Porphyomonas, Fusobacterium, Treponema, Tannerella, and other periodontal pathogens were abundant in the active group, while lactic acid bacteria  were abundant in the remission group.Peri-implantitis has a polymicrobial etiology and is a major cause of dental implant loss. Various clinical protocols for its prevention and treatment have been proposed; however, some cases show a rapid progression with non-resolving clinical symptoms. To clear a means of differentiating between such cases, the implants with peri-implantitis in this study were categorized as the active group and the remission group and that two kinds of samples were obtained from the same subjects (n = 20). The microbiome was analyzed through pyrosequencing of the 16S rRNA gene. From LEfSe results,  However, with an increase in the function time of implants, peri-implantitis has become a major concern among 28–56% of the patients and is a leading cause of implant loss5. Therefore, effective prevention and management of peri-implantitis are essential in maintaining the quality of life and health of the patients. Ailing implants are often managed with antimicrobial, surgical, and local irrigation6.Dental implants have a long-term survival rate in many cases7, its management is also based on periodontal therapy. Most patients with periodontitis respond well to treatment, and have stable periodontal tissue in the long term8. Similarly, over the treatment course of peri-implantitis, the progression of bone resorption may be arrested and the clinical condition may stabilize. However, in some cases the clinical conditions such as bone resorption, suppuration, and bleeding progress rapidly9. The reason for this existing difference is unknown. In addition, peri-implantitis progresses faster than periodontitis in animal models10. Several studies have reported a predominance of common microbiota in these two diseases12. Studies investigating the microbiome associated with peri-implantitis using culture-independent experimental methods, such as deoxyribonucleic acid (DNA) hybridization and 16S rDNA sequencing, have revealed the predominant microbiota unique to peri-implantitis sites and those that are common between peri-implantitis and periodontitis17. Pyrosequencing of polymerase chain reaction (PCR)-amplified 16S rRNA is an innovative method of arrays that concurrently produce thousands of sequences from individual samples. This novel volume of data enables fully inclusive research of taxonomically distinct communities, revealing the microbial diversity of this disease20.Since the pathogenesis and clinical symptoms of peri-implantitis are similar to that of periodontitisHowever, these reports of bacterial flora analyses do not distinguish between cases of remission and active disease. Thus, it is unclear how the microbiota alters with the changes in disease progression.In this study, we evaluated the differences in the microbiota associated with remission and active peri-implantitis.5. In this study, we defined the remission group as those with stabilized symptoms (suppuration and bleeding) after local irrigation for peri-implantitis, and the active group as those with persistent symptoms. The inclusion criteria for this study were; peri-implantitis diagnosed according to the criteria of the 2017 workshop, presence of both remission and active groups in the same mouth, proper positioning and proper occlusion, at least one year after placement and follow-up of at least six months. The depth of the peri-implant pocket, suppuration and bleeding were confirmed by probing22,. Bone resorption was confirmed through the radiographic examination22, furthermore the extent of bone resorption was calculated by measuring the distance from the implant shoulder  to the most coronal portion of the intraosseous part of the implant and performed in accordance with the " Ethical Guidelines for Medical Research Involving Human Subjects, Hiroshima University. The exclusion criteria were presence of systemic diseases, antibiotic use, pregnancy, smoking and diabetes. Informed consent was obtained from all participants. A total of eight patients with both two kinds of peri-implantitis were includedFig. b.The implants of the patients with peri-implantitis in this study were categorized as active group and remission group. Further, two kinds of samples were obtained from the same subjects (n = 20). Plaque samples from the peri-implant pockets at the greatest probing depth were obtained using a sterile paper point. Paper points were placed into sterile collection tubes and stored at − 80 °C. Following clinical examination and sample collection, the peri-implant tissues were irrigated as per the usual method.The paper point sample was transferred to an Eppendorf safe lock tube and processed using a PureLink™ Microbiome DNA Purification Kit  according to the manufacturer’s protocol. The quantity of DNA was assessed using a spectrophotometer .The v3–v4 hypervariable regions of the bacterial 16S rRNA gene were amplified by PCR with primers  and sequenced using an Illumina MiSeq sequencer .The process of DNA isolation, gene library preparation, and sequencing was performed at the H. U. Group Research Institute G. K. . The researcher and bioinformatician were blinded to the clinical information of the patients, except for their group.24 (version 2021.4.0). The characterization of amplicon sequence variants (ASV) was processed by DADA2. Singletons and rare ASV (bellow 0.001%) were removed. Taxonomy was assigned to ASV using the q2-feature-classifier based on the SILVA 138.1.The raw sequence data were analyzed using the QIIME227, which can statistically extract features that can explain differences in populations of microbial communities under multiple conditions. The histogram and cladogram were based on LefSe. The non-parametric factorial Kruskal–Wallis sum-rank test was used for detecting features with significant differential abundance with respect to the group. Features violating the null hypothesis were further analyzed, which tested whether all pairwise comparisons between samples in different groups significantly agree with the group level trend using the unpaired Wilcoxon rank-sum test. LEfSe's α parameter for pairwise tests was set to 0.05, and the threshold on the logarithmic score of LDA analysis was set to 2.0. The heat map was plotted with rank-normalized abundances .Multivariate tests were performed using Permanova. The Kruskal–Wallis test was applied to compare the differences in alpha diversity of microorganisms . Bray–Curtis and UniFrac distances were used for the microbial beta diversity analysis. Differences in the relative presence of the microbiome were determined using linear discriminant analysis (LDA) effect size (LEfSe)There were eight patients who met the criteria for inclusion in this study, and consent was obtained from all eight patients. There were eight patients who met the criteria for inclusion in this study, and all eight patients gave consent on each clinic day at the outpatient department. Number of implants per pt is 6.0 per patent. Number of sites designated active and remission per patient is 1.6/2.1 per patient. Nine cases with suppuration and bleeding and 11 cases without suppuration and bleeding were observed in eight patients. Bone resorption and gingival erythema were observed around all the implants. The demographic and clinical characteristics of the patients are presented in Table Two samples Nos. 12 and 17) had insufficient DNA extraction or insufficient amplification by PCR. Next-generation sequencing was used for the detection, and the number of reads was the same as that of the negative control sample. The differences in the microbial diversity and composition between the active and remission groups were examined  species, Porphyromonas gingivalis, and Streptococcus species. Bacteria associated with periodontal disease other than P. gingivalis, such as Treponema denticola, Prevotella intermedia, and Aggregatibacter actinomycetemcomitans were detected. Lactic acid bacteria, including Lactobacillus and Bifidobacterium, were rare. In addition, Lactobacillus rhamnosus, Lactobacillus fermentum, and Enterococcus faecalis, which are utilized as probiotics, were detected. The other dominant taxa are shown in Fig. . Streptococcus, Fusobacterium, Porphyromonas, Prevotella, Treponema, Actinomyces, Veillonella, Filifactor, Alloprevotella, Neisseria, Gemella, Tannerella, Olsenella, Campylobacter, Lactobacillus, Parvimonas, Dialister, and Eubacterium brachy groups were the most frequent at the genus level . g_Porphyomonas, g_Fusobacterium, g_Treponema, and g_Tannerella were more abundant in the active group, while o_Lactobacillales and g_Bifidobacterium were more abundant in the remission group. Bacteria considered as the causative pathogens of peri-implantitis were more common in the active group, while bacteria that were used as probiotics31 were more common in the remission group. Other LDA scores and cladograms are shown in Fig. LEfSe analysis was performed to compare the relative abundance  is unclear, the strength of this study is that all patients were sampled at both active and remission sites. This sampling method help account for individual variations. Furthermore, we successfully identified some representative bacteria at the species level. Several reports compare the microbiomes of healthy implant sites with those of peri-implantitis or peri-implant mucositisP. gingivalis, was higher in the active group on the taxa bar plot, while the relative presence of lactic acid bacteria was lower in the active group on the taxa heat map. The “keystone pathogen”33 and “microbial shift” hypotheses34 suggest that the number of malignant bacteria can increase due to the nutrient supply to the biofilm, causing the biofilm to become more pathogenic. In the present study, P. gingivalis showed a higher relative amount in the active group, which is consistent with these hypotheses. Thus, changes in the peri-implant environment lead to an association between the tissue and microbiota from symbiosis to dysbiosis. The presence of common bacterial species in the active and remission groups and the fact that their compositional ratios are subject to microbial shifts due to environmental factors may reflect these theories. These results indicate that peri-implant inflammation is associated with changes in the bacterial flora structure. In the taxa bar plot of this study, the major bacterial taxa of peri-implant sites were partially similar to that of periodontitis. In particular, the high prevalence of P. gingivalis in the active group far exceeded our expectations.The relative frequency of periodontal disease-causing bacteria, such as P. gingivalis, T. denticola, Tannerella forsythia, A. actinomycetemcomitans, P. intermedia, Fusobacterium, Campylobacter, and other periodontal pathogens, have been reported to be associated with implant disease. P. gingivalis, T. denticola, A. actinomycetemcomitans, P. intermedia, Fusobacterium, and Campylobacter were also annotated in the samples used in this study. Porphyromonas, Fusobacterium, Treponema, and Tannerella were more prevalent in the active group, as indicated by the LDA score. Thus, these bacteria may be the keystone species in the bacterial flora.Periodontal bacteria, such as The level of inflammation and pocket depth should be considered when an ailing implant is identified during SPIT. If inflammation is intractable, additional treatments such as flap surgery and probiotic therapy should be considered.36, identified in this study in the remission group, such as L. Rhamnosus and Bifidobacterium.Some of the lactic acid bacteria, utilized as probioticsThese findings suggest that lactic acid bacteria may have an effect on implantitis activity by periodontal pathogens. However we evaluated only the differences in the microbiota associated with remission and active peri-implantitis and not focused on lactic acid bacteria. Thus it is unclear how the microbiota alters with the changes in disease progression. The clinical study in the future should consider patients on probiotic therapy in the exclusion criteria, the possibility of confounding cannot be ruled out and aim to explore this aspect further in our future studies.


