HSPA). HSPA is used as a tool to monitor and evaluate the performance of health systems and to support evidence-based policymaking. In the pilot study for a first German HSPA, efficiency was assessed as one dimension.Indicators were selected based on a systematic search of established instruments in national and international HSPA initiatives. Criteria for the inclusion of indicators were data availability and international comparability. Where possible, indicators were evaluated in terms of their development over time (2000-2020), in comparison to eight European countries , and regarding equity aspects .Eight indicators to assess the efficiency of the German health system were identified and analysed accordingly. They cover the pharmaceutical sector, outpatient and inpatient care, and system-wide efficiency. Trend analyses were possible for all indicators, and most were also suitable for international comparisons. Overall, results of the chosen indicators indicate a moderate health system efficiency. The volume of generics as share of all pharmaceuticals, e.g., was 83% in Germany in 2019 (country average: 54%) and has been steadily increasing since 2000. In contrast, expenses for pharmaceuticals overall rose from 1.4% of GDP in 2004 to 1.7% in 2019, whereas it declined from 1.3% to 1.1% on average in the other countries.Within this first pilot study, a systematic and comparative German HSPA measuring the efficiency of the German health system using eight predefined indicators was proven to be feasible. The results give insights into efficiency measurements across different sectors, e.g., pharmaceuticals, identify developments of efficiency over time, and can support evidence-based policymaking.• In the pilot study for a first German HSPA, efficiency was evaluated using eight indicators covering pharmaceuticals, outpatient and inpatient care, and system-wide efficiency.• Based on the available data, which allowed trend analyses for all indicators and comparisons to eight European countries for most indicators, Germany’s health system efficiency can still be improved.


This systematic review evaluates published evidence on oral hygiene interventions conducted in Alzheimer’s disease (AD) patients. PubMed, Embase, Cochrane Library, CINAHL, Dentistry & Oral Sciences Source, and Web of Science were searched for articles published up to 19 April 2021. The main outcomes of interest were the Plaque index score (PI), oral health knowledge of participants or their caregivers, and behaviors and attitudes towards oral hygiene. Study quality was assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies of the National Institutes of Health. The study was conducted under PROSPERO registration code CRD42021247733. Two studies met the inclusion criteria. One was a pre-post study conducted in Brazil, and the other was a prospective cohort study carried out in China. The sample sizes of these studies were 29 and 168, respectively. Both studies were carried out in institutionalized patients and presented a significant loss to follow-up. The PI and gingival index scores both improved after the application of the respective interventions, yet the differing methodologies used precluded further comparisons. The studies were deemed to be of good and regular quality, respectively. Despite the need for more comprehensive interventions to ensure a better oral health status and a higher quality of life for AD patients, an alarming lack of studies have been conducted in this population. Alzheimer’s disease (AD) is the cause of 60 to 70% of cases of dementia . AccordiAs the disease progresses, self-care is seriously compromised . Many ADInterventions to improve oral hygiene in AD patients are important to reduce the burden of oral diseases in this population. These interventions should be aimed at improving the adoption of usual oral hygiene measures, accompanied by strategies to increase the patient’s knowledge about their disease and its repercussions on oral health. While AD is mild, some authors suggest focusing on comprehensive oral examinations and the use of long-lasting restoration, coupled with education on a proper oral hygiene routine and dietary recommendations ,7. CaregTo date, scientific publications on oral hygiene interventions among AD patients have mostly been limited to review articles or broad evaluations of populations with dementia or cognitive decline ,14. ThusThis systematic review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statements and is registered in the PROSPERO database (registration code: CRD42021247733) .Inclusion and exclusion criteria were established with the PICO method . Study types considered for inclusion were randomized controlled trials (RCTs), nonrandomized controlled trials, controlled before–after studies, interrupted time-series studies, and comparative observational studies. These studies involved the evaluation of methods of oral hygiene, including manual or electric tooth brushing, dental flossing, the use of mouth rinses, dental prophylaxis, oral hygiene instruction or training, and scheduled dental visits. Additionally, oral-hygiene-related knowledge-based interventions, oral-hygiene-related behavioral interventions, and oral-hygiene-related skills training for patients or caregivers were considered. Studies published in English, Spanish, or Portuguese that included participants with a diagnosis of AD from inception up to 19 April 2021 were eligible for inclusion. Review articles, systematic reviews, editorials, letters to the editor, congressional acts, and commentaries were excluded.Six databases were searched to identify studies of interest: PubMed, Embase, Cochrane Library, CINAHL, Dentistry & Oral Sciences Source, and the Web of Science. According to the recommendations for using Google Scholar to conduct systematic reviews, we limited the number of results reviewed to the first 10 pages ,17.A librarian with experience in medical research (DC) actively participated in the creation of the search strategies. All researchers reviewed and approved these strategies. Furthermore, searches of the reference list of all relevant articles were conducted. Publication status was not a restriction. The search strategy is referenced in the https://rayyan.qcri.org/, accessed on 2 April 2022), which allows the classification of publications as included, excluded, or maybe. Conflicts about the inclusion of any publication were resolved by discussion among the reviewers. To eliminate duplicate publications, search results were exported to EndNote X9 . Afterwards, two of the authors (AHV and ABP) independently screened the titles and/or abstracts of the retrieved publications to identify studies that potentially met the inclusion criteria. This was achieved with the Rayyan application  using a standardized data extraction sheet. Any disagreements were resolved through discussion with a third author (DA). The data extracted from each study included the date of publication, first author, journal name, type of publication, study objectives, period of data recollection, country, size and sample characteristics, intervention details, outcomes, and limitations. The main outcomes of interest were the Plaque index (PI) score, oral health knowledge (participants or their caregivers) and behaviors, and attitudes towards oral hygiene (participants or their caregivers). Additional outcomes of interest were gingival index scores, bacterial counts (using colony forming units), quality of life or oral health-related quality of life , caries measurements , the periodontal pocket depth (PPD), and bleeding on probing.The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies of the National Institutes of Health (NIH) was used by two reviewers (AHV and ABP) to independently evaluate the quality of the studies included . This inA narrative synthesis focus was used. Summary tables were employed to present findings. Descriptive tables were constructed with information on oral health care interventions among patients diagnosed with AD. Descriptive summaries of the results for AD patients, including country, sex, age, intervention, and outcomes, are reported.This study did not require the approval of an ethics committee, since this was an analysis of secondary aggregate data that are publicly available and do not allow the identification of the participants studied.We obtained a total of 2550 results from the search after eliminating duplicates. After the title and abstract screening, 22 articles were included in the full-text review. Only two of these had been conducted specifically on AD patients and evaluated oral health interventions while measuring outcomes of interest .Of the studies included, one study was published in 2014 and the other in 2020. One had a pre-post study design and was conducted in Brazil , and thep < 0.001)  .p < 0.001) [p = 0.009). The medium CAL and the medium PPD were 5.88 ± 2.58 (2.0–12.0) and 1.57 ± 0.69 (0.5–3.4), respectively, during the initial evaluation and reached 2.77 ± 1.27 (1.1–4.0) and 1.55 ± 0.40 (1.0–2.0), respectively, after six months of follow-up. The differences observed in the medium PPD were statistically significant (p = 0.0024), but the same was not true for the medium CAL (p = 0.446).The gingival index (GI) was reported by Zhang et al., who found that the baseline GI was 1.92 ± 0.28, 1.97 ± 0.36, and 1.95 ± 0.31 in the control, limited training, and comprehensive training groups, respectively . After s< 0.001) . The OHIThe study by Zhang et al. was deemed to be of good quality , while the study by Rolim et al. was found to be of regular quality (50%) .We intended to conduct a systematic review of studies that evaluated different interventions meant to improve oral hygiene among patients with AD. The primary outcomes of interest were the PI, oral health knowledge, behavior, and attitudes towards oral hygiene. After reviewing a total of 2550 