Background: Oxidative stress may play an important role in the pathogenesis of schizophrenia (SCH), and there is considerable indirect evidence that hypoxia is closely related to SCH, but direct evidence of hypoxia in SCH has never been found.Methods:In this study, superoxide dismutase (SOD), venous blood gas, and Positive and Negative Syndrome Scale (PANSS) were examined in 40 SCH patients and compared with those of 40 healthy controls. The patients were treated with combination of atypical antipsychotics and Ditan Huayu Lishen decoction (a Chinese medicine decoction) and examined in the acute and stable period, respectively. Comparisons of indicators between two groups were performed using an independent-samples t-test, comparison of indicators between the acute and stable periods in the SCH group was performed using paired-samples t-test. Pearson correlation and multiple linear regression analyses were performed to investigate the relationships between the effect indicators.Results: Higher venous pH, PvO2, and fasting blood glucose levels and lower SOD, lactic acid, and PvCO2 levels were found in SCH patients compared with the control group; SOD was negatively correlated with the general psychopathology subscale score (PANSS-G), and PvO2 levels were closely related to venous pH in SCH and related to PvCO2 in the control group. It was also found that SOD activity showed no significant difference in acute and stable period, whereas PvO2 showed a downward trend, and venous pH was decreased significantly after treatment. Both the venous pH and PvO2 were higher in patients with SCH than that in healthy controls.Conclusion: It suggests that histogenous hypoxia and acid retention exist in relation to SCH, and there is an improvement of acid retention and a downward trend in histogenous hypoxia after combination treatment. Venous pH, PvO2, and PvCO2 are trait variables, but not state variables of SCH. The theory of histogenous hypoxia and acid retention can well explain the decrease in pH value and the increase in lactic acid in brain tissue of patients with SCH. Histogenous hypoxia and acid retention closely related to glucose metabolism. So they may play an important role in pathophysiology for SCH. Schizophrenia (SCH) is a category of major mental health disorders of unknown etiology that encompasses significant abnormalities in cognitive, logical, emotional, behavioral, and other mental activities and leads to significant occupational and social function limitations . The lifThere is increasing evidence, however, that oxidative stress may play an important role in the pathogenesis of SCH . People Prior research has also demonstrated that exposure of healthy humans to chronic intermittent hypoxia increased oxidative stress by overproduction of reactive oxygen species (ROS) , and intAlthough there is considerable indirect evidence that hypoxia is closely related to schizophrenia, direct evidence of hypoxia in SCH has never been found.Abnormalities of oxidative stress are also known to exist in individuals with depression. In previous research, the current study's corresponding author confirmed the presence of histogenous hypoxia and an increased propensity for the accumulation of acidic metabolites in depressed patients by comparing samples of their venous blood gas (VBG) with those of healthy controls . The preThe purpose of the present study is to clarify whether there are abnormal oxidative stress linked to SCH and whether histogenous hypoxia and acid retention may be present. However, the effect of pharmacotherapy on these indicators remains unclear; furthermore, the link between them and the psychiatric symptoms of SCH remain unknown. To address these unknown aspects, we designed this study to compare the SOD and VBG analysis results in SCH patients with those of a healthy control sample group, as well as a self-controlled study to compare SOD and VBG results in acute and stable SCH patients.The research participants were SCH patients and controls. The SCH patients were recruited from among inpatients attending the Department of Traditional Chinese Medicine in The Affiliated Brain Hospital of Guangzhou Medical University. The control group was recruited from among the staff members of the Department of Traditional Chinese Medicine and was matched approximately with the SCH patients by gender and age.International Statistical Classification of Diseases and Related Health Problems (code F20)  . In otheThe inclusion criteria for the control group were as follows: (a) a good health record, featuring no physical illness or psychiatric disorder; (b) predominantly normal results from the most recent examination; (c) no sleeping disorders; and (d) no infection or alcohol-intake history within the previous week. Exclusion criteria for the control group were as follows: (a) presence of fatty liver disease, hypertension, gout, renal failure, diabetes, or other medical diseases; (b) abuse of alcohol and/or psychoactive substances; (c) pregnant or lactating female patients; (d) patients confined to bed or a wheelchair; and (e) infection or alcohol-intake history within the previous week.Participants from both groups were invited to attend a clinical interview. The SCH patients were interviewed by an experienced psychiatrist to determine whether they met the screening criteria.All participants were informed of the purpose, procedure, and possible benefits and risks of participation in this study. Participants who agreed to join the study were asked to sign informed consent forms and register their general data, encompassing the following: (a) background information, (b) demographic items, (c) previous history, and (d) medical history.Participants in the SCH group were assessed by an experienced psychiatrist, who used the Positive and Negative Symptom Scale (PANSS)  to measuElbow vein fasting blood was drawn in the morning from each participant through several tubes. Indicators included VBG analysis, SOD, and general biochemical indicators .O2), the venous partial pressure of carbon dioxide (PvCO2), lactic acid, potassium ions (K+), and fasting blood glucose (FBG).A single-use arterial blood gas needle was used for the VBG analysis, with samples taken from the elbow vein and tested using a fully automatic blood gas analyzer within 15 min of the sample being collected. The analysis indicators included the venous pH value, the venous partial pressure of oxygen , and succinum 5 g (take drenched). The recipe is suitable for various mental diseases caused by phlegm and blood stasis  and Chinese medicine decoction in hospital. AAS included olanzapine, clozapine, risperidone, quetiapine, and aripiprazole with routine dosage in this study. The Chinese medicine decoction was named Ditan Huayu Lishen Decoction for purging phlegm, removing blood stasis, and tranquilizing the mind, which was composed of the following ingredients: fructus aurantii immaturus, d stasis . The comThe vein blood gas analysis, SOD, and PANSS were evaluated after 4 weeks' intervention in hospital in the SCH group.d) was calculated with web-based effect-size calculator in https://www.campbellcollaboration.org/.All statistical analyses were performed using the PASW Statistics 20.0 software package. The measured data were presented with mean ± standard deviation (SD) following the data normality test. Enumeration data were presented with the constituent rate and ratio units. The test level was set to α = 0.05. The effect size , 15 females (37.5%)—and 40 in the control group−24 males (60.0%), 16 females (40.0%). There was no significant difference in gender balance between the two groups.In the SCH group, there were four participants (10%) who were postmenopausal; two participants (5%) held religious beliefs, but 38 cases (95%) did not; four participants (10%) reported a history of smoking; two (5%) had experienced first-episode psychosis and 38 (95%) recurrent episodes; 23 (57.5%) were receiving treatment , whereas 17 (42.5%) were not, and two cases had never been treated. The average withdrawal period from antipsychotic treatment was 9.71 months . The course of the disease was 102.30 ± 99.93 months. The course of Western medicine treatment was 79.61 ± 95.07 months.In the control group, three participants (7.5%) were postmenopausal; three (7.5%) held religious beliefs, and 37 (92.5%) did not; six participants (12%) reported a history of smoking. Thus, no significant differences were found between the two groups regarding the respective distribution of postmenopausal, religious beliefs, and smoking history data.The two groups featured no significant differences in terms of participants' relative ages, heights, weights, and body mass indexes (BMIs), but there were differences regarding education levels: the years of education completed by participants in the SCH group were lower than those in the control group .O2 values, and FBG in the SCH group were higher than those in the control group, whereas PvCO2 and lactic acid levels were lower, indicating statistical significance . There were no significant differences in K+ levels between the two groups. The SOD levels in the SCH group were lower than those of the control group, indicating statistical significance (p < 0.001). . –3.CO2 and SOD, education was negatively correlated with K+, and height was positively correlated with PvCO2 in the control group  had an impact on any of the effect indicators, correlation analysis between them was undertaken. It was found that SOD was positively correlated with BMI, and FBG was positively correlated with course of disease and course of treatment in the SCH group , whereasol group .r was measured. It was found that K+ was negatively correlated with the PANSS-G and PANSS-T score, and SOD was negatively correlated with the PANSS-G score, whereas venous pH, PvO2, PvCO2, and lactic acid were no correlated with it , whereas venous pH value showed positive correlation with it . Based on these results, a multiple linear regression analysis was performed with venous pH and PvCO2 as the independent variables and PvO2 as the dependent variable. As a result, venous pH was the only variable remaining in the regression model . The model was tested with F = 27.747, p < 0.001, indicating that the venous pH was significant. Thus, the regression model could be described as follows: PvO2 = −6,420.858 + 880.699 venous pH. The absolute values of the standardized residual and the student-adjusted residual were <3.In acute SCH patients, it was found that PvCO2 exhibited negative correlation with PvO2 , whereas venous pH value showed positive correlation with it . Venous pH was still the only variable remaining in the regression model . The model was tested with F = 21.739, p < 0.001, indicating the venous pH was significant.In stable SCH patients, it was found that PvCO2 exhibited negative correlation with PvO2 , whereas venous pH value showed positive correlation with it . PvCO2 was the only variable remaining in the regression model . The model was tested with F = 31.291, p < 0.001, indicating that the PvCO2 was significant.In the control group, it was found that Pvt-test was performed between before and after treatment in the SCH group. The results of each effect index were compared before and after treatment, The scores of PANSS and subscales were decreased, with the reduction rates at 48.82% (PANSS-P), 28.92% (PANSS-N), 28.07% (PANSS-G), and 34.39% (PANSS-T), respectively. This indicated that the patients were in a state of stabilization.Only 31 patients finished the evaluation after pharmacotherapy, and a paired-samples p < 0.05), whereas K+ was increased after treatment (p < 0.01). Other effect indexes showed no significant difference in acute and stable SCH patients, whereas the p-values of PvO2 (0.061) and PvCO2 (0.056) in the t-test were close to the critical value of 0.05   .Since the role for toxic radicals in the etiology of schizophrenia was proposed in 1950s . The priSOD is one of the critical scavenging enzymes that have been reported most commonly in schizophrenia. There are different results about SOD in SCH. Some researchers have reported an increase in SOD activity in the blood of SCH patients , 22–24, p < 0.001) not only in the acute episode, but also in the stable stage. Moreover, in the acute phase, SOD activity was negatively correlated with the general pathological score of PANSS. It suggests that there is abnormal oxidative stress (decreased antioxidant defense) in schizophrenia and that acute psychotic symptoms are inversely correlated with antioxidant capacity.According to the meta-analysis results, the level of activity of erythrocyte SOD was reduced in acuter elapse of psychosis, drug-naive first-episode psychosis, stable medicated outpatients, and chronic inpatients . These sO2 levels and lower PvCO2 levels compared with the control group, which suggests that the SCH patients experience significant differences in oxygen (O2) utilization.Although there is much indirect evidence linking schizophrenia to hypoxia –13, but 2 and carbon dioxide (CO2), occurs due to the difference in concentration of the substance undergoing diffusion across either side of the blood vessel wall. When arterial blood flows through capillaries and the partial pressure of O2 in the blood is higher than that in the tissue fluid, the O2 will spread into the tissue fluid. The partial pressure of CO2 in tissue fluid, however, is higher than that in blood; therefore, diffusion of CO2 into the blood occurs. The diffusion rate is positively correlated to the partial pressure difference between the arterial and venous O2 and CO2. The difference in arterial and venous O2 partial pressure may reflect the conditions under which O2 release, O2 uptake, and the utilization of O2 in tissues take place, and therefore, it can be used to study blood circulation and metabolism in tissues  levels and taking only into consideration the decreased PvO2 results found in the present study, it can be demonstrated that histogenous hypoxia exists in relation to SCH, because these are symptoms of histogenous hypoxia , 32.523 ± 11.518 mm Hg (Cohen d = 1.099), and 46.635 ± 5.708 mm Hg (Cohen d = −0.806) respectively , resulting in a decrease in pH and increase in lactic acid in the tissues and cells of the body. Glucose metabolism is closely related to hypoxia and acid retention, which will lead to mitochondrial dysfunction and energy metabolism disorders. There are several evidences to suggest that altered energy metabolism is present even at the earliest stages of SCH and may, in fact, contribute to the development of SCH . The abnOne of the limitations of this study is that only the combination of traditional Chinese medicine and Western medicine was used as the intervention method, and the control group of pure Western medicine was absent. Therefore, the effect produced by the combination drug therapy could not be distinguished from the effect of Western medicine or Chinese medicine. It needs to be further improved in future research.Another limitation is the large difference in educational attainment between the SCH group and the healthy control group. Differences in educational attainment may imply differences in socioeconomic status, nutritional status, and physical activity. Although there was no significant correlation between effect indicators and education years in correlation analysis subsequently, the impact of this difference on the overall results still needs to be concerned.O2, and FBG levels and lower SOD, lactic acid, and PvCO2 levels in SCH patients compared with the control group. Based on these findings, we inferred that histogenous hypoxia and acid retention exist in relation to SCH. We also compared results pertaining to VBG analysis and SOD of acute and stable SCH patients. We found that SOD activity showed no significant difference between acute and stable period, PvO2 showed a downward trend, and venous pH was decreased significantly in the stable period. We inferred that acid retention in tissues and cells was improved.In this study, we compared results pertaining to VBG analysis and SOD of SCH patients vs. healthy participants in a control group. We found higher venous pH, PvO2 were higher and PvCO2 was lower in acute and stable SCH patients than those in healthy controls. Thus, venous pH, PvO2, and PvCO2 are trait variables, but not state variables of SCH.Both the venous pH and PvThe theory of histogenous hypoxia and acid retention can well explain the decrease in pH value and the increase in lactic acid in brain tissue of patients with schizophrenia. Histogenous hypoxia and acid retention also affect glucose metabolism and cause energy metabolism disorder. Thus, they may play an important role in pathophysiology for SCH.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by the Ethics Committee of Affiliated Brain Hospital of Guangzhou Medical University. The patients/participants provided their written informed consent to participate in this study.H-YH designed the study. Q-LL and XH enrolled patients into the study and contributed to data collection. YL assisted with data collection. X-MZ and Y-BZ finished the lab tests. Q-LL did the statistical analysis and H-YH supervised it. XH and H-YH interpreted the data. XH wrote the original draft of the paper and H-YH revised it. All authors contributed to the article and approved the submitted version.This research was funded by the Guangdong Province Administration of Traditional Chinese Medicine (Program Number: 20171209), Affiliated Brain Hospital of Guangzhou Medical University.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.


Background: A reliable distinction between ischemic stroke (IS) and intracerebral hemorrhage (ICH) is required for diagnosis-specific treatment and effective secondary prevention in patients with stroke. However, in resource-limited settings brain imaging, which is the current diagnostic gold standard for this purpose, is not always available in time. Hence, an easily accessible and broadly applicable blood biomarker-based diagnostic test differing stroke subtypes would be desirable. Using an explorative proteomics approach, this pilot study aimed to identify novel blood biomarker candidates for distinguishing IS from ICH.Material and Methods: Plasma samples from patients with IS and ICH were drawn during hospitalization and were analyzed by using liquid chromatography/mass spectrometry. Proteins were identified using the human reference proteome database UniProtKB, and label-free quantification (LFQ) data were further analyzed using bioinformatic tools.Results: Plasma specimens of three patients with IS and four patients with ICH with a median National Institute of Health Stroke Scale (NIHSS) of 12 [interquartile range (IQR) 10.5–18.5] as well as serum samples from two healthy volunteers were analyzed. Among 495 identified protein groups, a total of 368 protein groups exhibited enough data points to be entered into quantitative analysis. Of the remaining 22 top-listed proteins, a significant difference between IS and ICH was found for Carboxypeptidase N subunit 2 (CPN2), Coagulation factor XII (FXII), Plasminogen, Mannan-binding lectin serine protease 1, Serum amyloid P-component, Paraoxonase 1, Carbonic anhydrase 1, Fibulin-1, and Granulins.Discussion: In this exploratory proteomics-based pilot study, nine candidate biomarkers for differentiation of IS and ICH were identified. The proteins belong to the immune system, the coagulation cascade, and the apoptosis system, respectively. Further investigations in larger cohorts of patients with stroke using additional biochemical analysis methods, such as ELISA or Western Blotting are now necessary to validate these markers, and to characterize diagnostic accuracy with regard to the development of a point-of-care-system for use in resource-limited areas. In recent years, treatment options for patients with ischemic stroke (IS) have largely expanded. Subsequent to the broad implementation of intravenous thrombolysis, mechanical thrombectomy has now become the standard of care for patients with intracranial large vessel occlusion –5. MoreoIn contrast to these “high-tech” advances to stand by in many high-income countries, low- to middle-income countries still face immense shortcomings in medical resources. This weighs heavily as these countries have to carry the majority of the global burden of stroke . RegardiThus, in resource-limited areas, an inexpensive and easy-to-use stratification tool to substitute CT-imaging before the initiation of secondary prevention would be desirable. Here recent research on blood-based brain biomarkers has revealed interesting results. Glial fibrillary acidic protein (GFAP) has been characterized in several prospective studies as a biomarker of ICH. However, it reliably distinguishes ICH from IS only within 6 h of symptom onset. Its potential use has been demonstrated in an Indian trial, too –21. On tThis pilot study aimed to identify candidate biomarkers suitable to differentiate IS and ICH within the first days after symptom onset. Hence, in an exploratory approach, the entire plasma/serum proteome was screened through mass spectrometry (MS) techniques. Ensuing, an extensive literature search was performed, to identify the relevant publications focusing on the diagnostic value of the candidate markers in acute stroke.For this explorative pilot study, we targeted to compare the two “prototypes” of stroke, i.e., patients with IS in the middle cerebral artery (MCA) territory and patients with ICH in the basal ganglia or the thalamus (“deep”) as well as in the parietal or temporal lobes (“lobar”). Both conditions typically present as a classical stroke syndrome, and differentiation between the entities solely based on clinical examination alone is usually not possible. To presume a considerable amount of brain tissue damage with release of brain proteins in the bloodstream, only patients with infarctions affecting at least one-third of MCA territory and only patients with hematoma volumes higher than 20 ml were included. For doing so, we screened plasma samples collected in the context of a prior prospective study on GFAP levels in neurological diseases performed in our center for these criteria . In totaThe Ethics Committee of the Goethe University Frankfurt am Main, Germany approved the protocols of the previous and the current study. The studies were conducted according to the principles of the Declaration of Helsinki. Written informed consent was obtained from each patient, or if applicable of the next-of-a-kin.According to the study protocol, 1 ml of ethylenediaminetetraacetic acid (EDTA)-plasma was collected during hospitalization at variable time points after stroke symptom onset and transferred into an Eppendorf tube . Within The protein content was determined by using the method of Lowry . For thi6 total ion counts with a maximal ion injection time of 160 ms. Only higher charged ions (2+) were selected for MS/MS scans with a resolution of 17,500, an isolation window of 2 m/z, and an AGC value set to 105 ions with a maximal ion injection time of 150 ms. MS-Data were acquired in profile mode, MS/MS data in Centroid mode. Each patient was measured one time. The two control donors were measured in technical triplicates and quadruplicates, respectively. All samples were measured consecutively with the same instrumental setup .Liquid chromatography/mass spectrometry (LC/MS) was performed on Thermo Scientific™ Q Exactive Plus equipped