articles, we identified only two that met the inclusion criteria. Both studies included a small sample size of institutionalized patients and presented loss to follow-up. Only one study included a comparison group. The study by Rolim et al. had the longest follow-up period of 6 months. Both studies found improvements in oral health after the intervention, but only the study by Zhang et al. was deemed to be of good quality. Both studies included improvements identified after the implementation of the oral health intervention. Zhang et al. identified that caregivers and patients who were part of the comprehensive learning group presented the best results in terms of the PI after 6 weeks of follow-up. Indeed, two other studies, one conducted in professional caregivers in nursing homes and one among guardians of preschool children, also found that educational interventions improve knowledge, attitudes towards oral health care, and the oral health of both guardians and their wards ,24. LikeThe studies identified involved institutionalized patients under the care of a professional caregiver and had a maximum follow-up period of 6 months. Zhang et al. conducted a clinical trial with caregivers who had received formal training to care for elders, but this is not the norm. Most patients are cared for by informal caregivers with only empirical experience and limited access to additional resources. Around 13% of adults aged 50 years and over that live in Organization for Economic Co-operation and Development countries report the provision of informal care at least weekly . Many adWhat is most alarming about our findings is the lack of high-quality studies that have addressed this aspect of AD patient care. There is currently a demand for further support in the care of the cognitively impaired. A systematic review of the needs of family caregivers of dementia patients concluded that support, personalized information, and education regarding care for loved ones are three of the main themes of caregiver requirements . Oral heAmong the limitations of our study, we must highlight the limited number of studies that were included. This is likely due to our inclusion of studies that evaluated patients diagnosed with AD and involved specific oral health outcomes. Nevertheless, AD is the most common form of dementia worldwide, and more interventional studies should aim to evaluate standardized outcomes that are relevant to clinical dentists. The few studies identified have different methodologies and are of differing levels of quality, which prevents further comparisons. Finally, we were unable to identify studies conducted in a community setting, suggesting that informal caregivers are being overlooked in this field of research. There is still an alarming lack of published studies on the use of oral health interventions among patients with AD. This prevents the development of recommendations that may prove to be useful in clinical practice. The studies included in this systematic review were conducted in institutionalized patients, had small sample sizes, and did not stratify results by the severity of the disease. In the future, longitudinal studies with standardized oral health outcomes are required to provide guidance that conforms to the needs of both patients and caregivers in specific settings. These studies should consider comprehensive and sustainable strategies based on the patients’ cognitive levels and baseline oral hygiene practices and be based in community settings.


The placental examination provides important information about the effect of maternal abnormalities on the placenta or the cause of preterm delivery, fetal growth restriction, or fetal neurodevelopmental damage. In this study, the frequency of placental pathologies of patients in a tertiary hospital was investigated.In this longitudinal and cross-sectional study, all removed placentas after any type of pregnancy termination referred to a pathological examination, within 1 year (2019–2020). All placentas were examined macroscopically and microscopically by two pathologists.p = 0.701), preeclampsia (p = 0.51) had no significant difference was seen in normal and abnormal placentas. Maternal age (p = 0.83), gestational age based on the last menstrual period (p = 0.38), and gestational age based on the first ultrasound (p = 0.78) did not show a significant relationship with any of the pathological complications categories.Unfortunately, because of the COVID-19 pandemic, the number of pregnant women in our hospital declined. A total of 258 placentas were examined. The type of delivery in 193 cases (79.4%) was cesarean section and 50 cases (20.6%) had a vaginal delivery. In the pathological assessment of placentas, 238 (92.2%) cases were normal and 20 cases (7.8%) were abnormal. Infarct and chorioamnionitis were the pathologies with higher frequencies . Intra-uterine fetal death (Pathological examination of the placenta from all live-birth deliveries is not worthwhile, and it’s recommended to modify the guidelines as to when the placenta is submitted for pathological evaluation. The placenta is an embryonic organ consisting of the umbilical cord, chorionic and amniotic membranes, and the parenchyma. Maternal or fetal abnormalities may cause placental abruption, because the mother and fetus intersect at this point. On the other hand, early placental abnormalities can affect the health of both mother and fetus. The placental examination provides valuable information about the effect of maternal abnormalities on the placenta or the cause of preterm delivery, fetal growth restriction, or fetal neurodevelopmental damage. The placental examination is an essential component of autopsy in cases of fetal or infant death –3.In the following cases, pathological examination of the placenta is recommended: (1) stillbirth (present or past), (2) infant resuscitation or hospitalization in the NICU, (3) pre-term or post-term delivery, 4) pregnancy with twins or multiples, (5) Apgar score below 7, (6) obstetric complications , (7) observation of gross abnormality in the placenta , 8) fetal or neonatal abnormalities or hydrops; and (9) obvious maternal disorders and diseases  thyroid disease, malignant placental neoplasm, fever/infection, abnormality or scarring of the uterus [ pregnanc fetal orAny tissue that removes from the human body is indicated for pathological examination, but only cases with indications are evaluated in many hospitals . The AmeOne of the most important and vital cases of abnormal placentas that requires early diagnosis and timely action is gestational trophoblastic diseases (GTD), which includes a wide range of proliferative disorders of placental trophoblastic tissue, including moles . CompletDue to the importance of placental pathologies and the complications it causes, in this study, the frequency of placental pathological manifestations in deliveries of Vali-Asr Hospital—Imam Khomeini Hospital Complex in Tehran was investigated.This longitudinal and cross-sectional descriptive study was performed in the delivery block of Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran. This study was performed According to the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Tehran University of Medical Sciences (TUMS) .During 1 year, all placenta samples were sent to the pathology laboratory for examination within 2 h after the end of pregnancy. The placenta was kept in a 10% formalin solution and delivered to the pathology department as soon as possible.In the laboratory, the following measures were taken to prepare placenta samples: the placenta samples were first examined macroscopically and then microscopically in the pathology department. Macroscopic examination in terms of maternal surface, umbilical length, hematoma, membrane transparency, and lobulation was performed for all samples. In the microscopic examination, after preparing H&E slides, all of them were examined for fibrosis, knot syncytial, trophoblastic cells, villi, fibroid deposit, inflammation, necrosis, vessels, and calcification. Data were recorded in a researcher-developed questionnaire.Data were entered in SPSS , and analyzed based on objectives. Descriptive statistics were expressed as number and percentage  for qualitative variables and as mean and standard deviation for quantitative variables. In analytical statistics, comparisons between two groups and several groups for qualitative variables were performed using the chi-square test. Mann–Whitney test (compared between two groups) and Kruskal–Wallis test  were performed for variables with abnormal data distribution. Significance levels were considered less than 0.05.Unfortunately, because of the COVID-19 pandemic, the number of pregnant women in our hospital were declined. A total of 258 placentas were examined. The type of delivery in 193 cases (79.4%) was cesarean section and 50 cases (20.6%) had a vaginal delivery. Demographic information and quantitative variables are listed in Table There was no history of the disease in 181 cases 70.2%) and hypothyroidism was the most common previous history of the disease . In the pathological assessment of placentas, 238 (92.2%) cases were normal and 20 cases (7.8%) were abnormal. The frequency of complications is listed in Table % and hypInfarct and chorioamnionitis were the pathologies with higher frequencies . The relationship between each category of pathology with IUFD and preeclampsia is shown in Table (p = 0.701)). In normal placentas, 5 cases (2.1%) were preeclamptic and in placentas with abnormal pathology, no case of preeclampsia was observed, and there was no significant difference in terms of preeclampsia in normal or abnormal cases of placental pathology (p = 0.51). Maternal age (p = 0.83), gestational age based on LMP (p = 0.38), and gestational age based on the first ultrasound (p = 0.78) did not show a significant relationship with any of the