with an ultra-high-performance liquid chromatography unit  and a Nanospray Flex Ion-Source . The peptides were eluted from the trap column by a continuously increasing concentration of organic solvent (4–50% acetonitrile and 0.1% formic acid) over 90 min at a flow rate of 250 nl/min and then, separated on an analytical column . The peptides were then ionized (2.6 kV) in the ion source and sprayed into the mass spectrometer. MS data were recorded by data dependent acquisition. The full MS scan range was 300–2,000 m/z with a resolution of 70,000, and an automatic gain control (AGC) value of 3 × 10Mass spectrometry data were analyzed by MaxQuant  (v1.5.3.30) using default settings . Proteinn = 4) and IS (n = 3), the control group contains all the replicates (n = 7) of the two donors. Identified proteins were filtered to at least three valid values in one group. Missing values were replaced by the lowest value of the data set. A two-tailed Student's t-test was used to examine the levels of significance.Contaminants from the internal MaxQuant list, only identified by site and reverse hits were removed from the initial protein ID list. The patients were grouped into ICH (http://bioinformatics.psb.ugent.be/webtools/Venn/).In addition, the statistics, correlations, and heat maps were created with Perseus as well. Other diagrams were created by using GraphPad Prism 8 (v.8.0.2) and an online Webtool from Bioinformatics and Evolutionary Genomics  illustrating the database search for the review of the literature. The exact search terms are listed in the After identifying the biomarker candidates, we performed a structured literature search to identify relevant publications focusing on the diagnostic value of these markers in acute stroke. For doing so, a PubMed search was performed with the following search terms: the protein's name, its aliases, and its abbreviations according to UniProtKB (release 2021_01) linked (“AND”) to “stroke, apoplexy, ischemic stroke, ischaemic stroke, intracerebral hemorrhage or intracerebral haemorrhage.” Only studies published before August 2021 were included. Identified reviews were screened for primary sources. The results were filtered by the first author (DM) of this manuscript after a review of the title and abstract of the manuscripts. Publications relevant to the context of the present investigation were finally selected for evaluation. Please see the flow diagram . The baseline characteristics of the study population are depicted in Among the 495 identified protein groups, a total of 368 protein groups exhibited enough data points to be entered into quantitative analysis. Noticeably more proteins are expected to be present in human blood samples, however, proteins with low expression are strongly underrepresented in such analyses. Albumin, immunoglobulins, and transport proteins make up a large part and are increasingly represented in peptide analysis. Therefore, the tryptic peptides were separated by cation exchange chromatography. The serum/plasma amount of thus identified proteins is comparable with those reported in the literature . To valiTaking into account these 368 proteins, we then compared the amount of each protein in the patients group (P) as a whole (IS and ICH together) with the healthy (C) controls. Here, 91 proteins could be identified with significantly different amounts (P vs. C) , we then screened for differences between ICH and IS, irrespective of differences to the control group and independent of the fold change, starting again from the original 368 proteins with enough data points . Here, 2p < 0.01) protein amount in the patients with IS as compared with the patients with ICH. Both proteins play a role in the kinin-kallikrein-system and are involved in thrombus formation (p < 0.05) protein amount in IS as compared to ICH patients were found for plasminogen (PLG), a central regulator in the fibrinolytic system, and Mannan-binding lectin serine protease 1 (MASP1), which was attributed a role in the blood clotting system by its thrombin-like activity physiological function of the identified proteins, it becomes apparent that all proteins, except APCS1 and CA1, are involved in the immune and/or coagulation system. This is not surprising because of previous findings on the pathophysiology of IS described as a “thrombo-inflammatory” disease , 117. ThAPCS and CA1 are not directly involved in coagulation or inflammatory pathways. APCS binds to apoptotic cells, is involved in chromatin degradation, and acts toxic to cerebral neurons , 126. CAFrom a clinical point of view, until now no single biomarker identified in the context of stroke is suitable to certainly distinguish IS from ICH –24, 128.A shortcoming of this explorative pilot study is the very limited sample size. Reconfirmation of the core findings in larger patient cohorts is mandatory. In addition, other detection methods, such as ELISA or Western Blotting need to be applied to verify the proteins identified by mass spectrometry.Furthermore, plasma samples were used for the primary comparison between IS and ICH. The control group, however, consisted of serum samples, thereby increasing the heterogeneity of the study.Another limitation with the risk of a possible selection bias is the imbalance of baseline variables (such as age and sex) between the diagnosis groups. However, we focused on comparing “prototype” strokes as described above, and other exploratory studies based on the mass spectrometry techniques were designed in a similar way, nevertheless allowing the successful identification of novel biomarker candidates –135.In summary, in this exploratory proteomics-based study, nine candidate blood biomarkers for differentiation of IS and ICH were identified. The proteins belong to the immune system, the coagulation cascade, and the apoptosis system, respectively. Due to the exploratory nature of the study, further investigations in independent, well-matched, and large-scaled cohorts of stroke patients are now necessary to validate these markers, and to characterize diagnostic accuracy with regard to the development of a point-of-care-system differentiating IS and ICH in resource-limited areas.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of the Goethe University Frankfurt am Main. The patients/participants provided their written informed consent to participate in this study.DM and IW: acquisition, analysis and interpretation of data, and drafting the work or revising it critically for important intellectual content. SL and CF: substantial contributions to the conception or design of the work and drafting the work or revising it critically for important intellectual content. All authors contributed to the article and approved the submitted version.This study was supported by the Deutsche Forschungsgesellschaft (DFG) project SFB815/Z1 (IW).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.


Several studies have reported conflicting results regarding the association between sarcopenia and outcomes in patients with diffuse large B-cell lymphoma (DLBCL). This meta-analysis aimed to evaluate the prognostic value of sarcopenia in patients with DLBCL.PubMed, Embase, and Cochrane Library databases were searched to identify trials exploring the association between sarcopenia and prognosis in patients with DLBCL treated with chemotherapy. A meta-analysis of overall survival (OS), progression-free survival (PFS), treatment completion, and rate of complete response (CR) was performed.Twelve studies that involved 2,324 patients with DLBCL were included. Sarcopenia was associated with poor OS and PFS in patients with DLBCL, even after adjusting for confounders. Patients with sarcopenia had lower rates of CR and treatment completion than patients without sarcopenia.Sarcopenia is a negative predictor of prognosis in patients with DLBCL. Additional and prospective studies investigating the diagnostic criteria for sarcopenia are warranted. Lymphomas are solid tumors in the immune system. Non-Hodgkin lymphoma accounts for ~90% of all lymphomas . DiffuseSarcopenia is defined as a progressive and generalized skeletal muscle disorder associated with an increased likelihood of adverse outcomes, including falls, fractures, physical disability, and mortality . SarcopeRecent studies have explored sarcopenia as a prognostic factor for patients with DLBCL. However, the results were inconsistent and controversial. One meta-analysis reported that sarcopenia predicted OS in patients with malignant hematological diseases, while only four studies on patients with DLBCL were included in the meta-analysis . ImportaThis meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We searched all the published articles in the PubMed, Embase, and Cochrane Library databases until July 2021 for all references using the keywords, MeSH terms “sarcopenia” and “diffuse large B-cell lymphoma,” and other related words. The complete search used for PubMed was {[sarcopenia (MeSH Term)] OR muscle OR cachexia OR body composition} AND {[diffuse large B-cell lymphoma (MeSH Term)] OR [non-Hodgkin lymphoma (MeSH Term)]}. Unpublished studies and original data were not included. To avoid oversights in the literature search, two independent researchers searched for the relevant trials twice.Studies were included if (1) the study was designed as a prospective cohort study or a retrospective study; (2) patients diagnosed with DLBCL were treated with chemotherapy; (3) skeletal muscle mass or function was measured before treatment; and (4) outcomes included OS, PFS, treatment completion, and rate of complete response (CR). Studies published as abstracts and case reports were excluded. Studies in which participants were not diagnosed with DLBCL and the diagnosis of sarcopenia was not clearly defined were also excluded.Data from the included studies were extracted by two authors and checked by another author. The following data were collected: name of the first author, year of publication, characteristics of the study participants, number of participants, definition of sarcopenia, method to measure muscle, muscle measurement time, prevalence of sarcopenia, and anti-tumor therapy method for DLBCL and outcomes.The quality of the included trials was evaluated using the Quality In Prognostic Studies (QUIPS) tool by two reviewers independently—study participation, study attrition, prognostic factor measurement, outcome measurement, study confounding, and statistical analysis and reporting were assessed. If more than four of these six criteria had a low risk of bias, the study was considered to have a low risk of bias, and if two or more criteria had a high risk of bias, the study was considered to have a high risk of bias. The remaining studies were classified as having a moderate risk of bias .I2 > 50% indicated heterogeneity. When heterogeneity across studies was identified (I2 > 50%), the random-effects model was used to calculate the pooled hazard ratio (HR) and corresponding 95% confidence intervals (CIs). If studies were homogeneous, a fixed-effects model was used for the analysis. Most of the HR values were extracted from the univariate and multivariate Cox regression analyses, and a few were calculated using the Kaplan–Meier curves. If several methods were used to diagnose sarcopenia, such as skeletal muscle index (SMI) and skeletal muscle density (SMD), SMI was used in the meta-analysis for OS and PFS. A predefined subgroup analysis based on the anti-tumor treatment, skeletal muscle measurement method, and rate of sarcopenia was performed to identify the potential sources of heterogeneity and further explore the prognostic role of sarcopenia. Publication bias was assessed using. The funnel plots and Egger's regression intercept analysis.Stata software  was used for statistical analyses. A heterogeneity test was performed for each analysis, and A total of 659 related studies were extracted from the above-mentioned databases; 12 met the eligibility criteria and were thus included in the meta-analysis . The samI2 = 47.7%), in which patients with sarcopenia tended to have a shorter OS than those without sarcopenia . According to the multivariate analysis of eight trials, the association between pretreatment sarcopenia and poor OS was significant   .P > 0.05; I2 = 39.8%; To comprehensively evaluate the association between sarcopenia and OS in DLBCL, subgroup analysis was performed based on the anti-tumor treatment, skeletal muscle measurement, and rate of sarcopenia. In most subgroup meta-analyses, the pooled data indicated an association between sarcopenia and shorter OS in patients with DLBCL. Subgroup analysis also showed that sarcopenia had no significant impact on OS of patients with DLBCL treated with multiple treatment methods , while low, non-significant heterogeneity was detected . The adjusted summary HR from eight selected trials was 1.64 , in which low, non-significant heterogeneity was detected (I2 = 0.0%)  .P < 0.01; I2 = 0%) but not in those treated with multiple treatment methods . The other subgroup analyses showed an association between sarcopenia and poor PFS  (Five studies assessed the association between sarcopenia and treatment completion. The pooled results from the fixed model indicated that sarcopenia decreased the rate of treatment completion [odds ratio (OR) = 0.50; 95% CI = 0.37–0.65, = 21.1%) .P < 0.01). Howev er, there was significant heterogeneity between studies (I2 = 72.3%).Five studies analyzed the relationship between sarcopenia and the rate of CR in DLBCL. As shown in P = 0.344)  .Our meta-analysis showed that sarcopenia was associated with poor survival, even after adjustment for confounders. Furthermore, the meta-analysis outcomes showed a low rate of CR in patients with sarcopenia after R-CHOP therapy. In addition, patients with sarcopenia tended to fail to complete the treatment plan compared to patients without sarcopenia. These results are consistent with a recently published meta-analysis study, which demonstrated that overall mortality of hematopoietic cancer was significantly associated with sarcopenia. However, only two studies that involved patients with DLBCL were included, and several recently updated researches were not .In our study, the incidence of sarcopenia ranged from 23.9 to 55.6%, which was consistent with the previous study involving United States veterans with DLBCL, which was >30% based on CT diagnosis before chemotherapy . The sigThe mechanism of sarcopenia is complex. Aging is a crucial risk factor for sarcopenia. The aging process breaks the balance between muscle protein synthesis and catabolism, eventually leading to gradual loss of skeletal muscle loss . The mec2/m2 decrease in SMI, the risk of any grade 3–4 toxicity increased by 34%  was used as the diagnostic criteria for sarcopenia, there was no difference in the rate of CR between the sarcopenia and non-sarcopenia groups . Anotherd by 34% . Anotherd by 34% . Increasd by 34% .Most importantly, the meta-analysis provided convincing evidence that sarcopenia was associated with low OS and PFS. The association between sarcopenia and prognosis was independent of other prognostic factors, such as age, sex, prognostic index, and hypoalbuminemia. The pathogenesis of poor survival in patients with cancer and sarcopenia is unclear. A commonly postulated mechanism is that greater drug toxicity results in decreased treatment tolerance and reduction in effective drug doses , 40. AnoAlthough sarcopenia was associated with poor survival in patients with DLBCL, the prognostic value of low body mass index (BMI) in the included studies remains controversial. Two studies showed that low BMI was associated with poor OS and PFS , 22. HowOur study has some limitations. All included trials were retrospective studies. There was considerable heterogeneity in the meta-analysis with respect to patient cohorts as a result of using different diagnostic criteria for sarcopenia. Although the muscle mass in all included studies was measured on CT, the scan level of CT used in each study was different, and the cut-off values varied. In addition, the various treatment strategies used in the studies were also likely to contribute to heterogeneity. Another limitation of our meta-analysis is the different definitions of OS and PFS in the studies. Further, the lack of measurement of relevant indicators of muscle function is a limitation. The included studies were retrospective and evaluated muscle mass only on CT, but not by muscle function. The definition of sarcopenia includes not only the reduction of muscle mass but also the degeneration of muscle function. Moreover, gene mutations also play a key role in determining the prognosis of patients with DLBCL. However, none of the included articles investigated the effect of sarcopenia on prognosis in patients with DLBCL with different gene mutations. Therefore, further studies using rigorous design are warranted to verify the strength of prognostic role of sarcopenia in patients with DLBCL.The prevalence of sarcopenia is higher in patients with DLBCL than in the general population. Loss of skeletal mass is associated with poor survival in patients with DLBCL. Sarcopenia also negatively affects the rate of treatment completion and CR to immunochemotherapy. Identification of consensus diagnostic criteria for sarcopenia and design of prospective studies that incorporate measurements of muscle strength and physical function are the areas for further research.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.XJ: conceptualization, methodology, software, investigation, and writing—original draft. X-TX: methodology, software, and investigation. M-XT: resources, data curation, and investigation. D-LH and H-JW: writing—review and editing. All authors revised and approved the final manuscript.This study was supported by the Provincial Natural Science Foundation of Hunan (2021JJ30066).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.


We investigated the impact of exposure to literary and popular fiction on psychological essentialism. Exposure to fiction was measured by using the Author Recognition Test, which allows us to separate exposure to authors of literary and popular fiction. Psychological essentialism was assessed by the discreteness subscale of the psychological essentialism scale in Study 1, and by the three subscales of the same scale  in Study 2 that was pre-registered. Results showed that exposure to literary fiction negatively predicts the three subscales. The results emerged controlling for political ideology, a variable that is commonly associated with psychological essentialism, and level of education. MTurk is a crowdsourcing marketplace for work which is used extensively in behavioral research and has been proven to be a reliable source of good quality data .Participants (residents of the United States) were recruited The ART suggested by Acheson et al.  was usedM = 0.29, SD = 0.23; ART Popular M = 0.28, SD = 0.23; ART foils M = 0.01; SD = 0.04. The discreteness subscale of the essentialism scale developed by Bastian and Haslam . Participants further answered three items asking participants to what extent they self-identified as liberal (1) or conservative (7), in general, from a fiscal and social point of view. A composite score was created by averaging responses to the three items (α = 0.93), with high values indicating more conservative .We thus followed exactly the same procedure used in the earlier research   participants compared with the pre-registered (N = 218) participants. After deletion of participants following the pre-registered criteria (N = 57), the sample included 243 participants . Education was also recorded: elementary school [0]; middle school [0]; some high school [3]; high school [24]; some college [47]; college [121]; and postgraduate [48].Study 2 was pre-registered. Participants (residents of the United States) were recruited M = 0.23, SD = 0.21; ART Popular M = 0.22, SD = 0.21; and ART foils M = 0.03; SD = 0.05. To assess psychological essentialism, in addition to the discreteness subscale , the two other subscales, namely, informativeness and biological basis, developed by Bastian and Haslam . Participants also answered one item indicating their self-identification as liberal (1) or conservative (7) with high values indicating more conservative . They also indicated their level of education on an improved scale comprising seven levels .The ART was included and scored as for Study 1, and resulted in similar scores: ART Literary d Haslam  were useWe used the same GLM  we pre-registered the details of data collection and management, as well as the deletion criteria and statistical analyses. The hypothesis found clear support from the results of the analyses of the two studies: exposure to literary, but not popular, fiction was associated with reduced essentialism in terms of perceived discreteness (Study 1) and both discreteness and informativeness (Study 2). The same result emerged on the third subscale suggested by Bastian and Haslam , i.e., bWe also conducted supplementary analyses that were not pre-registered, in which a different strategy was adopted for casual or self-aggrandizing responding to the ART—i.e., selection of foils as authors. These analyses revealed the same pattern, i.e., exposure to literary fiction negatively predicted essentialism. They also showed the opposite pattern for exposure to popular fiction, i.e., the more exposure to popular fiction, the greater psychological essentialism.We first discussed the main hypothesis tested in this study and then discussed the results of the supplementary analyses.The main finding confirming our hypothesis adds to the growing literature on the effect of exposure to fiction on social cognition. This work has mostly focused on ToM, but recent findings indicate that exposure to literary fiction is also uniquely associated with attributional complexity for social events, i.e., increased social accuracy and, to a lesser extent, with reduced egocentric bias  and by parents” . In other words, at least in the Western world, we teach our children to think in essentialistic terms, probably because of the strategic advantage that such thinking provides  a different set of social cognition processes, in which the research shows to be more akin to individuated perception. Literary fiction, therefore, might be undermining, or providing a counterpoint to, the default mode of social perception. For this reason, we believed that while theorizing is consistent with the theoretical perspective proposed in this study, a positive effect of exposure to popular fiction on category-based perception and thus also on essentialism might be difficult to prove empirically. Further research, however, may well find conceptually similar findings, possibly using correlates of psychological essentialism.While Gelman and Hirschfeld  also notNotwithstanding the above, the reanalysis of both studies presented in this study, in which a different strategy to control for the effect of careless or self-aggrandizing responses on the ART was used, revealed, for discreteness, an effect of exposure to popular fiction that is consistent with the rationale concerning the possible effects of popular fiction presented in this study and in other publications (e.g., Kidd and Castano, Earlier research showing the differential impact of exposure to literary vs. popular fiction on ToM is complemented by experimental work (e.g., Kidd and Castano, ad hoc collected sample of