pathological complications categories.Regarding IUFD, no significant difference was seen in normal and abnormal placentas  than in uncomplicated deliveries . On the Loverro and et al. in 2022 showed that although many reports said that examination of the placenta provided information which important for the management of pregnancy, it still presents unresolved problems because of the pathologic aspect in normal pregnancy .The variables of maternal age, gestational age based on LMP, and gestational age based on the first ultrasound did not show significant differences in placentas with normal and abnormal pathology. Past studies have shown that fetal vascular malformation and delayed puberty are associated with increasing maternal age during pregnancy .Choriocarcinoma is most often seen with complete mole, ectopic pregnancy, non-molar intrauterine abortion, and unusually with partial mole. Choriocarcinoma with or after a “normal” pregnancy is very rare . Intra-pThis study had some limitations, such as problems in sending the placenta to the laboratory quickly. To solve this problem, proper coordination and continuous monitoring were performed during the delivery emergency, and samples were sent with appropriate conditions and time to Vali-Asr Hospital laboratory. Finally, the small sample size of the study made it possible to reduce the study power and, therefore, further studies such as multicenter research with larger sample size is needed.Pathological examination of the placenta is very important for early examination and finding cases that may have a poor prognosis of mother and infant; However, according to the results of the present study, since there was no significant difference in placental pathology in cases of IUFD and preeclampsia in mothers of different ages and gestational ages, so Pathologic examination of the placenta from the all live birth deliveries is not worthwhile and due to the cost to the Health System is recommended only in suspicious and high-risk cases. multicenter cohort studies with large sample sizes are needed to confirm these results.


Hevea brasiliensis Muell. Arg) and refuse-derived fuel (RDF) waste with no added binder. Three different conditions of mixed pellets were developed to compare their chemical and physical properties to rubberwood pellets. The produced samples were subjected to both ultimate and proximate analyses. The contents of C, H, N, S, and Cl significantly increased with the increasing amount of refuse-derived fuel in the samples, resulting in reduction of the volatile matter. The mechanical durability of the pellet samples ranged between an average value of 98 and 99%. Mixed pellets containing 50% of rubberwood and 50% of refuse-derived fuel have improved heating values by 22.21% compared to rubberwood pellets. Moreover, mixed pellets having 50% of wood and 50% of refuse-derived fuel had the highest density and the highest energy compared to the other samples. Based on the findings of this study, it appears that the manufactured mixed pellets have the potential to be used as high-energy fuel.The objective of this study was to investigate the production and properties of mixed pellets made from rubberwood ( Wood pellets are typically made from compacted sawdust or other woody materials, meaning that they are related to biowaste utilization . PelletsHevea brasiliensis Muell. Arg) is the most vital raw material for the wood-based industries in both Thailand and Malaysia [3 input of rubberwood logs to sawmills, 3944 m3 sawdust could be generated during the sawmilling process. It was noted that this sawdust was used by the sawmills for fuel generation. Rubberwood waste is abundant in Thailand’s southern provinces, and it has great potential for biofuel applications [Rubberwood , on the other hand, is a by-product of municipal solid waste (MSW), which is expected to reach 2.6 billion metric tons by 2030 . MSW lanSeveral types of vegetal biomass materials have been co-pelletized with MSW for pellet production. Wood and energy crop residues with different mix compositions has been used to improve the quality of wood pellets while lowering their cost . As a reTo the best of the authors’ knowledge, there have been few studies on the co-pelletization of rubberwood and RDF. As a result, knowledge of the effects of co-pelletization of rubberwood and RDF on the performance of pellets produced is limited. Therefore, the objective of this research was to investigate the energy potential and some properties of mixed pellets made from rubberwood and RDF. Furthermore, the results of this research could provide evidence that mixed pellet fuel can be used as a feed stock in thermal waste-to-energy technologies.Commercially produced rubberwood sawdust, a waste product supplied by BNS Wood Industry Co., Ltd., a sawmill located at Mueang, Surat Thani, Thailand, was dried in a hot-air oven at a temperature of 103 ± 2 °C for 48 h to reach a moisture content of 0%. Before being used to make pellet samples, dried sawdust was screened on a sieve with 18 mesh to remove any oversize particles. Municipal solid waste (MSW) samples that had been landfilled for 1.5–2 years were collected from a landfill area in Pattalung Province, Thailand. The collected MSW samples were separated into combustible and incombustible materials, using a separating machine and manual selection by workers. After separation, the combustible materials were converted into refuse-derived fuel (RDF) by a machine operated by a private company in Thailand’s Mueang, Nakhon Si Thammarat. RDF wastes that have been processed to separate glass, metal, and inorganic materials were shredded to the point where 95% of the weight passes through a 2 in. square mesh screen and was denoted as RDF-3 . FinallyThe dimension, density, and color of the samples were determined. Three replications of each pellet type were completely randomized and used for sample testing. 3), M is the mass of the pellet (g), and V is the volume of pellet (cm3).The samples’ dimensions and weights were measured and weighed with precisions of 0.01 mm and 0.0001 g, respectively. The density of the pellet was calculated by using the following equation: A is the mass of the pellet pieces after tumbling (g), and MB is the mass of the pellet pieces before tumbling (g).Mechanical durability testing of the samples was carried out in accordance with the procedure outlined in EN 15210-1. It is a 10 min tumbling box test that determines the resistance of densified fuels to shocks and/or abrasion caused by handling and transportation processes (EN 15210-1: 2009). The broken pellet pieces and dust were separated and weighed by using a 3.15 mm sieve. The mechanical durability was calculated by using the following equation: The heating value or gross calorific value of pellet samples was determined by using an automatic bomb calorimeter, Leco A-350, St. Joseph, MI, USA. The measurements were made in triplicate, and the results are given as means with standard deviations in MJ/kg ASTM D 3286-96). The samples were also subjected to proximate analysis in order to determine the impact of moisture content (MC), volatile matter (VM), ash content (AC), and fixed carbon (FC) on the gross calorific value. The VM, AC, and FC quantities were determined by measuring the mass loss that a sample undergoes at a temperature of 900 °C, under a nitrogen atmosphere, and then held at 900 °C, under atmospheric air [6-96. TheThe samples were finally analyzed by using the ASTM D5373-93 (1997) procedure, ASTM, West Conshohocken, PA, USA. In an ultimate analysis, the contents of elemental carbon (C), hydrogen (H), nitrogen (N), and sulfur (S) in pellets were determined by using a Perkin Elmer, 2400 Series II CHNS/O analyzer, USA. The chlorine (Cl) content was determined by using a 785 DMP Titrino from Metrohm in Switzerland.A scanning electron microscope (SEM), FEI Quanta 250, Waltham, MA, USA was also employed to examine the microstructure samples. The images were captured by using a SEM set to 15 kV, and all of the specimens were coated with a thin gold layer prior to analysis. The images were taken from cross-sections of pellets with a diameter of 6 mm.®, Microsoft, Redmond, WA, USA, analysis of variance (ANOVA) was used to determine the significant differences between the four types of pellet specimens. Duncan’s multiple range tests, as well as SPSS Statistics version 22, were used for additional analysis. A p-value of 0.05 was used as the level of confidence.For data analysis, a completely randomized design of sample types was used. Using XLSTAT in Microsoft Excel 3653) when compared to the pellets with the addition of RDF-3.p < 0.01). Furthermore, when the RDF-3 ratio is increased, the calorific value improves in a linear fashion. It is a fact that this value is dependent on the MSW source, which contains a variety of waste compositions. Rezaei et al. [As shown in i et al.  investigAn ultimate analysis was carried out to investigate the carbon, hydrogen, nitrogen, sulfur, and chloride content of the pellets. The results are listed in This study demonstrated that RDF-3, a product of municipal solid-waste transformation, can be mixed with rubberwood to produce a pellet fuel. Pellets with a mixture of 50% rubberwood sawdust and 50% RDF-3 demonstrated the capability of a fuel material with the highest density and energy. The increased RDF ratio had a significant impact on the heating value of mixed pellets, while the volatile matter values were also significantly reduced. Meanwhile, the mechanical durability of the W5R5 sample was 99.07%. Combining both feedstock types appears to have the potential to yield value-added blend pellets for use in biomass power plants and other applications. Other properties, such as the elemental compositions of mixed pellets, would be interesting to investigate in future research to gain a better understanding of how this type of product behaves.


Nonalcoholic fatty liver disease (NAFLD) and chronic hepatitis B (CHB) are both the most common underlying diseases leading to cirrhosis and hepatocellular carcinoma, and NAFLD and HBV infection are the first and second leading causes of chronic liver disease in China. However, there are still a lot of controversies about whether the combined presence of CHB and NAFLD will affect the course or outcome of liver disease together with HBV, and how the two affect each other.  To investigate the effect of nonalcoholic fatty liver disease (NAFLD) on antiviral therapy in patients with chronic hepatitis B (CHB). VIP.com, and Wanfang Data Knowledge Service Platform were used. The time frame was from the creation of the database to June 2022. The search subject terms were hepatitis B, CHB, or NAFLD. The observation group consisted of patients with e antigen-positive CHB with NAFLD, and the control group consisted of patients with e-antigen + CHB. Extracts including title, name, date of publication, number of samples, antiviral drugs, and outcome indicators were used for Meta-analysis. Funnel plots were drawn to analyze literature bias.  Computer searches of databases such as PubMed, CNKI, n = 547, control group: n = 801) were finally included.  Seven papers including 1348 patients with HBeAg + CHB  were finally included. Results. Meta-analysis showed that CHB patients with NAFLD had lower efficacy than CHB patients after 48 weeks of antiviral treatment with nucleotide analogs, as measured by three outcome indicators HBV DNA conversion rate, ALT-normalization, and HBeAg conversion rate.  Seven papers including 1348 patients with HBeAg + CHB (observation group:  NAFLD reduces the effect of antiviral therapy in CHB patients, and the clinicopathological features of patients with NAFLD combined with chronic hepatitis B are different from those of patients with chronic hepatitis B alone, so early diagnosis by liver histological examination should be actively performed and reasonable antiviral therapy should be administered. NAFLD is one of the chronic liver diseases that has become one of the major chronic liver diseases in China and the most common chronic liver disease in the world, which is associated with insulin resistance and also with genetic susceptibility to liver damage when metabolic stress is produced, characterized by hepatic steatosis, and its disease spectrum includes from simple steatosis, nonalcoholic steatohepatitis, cirrhosis and cryptogenic cirrhosis , 2. WhenIn Western countries, the prevalence of NAFLD in the general population is about 30%, and the prevalence is even higher in obesity. The prevalence of NAFLD has been reported to affect 80–100 million people in the United States, of which 10–22% may develop NASH , 7. The Antiviral therapy is crucial for disease progression in CHB patients, and in recent years, antiviral therapies have been widely used in the clinic, and this modality has achieved notable success in the treatment of chronic hepatitis B. Data  showed tVIP.com, and Wanfang Data Knowledge Service Platform databases were used in conjunction with the actual situation. The time range was from the establishment of the database to June 6, 2022. The keywords were Chinese search subject headings: hepatitis B, CHB, or NAFLD. English subject headings: Chinese and Red Cross, NAFLD. The observation group consisted of patients with e antigen-positive CHB, and the control group consisted of patients with e-antigen + CHB. Extracts including title, name, publication date, sample number, antiviral drug, and outcome index were used for Meta-analysis. Funnel plots were drawn to analyze literature bias. It is reported below.Based on this, in order to investigate the clinical effect of a simple antiviral method for chronic hepatitis B, computerized searches of PubMed, CNKI, VIP.com, and Wanfang Data Knowledge Service Platform were searched using computers. The time range was from database creation to June 6, 2022. The keywords were Chinese search subject headings: hepatitis B, CHB, or NAFLD. English subject headings: Chinese and Red Cross, NAFLD. The observation group consisted of patients with e antigen-positive CHB, and the control group consisted of patients with e antigen + CHB. Extracts including title, name, publication date, sample number, antiviral drug, and outcome index were used for Meta-analysis. Funnel plots were drawn to analyze literature bias.Databases such as PubMed, CNKI, Inclusion criteria were as follows: the observation group of the research objects is the CHB patients with NAFLD who are positive for e antigen. The control group was CHB patients with positive e-antigen; study type: cohort study or case-control study; outcome indicators: serum HBV DNA level decreased to below 3 lg IU/mL, ALT normalized, and HBeAg negative conversion.Exclusion criteria were as follows: (1) full text not available; (2) incomplete data; (3) duplication in the literature; (4) conclusion that the indicators do not match.The extracted content includes the title, first author, publication year, subject numbers, antiviral drugs, and outcome indicators.P < 0.05 was considered statistically significant. RR and its 95% CI were chosen as statistical data. Heterogeneity between the literature was tested by the P test and the I2 test. P < 0.05 and I2 < 50% indicated that the literature was homogeneous (no heterogeneity) and a fixed-effects model was used, otherwise a random-effects model was used.Statistical software 5.3 was used and VIP.com, and Wanfang Data Knowledge Service Platform. The time range was from the establishment of the database to June 6, 2022. Keywords: hepatitis B, nonalcoholic hepatitis. A total of 7 articles were included, including 1348 HBeAg + CHB patients, 547 observation cases, and 801 controls. The screening flow chart is shown in A computer search of databases such as PubMed, CNKI, As shown in As shown in As shown in A funnel plot analysis was performed on the rate of HBV conversion in the included literature .Chronic hepatitis B refers to a chronic disease characterized by the degree of hepatocellular damage after infection with hepatitis B . ChronicThe results of this study showed that the patients' AST, TG, TC, and ALT improved more significantly when they were treated with hepatoprotective therapy and the observation group was treated with antiviral therapy alone. Although the basic hepatoprotective