participants. The same sample-aggregation technique was used in the other two articles that factor-analyzed the ART (Moore and Gordon, We have already mentioned the limitation stemming from the correlational character of the results presented. In this study, we drew attention to other limitations. One limitation is that evidence from Study 1 has been obtained from a collection of three different samples, rather than an what we think about the social world, but also how we think about it. It complements and extends the emerging body of empirical research on the impact of fiction, both in written form and in other formats, and it further shows the contributions to the debate around the cultural transmission of social cognition processes and thinking styles.In this study, we presented an evidence that exposure to literary fiction is associated with lower psychological essentialism. This finding is consistent with theorizing about the role of fiction in shaping not only The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Comitato Etico—Dipartimento COSPECS. The patients/participants provided their informed consent to participate in this study.EC developed the hypothesis, designed study, and wrote first draft. MPP, OGC, VC, and PP contributed to preparation of material, data interpretation, and writing. All authors have approved the final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Female breast cancer (BC) patients exposed to gonadotoxic chemotherapy are at risk of future infertility. There is evidence of disparities in the discussion of fertility preservation for these patients. The aim of the study was to identify factors influencing the discussion of fertility preservation (FP).We analyzed consecutive BC patients treated by chemotherapy at Institut Curie from 2011-2017 and aged 18-43 years at BC diagnosis. The discussion of FP was classified in a binary manner (discussion/no discussion), based on mentions present in the patient’s electronic health record (EHR) before the initiation of chemotherapy. The associations between FP discussion and the characteristics of patients/tumors and healthcare practitioners were investigated by logistic regression analysis.+/HR+ (16%) and 81 HER2+/HR- (6%). All patients received chemotherapy in a neoadjuvant  or adjuvant  setting. A discussion of FP was mentioned for 447 patients (33%). Earlier age at diagnosis (discussion: 34.4 years versus no discussion: 40.5 years), nulliparity (discussion: 62% versus no discussion: 38%), and year of BC diagnosis were the patient characteristics significantly associated with the mention of FP discussion. Surgeons and female physicians were the most likely to mention FP during the consultation before the initiation of chemotherapy . The likelihood of FP discussion increased significantly over time, from 15% in 2011 to 45% in 2017. After multivariate analysis, FP discussion was significantly associated with younger age, number of children before BC diagnosis, physicians’ gender and physicians’ specialty.The median age of the 1357 patients included in the cohort was 38.7 years, and median tumor size was 30.3 mm. The distribution of BC subtypes was as follows: 702 luminal BCs (58%), 241 triple-negative breast cancers (TNBCs) (20%), 193 HER2FP discussion rates are low and are influenced by patient and physician characteristics. There is therefore room for improvement in the promotion and systematization of FP discussion. Breast cancer (BC) is the most frequent cancer in women , and aboOncological treatments may impair the fertility of premenopausal patients with BC. Chemotherapy may induce premature ovarian failure, depending on the woman’s age and the drugs used, their dose and the duration of treatment . Adjuvanin vitro fertilization procedures is the most frequently used  techniques are available, and the freezing of embryos or oocytes after controlled stimulation for future tly used . If thisernative .Previous studies have suggested that many BC patients are interested in maintaining their future fertility at the time of diagnosis. However, they do not systematically receive information about the fertility risks of treatment and fertility preservation options , with suPublications to date on the factors predictive of FP discussion in BC are mostly limited to small qualitative studies. Disparities in referral patterns and access to FP have been observed with respect to the demographic, clinical and socioeconomic characteristics of patients. A few studies have shown that patient age, and parity, the type of treatment, type of center and physician characteristics may affect the likelihood of FP discussion , 10, 12.The objective of this study was to identify the factors associated with FP discussion in a population of women receiving chemotherapy for BC to improve patient counselling and timely access to FP services.We analyzed a cohort of female patients with invasive BC aged between 18 and 43 years at the time of BC diagnosis, treated by chemotherapy at Institut Curie between January 1, 2011 and September 30, 2017. The upper limit of 43 years was chosen as this is the maximum age for reimbursement of assisted reproductive technology in France. In the study, we also used the 37 years as a cut-off point, as it has been shown that the age of 37 years is correlated with an accelerated disappearance of ovarian follicles in mid-life , 14. TheThe cohort was constructed with the ConSore  search eThe exclusion criteria were another cancer before BC, distant metastases at diagnosis or within six months of diagnosis, bilateral breast cancer, refusal of treatment, hysterectomy, tubal sterilization or bilateral ovariectomy performed before diagnosis, patient refusal of the use of their data. We did not include patients who did not receive chemotherapy because in the 2 institutions in which the patients were treated that we analyzed, patients without chemotherapy were not offered fertility preservation procedures at the time of the study. All medical charts were manually verified from September 2017 to March 2018. The study was approved by the Breast Cancer Study Group of Institut Curie and was conducted in accordance with institutional and ethical rules concerning research on tissue specimens and patients.The objective of this study was to identify factors associated with discussion of FP in this population, and discussion of FP was used as the primary endpoint.th, April 2019, reference cri-data DATA190136).Under French regulations, written informed consent from patients was not required for this study. This study is a part of the young breast cancer project (YBCP), an institutional project aiming at characterizing BC care pathways in young women. It was approved by the breast cancer group and institutional board  at diagnosis, date of first consultation at Institut Curie, date of first biopsy showing malignant histological features, date of first chemotherapy, date of surgery, and BRCA status, when available. The date of the first consultation at Institut Curie was taken as the date of diagnosis.We retrieved the following tumor characteristics from the patients’ medical records: clinical T (size) stage and clinical N  status, immunohistochemical characteristics, such as the detection of estrogen receptors (ER), progesterone receptors (PR), HER2 status, Ki67 and histological grade. Cases were considered estrogen receptor (ER)- or progesterone receptor (PR)-positive (+) if at least 10% of the tumor cells expressed estrogen and/or progesterone receptors (ER/PR), in accordance with the guidelines used in France . HER2 exHER2-positive breast cancer, in accordance with national guidelines. Most patients received adjuvant radiotherapy. Endocrine therapy  was prescribed when indicated. Every patient included in our study received chemotherapy (neoadjuvant and/or adjuvant).Patients were treated according to national guidelines. Treatments were decided after multidisciplinary consultation meetings considering the characteristics of the patients and prognostic factors. For patients receiving neoadjuvant chemotherapy, surgery was performed four to six weeks after the end of chemotherapy. Trastuzumab was used in an adjuvant and/or neoadjuvant setting for i.e. the delivery of information about the existence of fertility preservation procedure before chemotherapy — was assessed from electronic health records (EHR) as a binary variable (discussion/no discussion), and through a two-way process. Any discussion on damages on fertility induced by chemotherapy counted as “FP Discuss”. Only files with no information on fertility risks were classified as “FP No-Discuss”. We first extracted specific string character patterns by text mining (TM), using specific key words associated with a high likelihood of FP discussion having occurred ”, “ov* fragment preservation”, “ov* cryopreservation”, “ov* cryoconservation”), making it possible to identify the keyword concerned directly in the EHR. This text recognition method was developed and validated on two independent datasets and has been shown to have a better performance than the manual rereading of medical records to identify pregnancies (Discussion about FP (FP discussion) — gnancies . For patversus female), age at consultation (junior < 45 years old versus senior > 45 years old) and type of specialty , together with the rank of healthcare provider (ranging from 1 to 3). Once FP had been discussed with a healthcare provider, subsequent consultations were censored.For any consultation with a medical doctor occurring between BC diagnosis and chemotherapy, demographic information about the physician was collected: sex , and the method used (oocyte or embryo vitrification after IVM or after controlled ovarian stimulation (COS), cortex cryopreservation).t tests were performed otherwise. Associations between categorical variables were assessed in chi-squared tests, or with Fisher’s exact test if at least one category included fewer than three patients. A value of P < 0.05 was considered significant. Data were processed and statistical analyses performed with R software version 3.1.2 .The study population was described in terms of frequencies for qualitative variables, or medians and associated ranges for quantitative variables. For the comparison of continuous variables between groups, Wilcoxon-Mann-Whitney tests were used for groups including fewer than 30 patients, and for variables with multimodal distributions, and Student’s Data were evaluated using multiple correspondence analysis (MCA). This method involves a multivariate analysis of categorical data and allows joint observation of a vast number of variables. By grouping various characteristics, it attempts to establish a profile capable of suggesting a predisposition to specific situations. Analysis was conducted with the package library (FactoMineR), which performs various mathematical procedures to define the best organization of variables and allocate variables into a four-quadrant plot divided by two axes. Results are interpreted by observation of clusters formed by variables. These clusters represent relations between the variables; the closer they are on the plot, the greater the frequency of their co-occurrence. The two axes separate variables plotted on the left upper quadrant from those in the right lower quadrant and those in the right upper quadrant from those in the left lower quadrant, establishing groups of variables with opposing profiles. It gives a representation of the absolute contribution of each variable according to its distance from the axis, both towards the positive and towards the negative side; the greater the distance, the greater its significance in the interpretation of results.We used a mixed model combining mixed effects and random effects for the multivariate analysis. The fixed effects influence the mean of the variable of interest (FP discussion) and the random effects influence only the variance of that variable. We used this model based on the assumption that the observations in our database are not independent (i.e. that the occurrence of a FP discussion can be the same depending on the characteristics of the doctors and patients). Thus, the residual variance of the model is partitioned into a between two components: patients and doctors.versus 66%), a larger proportion of luminal tumors (64% versus 54%), and a lower likelihood of receiving neoadjuvant as opposed to adjuvant chemotherapy (35% versus 52%) in older patients than in younger patients.In total,1357 patients were included in the study Table 1.Some mention of FP discussion was found in the EHRs of 447 (33%) of the 1357 patients, whereas no such mention was not found in the EHRs of 909 patients (67%).versus 40 years, p<0.001) (p=0.05) and neoadjuvant chemotherapy (p<0.001) were also significantly associated with FP discussion   Table 2.FP discussion was more frequently mentioned during the first pre-chemotherapy consultation, than during the following visits .versus center 2) (p=0.14).Doctors’ specialty was significantly associated with the likelihood of FP discussion. Surgeons were more likely to discuss FP with patients (22%) than medical oncologists (14%) and radiation oncologists (10%)  . Seventeen patients received treatment with LHRH analogs. The main factor associated with the occurrence of FPPs was the occurrence of FP discussion (only three patients underwent FPPs without prior FP discussion).Out of 447 patients who had a FP discussion, 259 patients (58%) had a FP procedure and 188 (42%) didn’t have Table 4.n=175) underwent IVM, and one third (n=84) had at least one COS. The factors associated with the type of FPP  were low (33%) in a consecutive series of 1,357 female breast cancer patients exposed to gonadotoxic chemotherapy. Furthermore, we discussed the correlation between FP discussion and the characteristics of patients/tumors and healthcare practitioners. We found that younger age, number of children before breast cancer diagnosis, physicians’ gender and physician’s specialty were independent predictors of FP discussion. We also found an increased likelihood of FP discussion over time. In general, the findings in the present study support the above-mentioned conclusion. The results of our study confirm and reinforce previous findings from the literature.One of its key findings is that FP discussion was mentioned in only one third of EHRs. These rates lie in the lower part of the range of published values, which generally range from 30 to 70% , 12, 20.Our findings confirm that several patient-related factors are associated with the likelihood of FP discussion, as summarized in Consistent with another study , we founIn our study, no factor related to BC disease  was found to be significantly associated with the likelihood of FP discussion. Conflicting results have been reported , but sevSeveral practitioner-related factors were associated with the likelihood of FP discussion, including specialty in particular. Surgeons were the most likely to discuss FP with their patients, followed by medical oncologists and then radiotherapists. We also identified the sex and age of the medical practitioner as significantly associated with the likelihood of FP discussion. Korkidakis et al.  analyzedFinally, we confirm the crucial importance of FP discussion for favoring the performance of FPPs. Only three of the 262 patients who underwent PF procedures had not previously discussed FP with their doctors. Our data therefore indicate that a lack of discussion about FP during in-house consultations severely impedes patient choice as to whether to undergo FPPs. However, almost one third (188/447) of the patients who received information about FP chose not to undergo FPPs, or were not eligible for the procedures. We found the same factors associated with the FP procedure in the group of patients who had a FP discussion: age and parity. Previous studies analyzing annual income or health insurance as possible factors influencing discussion about FP found no association with these factors , which cOur study has several strengths, in particular, the inclusion of a large number of patients and doctors, allowing an analysis of a multitude of variables. However, it also has limitations, such as its retrospective nature, in particular. Information on the FP discussion was retrospectively obtained from the patient’s electronic health record. Since some doctors may not record their discussion with patients about FP in the electronic health record system, results from this study may underestimate the rates of FP discussion. The healthcare providers play an important role in the discussion of fertility preservation. However, less than 50% of the patients had FP with their doctors and only 19% of the patients had FP procedures. More characteristics of the healthcare providers are recommended to be analyzed and discussed, such as their knowledge about FP procedures, or how much time spent for each communication on FP with patients would be of major interest to further understand determinants associated with physician’s related barriers and facilitators.This work has several clinical implications and identifies areas in which there is room for improvement. It highlights a patient population with unmet needs regarding information on FP . It also calls for better training for healthcare providers to raise awareness on this topic, particularly among male doctors, through seminars , joint tvia posters or flyers in waiting rooms, patient advocacy, and communities could help to increase the proportion of patients who are informed and empowered, and able to decide independently whether or not they wish to undergo FPPs if it is possible, before receiving gonadotoxic treatment.Prestructured fields in the EHR may be pertinent tools for preventing omissions and could provide an alert in real time, prompting such discussion. Alerts of this type have already proved effective for preventing drug interactions and are currently used in this context , 31. A sThe original contributions presented in the study are included in the article/Conceptualization, AH, AT, FR, and A-SH. Methodology, FC and A-SH. Software, JB, A-SH. Validation, AH, AT, VC, CaS, A-SH, and FR. Formal analysis, A-SH. Investigation, AH, AT, VC, J-YP, and J-GF. Data curation, AH, AT, CaS, and A-SH. Writing—original draft preparation, AH and A-SH. Writing—review and editing, AH, AT, CaS, EL, BG, AT, FC, EDu, EDa, J-YP, J-GF, FR, and A-SH. All authors contributed to the article and approved the submitted version.The authors declare that this study is a part of The Young Breast Cancer Project. The Young Breast Cancer Project was funded by Monoprix. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.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.


Rapid population growth and increasing food demand have impacts on the environment due to the generation of residues, which could be managed using sustainable solutions such as the circular economy strategy (waste generated during food processing must be kept within the food chain). Reusing discarded fish remains is part of this management strategy, since they contain high-value ingredients and bioactive compounds that can be used for the development of nutraceuticals and functional foods. Fish side streams such as the head, liver, or skin or the cephalothorax, carapace, and tail from shellfish are important sources of oils rich in omega-3. In order to resolve the disadvantages associated with conventional methods, novel extraction techniques are being optimized to improve the quality and the oxidative stability of these high-value oils. Positive effects on cardiovascular and vision health, diabetes, cancer, anti-inflammatory and neuroprotective properties, and immune system improvement are among their recognized properties. Their incorporation into different model systems could contribute to the development of functional foods, with market benefits for consumers. These products improve the nutritional needs of specific population groups in a scenario where noncommunicable diseases and pandemic crises are responsible for several deaths worldwide. Today, more than ever, health and well-being play very important roles as the population wants to stay healthy in the face of the COVID-19 crisis . In thisWith rapid population growth, there is an increasing demand for food  but the n-3 polyunsaturated fatty acids (n-3 LCPUFAs) that the body cannot synthesize and that are essential for mammals [n-3, EPA) and docosahexaenoic acid  are included. There are many studies that reflect the importance of these fatty acids in health. Anti-inflammatory properties; positive effects on cardiovascular and vision health, diabetes, cancer, immune system improvement, and development of the nervous system; reduced risk of Alzheimer’s diseases; and better digestibility are among their recognized properties [Diet plays an important role in disease prevention and health promotion, since there are compounds such as long-chain  mammals . In thisoperties ,13,14. Ioperties . In factSalmo salar and Sardinops sagax; prawns, Penaeus plebejus; and cephalopods, Octopus tetricus and Sepioteuthis australis). In addition, the contents are significantly higher in pelagic than in demersal species [The quantity and quality of these fatty acids, known as omega-3, depend on many factors, including fish species, size, and age; gender; diet; habitat temperature; season; and extraction methods and conditions, among others ,16. In g species . In this species ,11.n-3 LCPUFAs, presenting methods of recovery of these fatty acids, their functional properties, as well as their possible applications in food model systems.During the filleting process, up to 60% of the fresh fish is cut off and generally treated as waste . Severaln-3 LCPUFAs [Seafood and the by-products generated from its processing are the main sources of  LCPUFAs . In fact LCPUFAs ,20, EPA  LCPUFAs . In this LCPUFAs , represe LCPUFAs . In Euro LCPUFAs .The values presented in n-6/n-3 and DHA/EPA ratios should be considered simultaneously. Several studies showed that lower DHA/EPA (1:2) ratios seem to be more effective at alleviating inflammatory risk factors [As mentioned above, these fatty acids have an important role in human health. There are different ratios that reflect this effect. In this regard, both the  factors . These vAccording to the information reported in the literature, only 5% of world fish oil production is used to extract omega-3 fatty acids destined for use as food ingredients or supplements . The resThe conditions and extraction method affect the composition and the quality of the lipids extracted from marine processing side streams . TherefoDifferent methods have been used for the extraction of omega-3 fish oil. Wet pressing is the method conventionally used for omega-3 fish oil. This extraction involves several steps: fish cooking, pressing, decantation, and centrifugation. Firstly, the fish is cooked and pressed. Then, the mixture is centrifuged to separate the fatty and aqueous fractions. The oil phase, which contains omega-3 fatty acids, is refined in several steps: neutralization, followed by bleaching, degumming or winterization, and deodorization . This prv/v) increased the yield to 25.44% in cephalothorax, while mixtures with acetone improved the yields in shrimp head and carapace [Another possibility for the extraction of oil from fish and for processing by-products is solvent extraction. However, this method is not as common in the industry. The