therapy could improve liver function, fibrosis level, and ballooning changes to some extent, the effect was more significant with the addition of the antiviral method, and the patients were able to achieve 89% and 100% of the liver function level and HBV DNA conversion rate after the treatment .It has been noted in the literature that there is also variability in the effectiveness of the use of antiviral treatment in patients with different NAFLD scores. Here among them the biochemical parameters of the 7 and 8 subgroups improved significantly compared to the pretreatment period, while the effect of antiviral therapy was more significant in patients with scores of 5–6. This fundamentally confirms that there is a correlation between the severity of fatty liver disease and the effectiveness of antiviral treatment for hepatitis B. The NAFLD score has a significant impact on the effectiveness of antiviral treatment for chronic hepatitis B disease. It is recommended that for this group of patients, intensive NAFLD treatment is used, which includes specific measures such as medications and exercise.Treatment of CHB includes antiviral therapy with interferon and nucleoside analogs. Due to different mechanisms, we included only patients receiving antiviral therapy with nucleoside analogs. A total of 7 publications, including 1348 HBeAg + CHB patients with NOS score ≥ 7, were included and were of high quality. The meta-analysis finally concluded from the perspective of three outcome indicators, HBV-conversion, ALT-normalization, and HBeAg conversion, that CHB patients with NAFLD had lower efficacy than CHB patients after 48 weeks of antiviral therapy with nucleoside analogs. This is consistent with the results observed in most of the literature.Antiviral treatment with nucleoside analogs is a long-term process. Due to the different follow-up time points of the included studies, this meta-analysis only examined the virological and biochemical responses after 48 weeks of antiviral therapy. However, there was a significant correlation between the duration of antiviral treatment and its response. Therefore, other experiments are needed to observe the efficacy at other time points.Through a literature search, we retrieved 16 relevant studies, but because 9 of them did not specify the e-antigens of the included patients, no comprehensive analysis was performed. Only 6 papers were included for analysis, which is not a large enough sample size and may be potentially biased.However, this meta-analysis has some drawbacks and limitations.In patients with more severe fatty liver disease, the implementation of antiviral therapy can improve the overall liver function of the patient; thus, enabling the demonstration that the combination of antiviral therapy for those with poor hepatoprotective therapy alone can promote disease regression. For NAFLD scores of 5 to 6, patients with liver function ALT greater than 3NLN are recommended to be treated with simple antiviral therapy. This can reduce the liver load to some extent.In conclusion, our study suggests that NAFLD inhibits antiviral therapy in patients with CHB. More experiments with larger samples are still needed to draw more accurate conclusions.In conclusion, in patients with chronic hepatitis B combined with NAFLD, the use of hepatoprotective therapy along with antiviral therapy can improve the overall HBV DNA and HBsAg conversion rate, as well as liver function, improve NAFLD classification, better repair the degree of liver damage, and improve liver function, which is worth further promotion in clinical treatment. It is worth to further promote its use in clinical treatment.


Grisel's syndrome (GS) is defined as atlantoaxial rotatory subluxation/fixation not associated with trauma or bone disease, usually following head and neck infection/inflammation or ear, nose, and throat (ENT) surgery. Many conditions could lead to Grisel's syndrome, of which mumps is rarely to be seen. This report discusses a case of GS in children with Type I atlantoaxial joint subluxation and previously diagnosed mumps. A 6-year-old boy who had cervical pain and torticollis for 2 weeks was admitted to our hospital. There was no trauma and he had not had ENT surgery but was diagnosed with mumps 2 weeks previously due to swelling of the left cheek and cervical lymph node. Physical examination and computed tomography confirmed a diagnosis of Grisel's syndrome with an ADI  of 1.6 mm. The patient then received occipito-mandibular traction for 6 days and recovered. No recurrence was observed at 1 year follow-up. Physicians should raise awareness of this rare complication of mumps to avoid life-threatening neurological impairments owing to Grisel's syndrome. Grisel's syndrome (GS) is defined as atlantoaxial rotatory subluxation/fixation not associated with trauma or bone disease, usually following head and neck infection/inflammation or ear, nose, and throat (ENT) surgery –3. It isMumps, or epidemic parotitis, resulting from mumps virus infection, is a common disease among children that usually presents with a satisfactory prognosis. Several complications, such as orchitis, oophoritis, myocarditis, and meningitis, have been widely recognized and reported . Mumps oGiven the possibility of later recovery and life-threatening neurological impairments caused by GS, we here report on a case of GS that developed in a child due to mumps in a Chinese population, aiming to enhance and improve the awareness and recognization of this rare complication in patients with mumps.9/L; neutrophils, 61.5%; lymphocytes, 32.2%; hemoglobin, 122 g/L; platelets, 629 × 109/L; C-reactive protein (CRP), 2.3 mg/L. Atypical lymphocytes were not found in the peripheral blood of the patient. A computed tomography (CT) scan confirmed the atlantoaxial rotary subluxation, with an increase in the atlanto-dens interval of 1.6 mm, corresponding to a Type I GS  for the publication of any potentially identifiable images or data included in this article.XD, XL, and CW revised the manuscript. YS, LY, and YX drafted the manuscript and provided the figures. All authors confirmed revisions and approved the final manuscript as submitted, and agreed to be accountable for all aspects of the work.This study was supported by the Science Technology Support Plan Projects in Sichuan province (Grant No. 2022YFS0240).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.