yield of this type of extraction depends on the solvent used. In this regard, Gulzar et al.  observedcarapace ,39.The yields obtained with conventional extraction methods are satisfactory; however, they also employ lengthy processes, have high solvent consumption, are mostly toxic, or use conditions that can degrade the quality of the extracted valuable compounds ,40. Ther2 flow, and 65 °C applied for 120 min on Longtail tuna (Thunnus tonggol) heads resulted in a PUFA-rich fraction with high quality and stability. EPA and DHA could also be obtained from the bones, scales, and skins of bigeye tuna (Thunnus obesus). Ahmed et al. [2 flow of 10 kg/h resulted in an oil with a combined EPA and DHA content in the range of 24.7–28.3%. Similar results were found by Létisse et al. [2/min, and 45 min.In this regard, SFE is one of the technologies successfully used for the extraction of omega-3 fatty acids from marine side streams . The appd et al.  found the et al.  using saMerluccius capensis–Merluccius paradoxus) were obtained by applying lower pressures (25 MPa) and temperatures (40 °C) and higher CO2 flows (10 kg CO2/h) [Hoplostethus atlanticus) and Atlantic salmon  as well as on the liver from jumbo squid (Dosidicus gigas).The application of less drastic conditions could even improve extraction yields. In this way, yields greater than 96% of the total oil contained in hake off-cuts (g CO2/h) . These cPandalus borealis Kreyer) with SFE [2 flow of 3–5 L/min for 90 min). Nguyen et al. [Shellfish is also an important source of bioactive components with potential health benefits. In this regard, krill, shrimp, and lobster appear to be alternative sources of omega-3 fatty acids . This ofwith SFE . The autn et al.  observedρ-anisidine value. Therefore, some authors have applied UAE processes under nitrogen atmosphere to reduce the loss of quality in the obtained oil [Labeo rohita) heads  heads . The resPEF is another innovative technology that enhances the extraction of bioactive compounds and oils from marine side streams ,55, beinMAE is another method used for the extraction of oil from fish processing by-products. However, it is not widely used and is usually combined with other traditional extraction methods to improve the extraction yields and to reduce lipid oxidation of the obtained oils . ChimsooAccording to the information reported in this section, it is plausible to conclude that these alternative methods are still under development and require additional research, with SFE being the most promising green extraction technology in obtaining oil from marine side streams.Wellness Foods”.Marine side streams are important sources of compounds with important technological, nutritional, and even functional properties, which when properly processed, can be reintegrated into the food chain. This entails the reduction of food processing waste and, therefore, the environmental impact of these types of industries. In this way, the food sector could contribute to a circular bioeconomy, making it possible to convert these by-products into marketable bio-products, generating new economic values and responding to society’s demand for a more efficient and sustainable environment. In addition, their incorporation into diets would contribute to improving its functional characteristics, thus diversifying the offer of the so-called “n-6/n-3 ratio must be balanced [The fortification of food products with functional ingredients has gained increasing interest , since cbalanced . In addibalanced  while, tThe stability and effectiveness of the fortification, and the susceptibility of omega-3 to oxidation depend on the strategy to include fish oils in the product  . In factw/w). This addition allows us to improve the technological properties of the product, increasing loaf volume, and decreasing chewiness  and gumminess , while no significant effect was observed in hardness . The microstructure also revealed that the microencapsulated oil was perfectly embedded in the crumb. Regarding color, higher redness and yellowness were observed in the samples with MFO, probably due to the astaxanthin content. As expected, the microencapsulation protected the product against oxidation and sensory deterioration. However, these effects were dose dependent. In this way, the addition of concentrations up to 3% resulted in slight increases in the volatile  markers of oxidation  and no adverse effects in overall acceptability .Bakery and pasta products are some of the applications of these omega-3 fatty acids ,70. In tw/w) was applied in biscuits [6 for 2-heptenal in 6% MFO under dark and light conditions, respectively). At the sensorial level, the overall likeness scores were higher than those observed in control samples .Similar results were observed when microencapsulated shrimp oil  [Another side streams that can be considered an important source of omega-3 fatty acids is the heads of sardines (liensis) . These mliensis)  evaluateliensis) ), one woliensis) . These lliensis) .Dicentrarchus labrax) trimmings and small pieces were included in the formulation of fresh pasta (durum wheat and spelt) [A fish concentrate prepared from the by-products generated during the filleting process of sea bass (d spelt) . MoreoveThe fortification of dairy products with omega-3 is a promising strategy for the supplementation of milk and fermented products , improving their nutritional value, stability, and health benefits. The fortification of these types of products can be carried out in the first stages of the food chain such as during feeding of the animals through the incorporation of fish oil into the feed of cows or goats .v/v) [As mentioned previously, encapsulation is the most efficient way to fortify foods with omega-3 fish oils. In fact, nanoliposomes have been used for milk fortification with omega-3 . This liv/v) . The anaYogurt is another product that can be fortified with omega-3, since it is one of the most consumed products worldwide and its matrix is very homogeneous ,90. TamjDespite the generally positive effects found with the use of encapsulation, contradictory results were found by Horn et al.  in creamw/w), respectively. These concentrations allow us to reach the minimum amount required to label a food as a “source of ω-3 fatty acids”  [Nowadays, meat industries are forced to reformulate their products due to consumer demands for healthier products . Therefo00 Kcal) . The res6 for MFO and BFO, respectively). Together with hexanal, Jiménez-Martín et al. [Pérez-Palacios et al.  evaluaten et al.  observedn et al.  in Cintaw/w) and 0.15% w/w EPA + DHA) than those necessary to distinguish both types of samples (>2.5% (w/w) and >0.2% w/w of EPA + DHA) [Regarding protein oxidation, significant differences were also observed between samples, with control samples being those that showed the lowest values, followed by MFO and BFO . These differences mentioned above were also observed in sensorial attributes, especially in BFO samples, while MFO displayed values very close to the control samples. This similarity of the microencapsulated samples with the control samples could be related to the fact that the enrichment levels were lower (0.5% (A + DHA) ,101. In Gadus morhua) liver and salmon  as partial substitutes (up to 15% w/w) of native fat in beef patties resulted in higher cooking losses and decreased hardness compared to samples that contained commercial encapsulated oils obtained from anchovies (Engraulis ringens) and sardines (Sardinops sagax sagax) [n-3 LCPUFAs increased from 0.35 g/100 g, obtained in the control samples to 12.86 and 19.90 g/100 g in samples where pork backfat was replaced with 50 and 75% by fish oil, respectively. Effects in the technological parameters were also found since hardness and gumminess decreased as the content of fish oil increased. In contrast, an important increase was achieved on aldehyde contents, probably due to the different levels of polyunsaturation among batches. With this in mind, the most widely researched strategy to introduce fish oils in meat products is the use of encapsulation.As commented upon before, the nutritional quality of meat products could be achieved by replacing animal fat with marine oils . The incx sagax) . Fish oix sagax) ,104. Domx sagax)  studied The nutritional deficiencies suffered around the globe, especially in the elderly group in some regions of the world, have increased the demand for functional foods and nutraceutical products, which reflects the special interest in fish oils rich in omega-3. The information collected in this review reflects the health benefits of these compounds but also shows that marine side streams offer a very important source of these fatty acids, especially in by-products with more fat such as viscera. The revalorization of these products has great benefits not only economically but also environmentally. On the one hand, the cost that their elimination would entail for the fish industries is reduced, and on the other hand, a great source of contamination posed by these side streams is avoided.New technologies are being optimized with the aim of obtaining higher extraction yields and higher-quality oils rich in omega-3 from these marine sources. Although these alternative green methodologies do not have the same drawbacks as traditional methods, especially in the use of solvents and high temperatures, it is still necessary to optimize them to avoid the development of oxidative processes that would reduce the quality of the products obtained.The unsaturation of these fatty acids makes them susceptible to oxidative processes that lead to nutritional and sensorial loss. This makes it necessary to search for alternatives solutions to solve this problem. In this regard, the combination of some of these technologies has been studied to increase the quality of the extracted omega-3 rich oils and, therefore, their beneficial properties, since their composition and structure remain almost intact. Another possibility would be to use anoxic environments during the extraction processes. Studies carried out under a stream of nitrogen show promising results and could be a solution to these deteriorations. However, the use of antioxidants seems to be the most efficient option. This strategy involves some controversy since synthetic antioxidants are often the most used for their efficiency and cost. However, the toxic effects linked to some of them make the use of natural antioxidants necessary, which motivates the search for new ones that could have their origin in agri-food co-products, thus complying with the principles of a sustainable circular economy (green approach).From an application standpoint, it is important to note that the way omega-3-rich oils are incorporated into foods is a crucial factor. This affects the sensory attributes and the oxidative stability and, therefore, the quality of the final product. Encapsulation appears to be the most favorable strategy. In fact, several studies reflected that microencapsulation markedly increases the oxidative stability of omega-3 fatty acids. In addition, the lack of information about the bioaccessibility, bioavailability, and impact in gut microbiota of these new developed food products make it necessary to complete these studies in order to ensure their absorption.It is plausible to conclude that marine side streams are a valuable source of omega-3 oils. Their application in food is a sustainable strategy that adds value to these parts often treated as waste while achieving important beneficial effects on the health of consumers. However, it is necessary to pay attention to the daily recommendations of these products for each population, since there is still no consensus about these among international organizations.