To investigate the effect of kangaroo mother care on the psychological stress response and sleep quality of mothers with premature infants admitted to the neonatal intensive care unit (NICU).A randomized controlled design was used to recruit participants. The study recruited 126 mothers of premature infants in the NICU from January 2019 to January 2020. The participants were divided into the experimental and control groups according to the random number table method (63 mothers per group). The control group was managed with conventional premature infant treatment, nursing programme, and discharge education, whereas the experimental group was managed with a 4-week kangaroo mother care intervention. The psychological stress state and sleep status of mothers with preterm infants in both the groups were evaluated using the Symptom Check List 90 (SCL-90) and Assens Insomnia Scale (AIS).P < 0.05). The total AIS score and the items such as night waking, total sleep time, total sleep quality, daytime mood and daytime body function were lower in the experimental group than those in the control group (P < 0.05).After the intervention, the total SCL-90 score and factor scores such as coercion, interpersonal relationships, depression, anxiety, hostility and additional factors, were lower in the experimental group than those in the control group (The Kangaroo mother care approach can relieve adverse psychological stress and improve the sleep status of mothers of NICU premature infants after mother-infant separation. It can be promoted and used in mothers of premature infants in the NICU to enhance physical and mental health. Mother-infant separation due to admission of premature infants to the neonatal intensive care unit (NICU) is a stressor for postpartum women, affecting their physical and mental health. Studies have shown that 20% of mothers with premature infants in the NICU have varying degrees of depressive symptoms: 43% have moderate to severe anxiety  and 15% Mothers with premature infants were recruited from the NICU of Hangzhou Women's hospital from January 2019 to January 2020 as the subjects of our study continuously. The survival rate and hospitalization period of preterm infants are closely related to the gestational age of preterm birth. The preterm infants who were born too early (<28 weeks) or too late (more than 34 weeks) may conflict with the study cycle of this study. So in our study, the inclusion criteria were as follows: (1) mothers who gave birth to premature infants at 28–34 weeks of gestation, with whose baby had an anticipated stay at this NICU for at least 4 weeks following recruitment, (2) hospitalized premature infants with stable vital signs, (3) those not requiring a invasive ventilator for breathing, (4) those who were able to tolerate feeding, (5) mothers who were healthy and free from infectious and skin diseases, (6) mothers with the ability to read and comprehend language, (7) and those who provided informed and voluntary consent. The exclusion criteria included the following: (1) premature infants with severe organ disease, severe deformity, severe neonatal hypoxic-ischemic encephalopathy, and invasive ventilator therapy; (2) mothers of premature infants who were unable to participate in the study throughout; and (3) mothers with a history of major mental illness and severe obstetric complications. Those who withdrew from the research process, had incomplete data or information, who could not complete the 4-week intervention, and who had medical disputes, faced forced discharge, abandonment, or were transferred to hospitals for treatment were eliminated from the study. This study was approved by the Ethics Committee of Hangzhou Women's hospital.This study was a single-center, prospective, observational, pilot randomized controlled study. Randomization was 1:1 allocation. The participants were randomized to experimental or control group using a random number table prepared by an independent statistician. Random assignments were generated by an investigator who was not involved in the testing or training. Due to the nature of the intervention, it was difficult to use blinding procedure.The subjects who were recruited but excluded from randomized distribution were given usual neonatal care. The control group was managed with routine treatment and a nursing programme for premature infants, all treatment and care were performed in the neonatal care unit, whereas the experimental group managed with KMC intervention based on the control group. The KMC intervention protocol followed with: the doctor determined the time of the first KMC implementation according to the condition of the premature infant. The NICU has a separate room where kangaroo cares can performed, the same room the each time. The KMC was set to be performed between 9:00 and 12:00 every morning, 1 h each time, three times a week, for four consecutive weeks. During KMC, researchers provided effective guidance and communication to mothers with premature infants, instructed on effective breastfeeding, and provided good breastfeeding-related education when KMC was performed for the first time; the mothers were taught the general basic care and parenting knowledge required to handle newborns. The doctors answered the questions to the mothers patiently and transmitted relevant information during their duration at the hospital effectively. For mothers who had higher SCL-90 scale scores, targeted psychological care was provided: listen and comprehend to the mothers' feelings and needs, Mainly aiming at the doubts and worries from mothers which researchers should be explaining well, giving some comfort and answering the questions timely.The questionnaire was initially designed by the researchers, and revised and improved to determine the final content after consulting clinical nursing experts. It included age, education level, current residence, monthly household income, gestational age, number of total pregnancies, mode of delivery, whether the first child, birth weight of the premature infant, payment method for medical expenses, etc. The general information questionnaire are shown in The SCL-90  was compThe AIS is an internationally recognized self-measurement scale for sleep quality. The scale includes eight items: sleep latency period , night waking, earlier waking than expected, total sleep quality (regardless of the length of sleep), total sleep time, daytime body function , daytime mood, and daytime fatigue. Each item is based on a 4-Level scoring method (from 0 to 3 points) and a total score of 0 to 24 points. A total score of 0–3 points indicates no sleeping disorder, 4–5 points indicates a possible sleeping disorder, and ≥6 points indicates a sleeping disorder. The higher the score, the worse the sleep quality. The scale's internal Consistency  coefficient was 0.90 and its test-retest reliability was 0.92 .N1 = N2 = 2 × [(μα + μβ)σ/δ]2 for the comparison of the mean of the two samples ], statistical inference between groups was performed by chi-square or Fisher's exact tests, measurement data were expressed as mean ± standard deviation (x ± s), the independent samples t-test was used for comparison between groups, and the paired samples t-test was used for comparison within groups. The analysis of covariance (ANCOVA) performed to clarify the results of the SCL and AIS scores between the experiment and control groups after the KMC intervention. Statistical significance was set at P < 0.05.SPSS 21.0 medical statistics software was used for statistical analysis, enumeration data were described by the number of cases [The first participant was enrolled on January 6th, 2019, and the follow-up was completed on January 10th, 2020. Eligibility was assessed in 329 patients, and 132 patients were enrolled and randomized. All subjects were mothers of premature infants admitted to the NICU of Hangzhou womwen's Hospital, with 66 cases in each group. In the experimental group, one withdrew from the study due to transfer to another hospital, one was automatically discharged from the hospital and did not meet the study requirements, and one was excluded due to incomplete data filling. In the control group, two were discharged from the study early, and one was excluded from the study due to omission of the questionnaire. For those who were excluded were not analyzed in our study, so at last, there were 63 subjects analyzed in each group. The flowchart of participant inclusion and exclusion is shown in There was no significant difference in the general characteristics between the experimental and control groups. The results are shown in P-value to avoid type 1 errors. Statistical significance in scl-90 was set at P < 0.05/11 (P < 0.0045). Before the intervention, there was no significant difference in the SCL-90 factors and total score between the experimental and control groups. After the intervention, in experiment group, the total score and factors such as somatization, coercion, interpersonal relationships, depression, anxiety, hostility (P < 0.001) and additional factor (P = 0.001) were decreased significantly compared with those before the intervention. While in the control group only somatization (P < 0.001) decreased significantly. After adjustment for the pre-tests, the total score , coercion , interpersonal relationship , depression , anxiety  and hostility  were statistically significant difference after the intervention between experiment and control groups . Before the intervention, there was no significant difference between the two groups of AIS items and total score. After the intervention, in experiment group, the total score, earlier waking, total sleep time, total sleep quality, daytime mood, daytime body function (P < 0.001) and night waking (P < 0.05) were decreased significantly compared with those before the intervention. While in the control group, there was no significant difference compared with those before and after. After adjustment for the pre-tests, the total score , total sleep quality , daytime mood , daytime body function  were statistically significant difference after the intervention between experiment and control groups .Psychological stress is a process in which individuals perceive the threat of stressors through cognition and evaluation under certain environmental stimuli, causing changes in psychological and physiological functions . When prP < 0.001). It indicate that KMC can promote breastfeeding and enhance the self-efficacy of mothers with premature infants. At the same time, it can reduce the psychological pressure, then relieve the anxiety, depression and other negative emotions caused by the separation of mother-infant. This is consistent with the study by Sinha et al.  Ethics Committee. The patients/participants provided their written informed consent to participate in this study.Conception and design: W-yC and M-yX. Acquisition, analysis, or interpretation of data: W-yC, M-yX, and Y-yW. Statistical analysis and drafting of the manuscript: W-yC. Supervision: T-HT. All authors have read and agreed to the published version of the manuscript.This study was supported by the Zhejiang Enze Medical Center Group Research Project (No. 20EZD68) and the Natural Science Foundation of Zhejiang Province (No. LBY21H040002).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.


The rapid development of antibiotic resistance in K. pneumonia has led to a major concern. In order to analyze the hotspots and develop trends in this field through visual the analysis, this study used CiteSpace software to summarize the available data in the literature to provide insights. A total of 9366 research articles were retrieved from the Web of Science Core Collection, and the number of published papers is increasing year by year. The country with the most articles was the USA, followed by China and India. The institution with the highest number of publications was LERU. The author with the highest number of articles was Li. The journal with the highest citation rate was Antimicrobial Agents and Chemotherapy. In addition, based on keyword coword analysis and cited literature prominence analysis by CiteSpace, the current research focus in the field was therapy, CRKP, and resistance genes. This paper provides a new quantitative visualization way for the development of the field in the recent ten years. The results show global trends that researchers can use to determine future directions. Klebsiella pneumonia, belonging to the family Enterobacteriaceae, is a natural inhabitant of the gastrointestinal tract microbiome of healthy humans and animals [K. pneumonia has reached as high as 70%, and the infection-related fatality rate has also reached 40%~70% [K. pneumonia and carbapenem-resistant Klebsiella pneumonia (CRKP) have emerged as a major global public health problem. animals . It has  animals . The glo 40%~70% . In receK. pneumonia by bibliometrics [K. pneumonia in recent 10 years. According to data from the Web of Science Core Collection (WoSCC), the CiteSpace5.8.R3 software system was employed to display the detailed analysis based on visualization of the cooperative network of the countries, coauthors, and co-occurring keywords [K. pneumonia in the future.In this study, we reviewed the literature on antibiotic resistance of ometrics . This stThe data from 2012 to 2021 (10 years) were from WoSCC on April 13, 2022, to reduce bias incurred by database updating. Search terms were used as follows: “(((((((TS=(Antibiotic resistance)) OR TS=(Antibiotic resistant)) OR TS=) OR TS=) OR TS=(Drug Resistance)) OR TS=(Drug Resistant)) AND ((TS=(Klebsiella pneumonia)) OR TS=(K. pneumonia)) AND (EDN==(“WOS.SCI”) AND DT==(“ARTICLE” OR “REVIEW”) AND LA==(“ENGLISH”)))” in Advanced Search. In addition to data collection, the CiteSpace 5.8.R3 (64-bit) software system was also used to show the detailed data analysis. All records such as titles, abstracts, and references are exported to CiteSpace for subsequent analysis.K. pneumonia is receiving more and more attention from researchers. Especially in the past three years, the number of publications has increased sharply, accounting for almost half of the total number of publications. Therefore, the analysis period of this study is from 2012 to 2021, and the research period is divided into one year.The Web of Science Core Collection (WoSCC) database shows 9366 publications that use our search terms, with 8398 articles and 968 reviews. In general, the number of papers published in recent years shows an upward trend, which indicates that the number of papers published in antibiotic resistance research in K. pneumonia in different countries can be understood by analyzing the country information according to the affiliation of the authors. Many institutions or universities from different countries around the world have contributed to this research field. Research papers from 178 countries have been published, and we have listed the top 10 most productive and influential countries and institutions in K. pneumonia antibiotic resistance research field, based on the total publications, citations, and H-index during 2012–2021  and Egyptian Knowledge Bank (EKB) are ranked second and third in terms of the number of papers.The distribution of studies on antibiotic resistance research in 012–2021 . As show012–2021 , League H-index, which represents the cited influence of papers, was given in the tables, too. Sometimes, a high total number of publications or citation number alone does not ensure a high H-index. Therefore, some scientists prefer to use the H-index to rank top countries (institutions), because this bibliometric indicator can more fully evaluate the impact of research [Besides the total number of publications, the research .H-index by a wide margin. However, in regard to prolific institutions, LERU is the most prolific institution with an H-index value of 65. We also analyzed the results using the CtieSpace 5.8.R3 to visually show the most productive countries (institutions) and their connections to each other  and Paterson (29) rank the top two, showing the absolute advantages and influence of these authors on antibiotic resistance research in K. pneumonia.Among the top 10 authors with publications, four are from China, three from the USA, two from Australia, and one from France, respectively, as shown in Generating a productive author collaboration network is shown in K. pneumonia. Among them, the number of publications of the top 10 journals is more than 140, accounting for 28.25% of the total number of publications, as shown in H-index, respectively. Among the 10 journals, one is in Q1 subregion, and eight are in Q2 subregion with impact factors ranging from 3.0 to 5.7, among which, Journal of Antimicrobial Chemotherapy has the highest impact factor.From 2012 to 2021, a total of 1301 journals worldwide published academic papers on antibiotic resistance research in Klebsiella pneumonia, antibiotic resistance, Escherichia coli, Enterobacteriaceae, and infection. In order of centrality, the top five keywords were biological activity (0.17), synergy (0.14), penetration (0.14), antimicrobial peptide (0.12), and high prevalence (0.12). Centrality refers to the ratio of the shortest path that passes through a certain point and connects the two points to the total number of shortest path lines between the two points, which is used to describe the importance of a node. The larger the value is, the more influential the node is in the key position in the network [Through keyword coword analysis, research topics and hotspots can be analyzed, and the transition of research frontiers in a certain knowledge field can be monitored . We used network .K. pneumonia and reveal the current research hotspots.Keyword clustering analysis can cluster similar points together and identify clusters that represent relevant research areas. We use CiteSpace to summarize the clustering of the keyword timeline map. Cluster size is the number of terms contained in each cluster. CiteSpace gives cluster ID 0 to the largest cluster, cluster ID 1 to the second largest, and so on. As shown in K. pneumonia is shown in Keyword burst detection refers to a significant increase in the frequency of keywords in a short period of time. If we understand the studies with high attention in this period, we can judge the hot topics and frontiers of research in the field accordingly. Keyword burst detection of antibiotic resistance research in 10 years in K. pneumonia. Depending on the burst strength, the first t papers are reviewed from two high-level journals: Lancet Infections Diseases and Clinical Microbiology Reviews [K. pneumonia [K. pneumonia and performed a pan-genome-wide association study (PGWAS) to look for associations between gene profiles associated with virulence and antibiotic resistance and the differing disease outcomes seen for K. pneumonia [According to  Reviews –12. The  Reviews . Anotherneumonia –17. Anotneumonia .K. pneumonia. We examined the characteristics of publications, collaboration between countries, institutions, and authors, and co-occurrence analysis of journals and keywords. In the past 10 years, there have been 9366 journal articles related to this field, and the number of publications increased rapidly, which showed that scientists are paying increasing attention to this area. Antibiotic resistance in K. pneumonia has emerged as a significant threat to global public health problems [This paper provides a visual and comprehensive literature review of antibiotic resistance research in problems .We find several interesting keywords with high co-occurrence frequency through co-word analysis. According to recent research, carbapenem-resistant Klebsiella pneumonia (CRKP) has been paid much attention. Carbapenems have strong antibacterial activity and a wide antibacterial spectrum. Carbapenems are the preferred drugs for the treatment of serious Enterobacteriaceae bacterial infections . HoweverK. pneumonia [K. pneumonia infections, several therapies are currently being developed. Phage therapy, phytotherapy, photodynamic therapy, antimicrobial peptides, and nanoantibiotics are the potential of some alternatives.Drug efflux, biofilm formation, enzymatic inactivation of the drug, alteration of drug targets, and reduced permeability due to porin loss or modification are the major mechanisms conferring antibiotic resistance to neumonia . For comPhages have low natural toxicity and high strain specificity. Due to the specificity of phages, their action is limited to the site of infection and can prevent the destruction of the inherent microbiome . This reK. pneumonia. This paper uses CiteSpace software to perform bibliometrics and visualization analysis on antibiotic resistance research in K. pneumonia data from the Web of Science database. This work presents direct and specific ways to describe existing information in different perspectives to the reader and can provide reference and reference for the relevant scientific research workers in the topic selection and development direction of the research.Additionally, we highlight the highly cited papers and reveal the research hotspots on antibiotic resistance research in


Cystic biliary atresia (CBA) is a rare and peculiar type of biliary atresia (BA) that is easily confused with infantile choledochal cysts (CCs). This study explored information for early CBA diagnosis and treatment.n = 12) and CC (n = 20) groups. Patient features, biochemical indexes, preoperative ultrasound characteristics, cholangiography features, and intraoperative findings were analyzed and compared between the two groups.The authors retrospectively analyzed the clinical data of 32 children with hilar cysts from January 2013 to May 2021. According to the diagnosis, they were divided into the CBA (P < 0.05). Additionally, B-mode ultrasound showed a cystic mass in front of the hepatic hilum, and the cyst size was much smaller in the CBA group compared with the CC group . Among all of the parameters, cyst width was the most accurate for identifying CBA and CCs. A cutoff value of 2.5 cm  showed 90.9% sensitivity and 95% specificity for cyst size.The alanine aminotransferase, aspartate aminotransferase, total bilirubin, and direct bilirubin levels in the CBA group were higher than in the CCs group (For children with early-onset severe jaundice, and if the width of the cystic mass was ≤2.5 cm, a diagnosis of CBA was highly likely. Early cholangiography and surgical treatment are necessary for the effective treatment of these infants. Biliary atresia (BA) is a disease characterized by severe jaundice caused by biliary obstruction in infancy. The disease etiology is unclear  and its This retrospective study included 12 cases of CBA and 20 CCs cases from the Affiliated Hospital of Zunyi Medical University from January 2013 to May 2021. A total of 12 patients with CBA were admitted for jaundice and clay-colored stool. Among the 20 CBD children, 4 cases were admitted due to yellow skin staining, 3 cases due to light stool color, and 13 cases due to the presence of a hilar cyst, discovered by prenatal ultrasound or physical examination. All patients were finally diagnosed by intraoperative cholangiography (IOC) and pathological examination. Each patient’s age, sex, and routine biochemical examination results  were recorded preoperatively. The following data were obtained from B-mode ultrasound, magnetic resonance imaging (MRI), and intraoperative examinations: the size and shape of the gallbladder, the size of the liver hilar cyst, and the presence/absence of the contrast agent in intra- and extrahepatic biliary tracts and cysts. Color ultrasound examination of the gallbladder and cyst sizes and examination methods were as follows: the length of the gallbladder was taken as the largest length of the lumen, the width of the gallbladder was the largest width of the lumen, and the size of the cyst was described by the largest length and width of the cyst. All children fasted for more than 4 h before the ultrasound examination. An MRI examination was performed for all patients. Two experienced pathologists, who were unaware of the collected data for clinical analysis, independently performed a retrospective examination of the liver specimens.The operative indications of CBA were persistent jaundice, clay-colored stools, increased TBIL, and DBIL/TBIL 50%. The operative indication for CCs was the presence of a cystic mass at the hilar area of the liver, which is typically treated after the first month. The same surgeon performed all of the surgeries in this study.IOC showed that the intrahepatic and extrahepatic bile ducts were not development, and a cystic mass was found while exploring the hilum of the liver. The proximal end of the mass formed fibrous plaque in the hilar atresia, which contained colorless or yellowish fluid. Postoperative liver pathology showed bile duct hyperplasia and cholestasis, which was subsequently diagnosed as CBA. Furthermore, IOC showed that the intrahepatic and extrahepatic bile ducts were development, and postoperative pathology showed no or slight bile duct hyperplasia, which was subsequently diagnosed as CCs.P < 0.05 was considered statistically significant. Additionally, receiver operating characteristic (ROC) curve analysis was applied to analyze the indicators that showed significant differences.The SPSS Statistics 23.0 software program was used for data analysis in this study. Data that were subject to normal distribution were expressed as mean ± standard deviation (SD), and a Student’s t-test was adopted according to the specific context. Non-normal distribution was represented by the median (range). Non-parametric tests  were also conducted, and A total of 32 children (12 with CBA and 20 with CCs) were included in this research. There were 5 males and 7 females in the CBA group and 2 males and 18 females in the CC group. The mean age at the time of surgery was 65.58 ± 27.10 days . All children were from Guizhou Province, and there was no statistical significance in sex, weight, or age between the two groups . One chiP = 0.91), and there was a significant difference between the two groups (P < 0.001). There was no significant difference in the white blood cell count, percentage of neutrophils and lymphocytes, red blood cell count, or hemoglobin levels between the two groups  showed sensitivity of 90.9% and specificity of 95% for cyst size ; in some cases, cyst imaging findings were not accompanied by biliary imaging findings (n = 5) (n = 5), had necrotic tissue (n = 1), and included a small amount of bile-like material (n = 6). However, contrast media were found to have passed through the biliary tract in the CC group  . If the CC group .P < 0.001, The 12 patients with CBA were treated using the Kasai procedure, and cysts were located by hepatic portal probing, referencing the findings on color ultrasound. After cutting the cyst, its wall was observed to have been observably thickened with edema, and a small amount of bile pigment was visible. A small amount of a yellow, bile-like substance was found in the cyst in 8 cases, stereo cysts were found in 3 cases, and necrotic tissue without bacteria was found in 1 case, with no intrahepatic biliary connections. The width of the cyst was much smaller in the CBA than in the CC group   could imDue to the limitations of ultrasound and biochemical examinations, these methods cannot be used as a gold standard for the definitive diagnosis of CBA or CCs. In this context, laparoscopic exploration is a means of investigation alongside surgical treatment. Laparoscopic examination and intraoperative biliary tract imaging can thus be performed early on to make a definitive diagnosis of either CBA or CCs. Long-term follow up has shown that only 30–50% of patients experience an excellent permanent prognosis . PostopeThis study includes some limitations due to its small number of cases and because all the patients were selected from a single center in Zunyi, Guizhou. The study’s regional distribution of diseases varied significantly, and Asian individuals were more likely to be affected. Therefore, the results of this study may only apply to children in this particular region. Data from multiple centers are needed to confirm the findings of this study in future research. Only 12 children received a final diagnosis of CBA by IOC at the authors’ hospital during the past eight years, which may have been related to a reduced incidence, and could have affected the results of the ROC curve analysis. Therefore, the conclusions drawn in this paper require further confirmation through studies with larger samples.In summary, CBA should be considered in children with early-onset severe jaundice, caused primarily by DBIL elevation and cystic masses that are smaller than 2.5 cm in width and situated at the hepatic hilum. CBA requires early cholangiography and surgical treatment.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Ethics Committee of Affiliated Hospital of Zunyi Medical University. The patients/participants provided their written informed consent to participate in this study.Y-TC and ZJ: conception and design of the research. Y-TC and M-JG: acquisition of data. Z-BZ and ZJ: analysis and interpretation of the data. LH, QD, and ZJ: statistical analysis. ZJ: obtaining financing. Y-TC and D-WZ: writing of the manuscript. Y-ML and ZJ: critical revision of the manuscript for intellectual content. All authors read and approved the final draft.