Background and Objective: Alzheimer’s disease (AD) is a progressive neurodegenerative disorder, that is, characterized by cognitive decline. To date, there are no effective treatments for AD. Therefore, the objective of this study was to map new perspectives on the effects of pharmacological treatment on cognitive function and the overall psychological state in patients with AD.Methods: Two independent researchers searched for randomized clinical trials (RCTs) exploring new pharmacological approaches related to cognition in Alzheimer’s disease in adults from 2018 to 2023 in PubMed, Web of Science, Scopus, and Cochrane Library databases. A total of 17 RCTs were included in this review.Results: The results show that in recent years, new drugs have been tested in patients with Alzheimer’s disease, including masitinib, methylphenidate, levetiracetam, Jiannao Yizhi, and Huannao Yicong formulas. Most studies have been conducted in populations with mild to moderate Alzheimer’s disease.Conclusion: Although some of the drugs found suggested improvement in cognitive function, the scarcity of available studies highlights the need for further research in this area.Systematic review registration: [www.crd.york.ac.uk/prospero], identifier [CRD42023409986]. Alzheimer’s disease (AD) is a multifactorial progressive neurodegenerative disorder characterized by memory loss, disorientation, and gradual decline in intellectual ability . It affeAD is a progressive neurodegenerative pathology for which there is no definitive cure. However, there are different types of treatments that can help delay its progression and improve the quality of life of affected patients. Treatment options include medication, occupational therapy, cognitive stimulation therapy, physical exercise, massage therapy, music therapy, and nutritional supplements . PharmacDespite advances in available treatments for AD, there is still no definitive cure. Therefore, new treatment approaches are constantly being investigated, such as immunotherapy, gene therapy, light therapy, diet, and physical exercise. Research on new approaches aims to find a more effective and specific therapy than the current treatment options, with the goal of finding a cure for this disease that affects millions of people worldwide .Several psychometric instruments have been used to assess the cognitive and functional performance of patients with AD and other related dementias. The Alzheimer’s Disease Assessment Scale-Cognitive Subscale (ADAS-cog) evaluates memory, attention, reasoning, language, orientation, and praxis . The CliThis study aimed to map out new perspectives on the effect of pharmacological treatment on cognition and overall psychological state in patients with AD.From February 2023 to March 2023, a search was conducted across four databases,  to identify documents published within the past 5 years. To achieve the most comprehensive results possible, the search strategy employed was “Alzheimer Disease/drug therapy” [Mesh].The inclusion criteria for this search were as follows: 1) original articles of randomized clinical trials (RCT); 2) studies conducted in living humans with AD; 3) focusing on cognitive state or psychological aspects, such as memory, mood, etc.; 4) AD must be established at the start of the intervention; 5) adult population over 18 years, both men and women; 6) intervention must be a pharmacological treatment; 7) articles published in English; 8) published within the last 5 years, specifically from 2018 to 2023; 9) with full text available; and 10) methodological quality must score greater than three points on the JADAD scale .in vitro, in vivo, and/or post-mortem; 2) studies on biochemical composition or biomarkers; 3) studies on nutritional aspects, or other therapeutic alternatives; and 4) studies on the prevention of AD.The exclusion criteria were as follows: 1) studies conducted in animal models, Two researchers conducted the search and screening of the documents, and any discrepancies in the selected documents were resolved through consensus between the researchers. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the code [CRD42023409986].A total of 738 documents were initially identified, 17 of which were included in the study. The selection process of the studies included in this review is summarized in p < 0.001), indicating improved cognition. Masitinib also improved overall function, as assessed by ADCS-ADL (p = 0.038). However, this drug has potential safety concerns, including maculopapular rash, neutropenia, and hypoalbuminemia (p < 0.05). However, changes in the ADCS-ADL and CDR-SB scores were not significant. Furthermore, GV1001 was well-tolerated without safety issues  cleaving enzyme (BACE-1) and γ-secretase on the amyloid precursor protein (APP). Inhibition of BACE-1 in preclinical models has been shown to reduce Aβ production and amyloid plaque deposition, which may potentially delay the progression of AD. Verubecestat is a selective inhibitor of BACE-1 that reduces Aβ levels in the cerebrospinal fluid of healthy individuals and AD patients by more than 60% . HoweverLadostigil is a novel therapeutic agent that acts as an inhibitor of both monoamine oxidase (MAO) and acetylcholinesterase (AChE) in the brain. It has also been found to possess neuroprotective and antiapoptotic properties by preventing oxidative-nitrate stress and gliosis . MAO is Semorinemab is a humanized monoclonal IgG4 antibody that targets the N-terminal domain of tau protein. Its mechanism of action is based on its ability to bind and eliminate Aβ protein fragments, which accumulate as plaques in the brains of patients with AD. Semorinemab was selected for development because of its high affinity and specificity for all known isoforms of full-length tau. Neurofibrillary tangles composed of aggregated tau protein are a hallmark neuropathological feature of AD and are correlated with the clinical severity of the disease. Monoclonal antibodies targeting tau protein may have the potential to slow or stop the spread and accumulation of pathological tau, thereby improving the progression of AD. However, a 73-week treatment with semorinemab in patients with prodromal to mild AD did not result in significant improvements in CDR-SB, ADAS-cog13, and ADCS-ADL. The treatment also did not reduce the rate of cerebral tau accumulation or clinical decline in patients with prodromal-to-mild AD. The safety profile of semorinemab was found to be acceptable and well-tolerated .Dopamine is a crucial neuromodulator that influences several distinct synaptic processes and plays an important role in controlling higher cognitive functions such as memory, learning, and decision-making. Dopaminergic dysfunction may contribute to cognitive impairment in patients with AD. Intervention with a transdermal rotigotine patch, a dopaminergic agonist, did not have an effect on global cognitive dysfunction in patients with mild to moderate AD, as evaluated by the ADAS-cog. However, a significant improvement was observed in the deterioration of activities of daily living, as measured by the ADCS-ADL. This effect appears to be related to minor cognitive dysfunction in the frontal lobe .One of the key features of AD is an abnormality in glutamatergic neurotransmission related to the function of the N-methyl-D-aspartate (NMDA) receptor in the cortex and hippocampus. Activation of the NMDA receptor signaling pathway produces postsynaptic signaling events through the elevation of second messengers such as cyclic guanosine monophosphate (cGMP). In conditions of NMDA receptor hypofunction, such as in AD, it is hypothesized that inhibition of phosphodiesterase type 9 (PDE9), which hydrolyzes cGMP, may increase cGMP levels and improve NMDA receptor signaling. This could lead to increased plasticity and synaptic stabilization through enhanced long-term potentiation (LTP), thus potentially improving cognitive functions. BI 409306 is a selective and potent inhibitor of PDE9 that has been investigated for the symptomatic treatment of AD. However, administration of this drug at various doses for 12 weeks did not improve NTB, CDR-SB, ADAS-cog11, or ADCS-ADL scores in patients with mild AD. It has not been demonstrated to be effective in improving cognition in patients with prodromal or mild AD .p = 0.2249) or ADCS-ADL scores (p = 0.8260). Nevertheless, it was observed that Intepirdine demonstrated a favorable safety profile, similar to placebo , which facilitates the administration of the AMPA synaptic receptor. According to Levetiracetam is an antiepileptic drug that acts as a positive modulator of the SV2A protein, which is a member of the SV2 protein family involved in neurotransmission and is found in most nerve terminals. Levetiracetam binds to the SV2A protein and modulates its function to inhibit neurotransmitter release and reduce neuronal activity . DecreasCurrently, research is being conducted to determine the effectiveness of antidiabetic treatments in improving AD due to the possible relationship between type 2 diabetes and AD. Type 2 diabetes is a metabolic disease that affects insulin activity in regulating blood glucose levels. Insulin resistance in the brain, which is an important factor in the development of type 2 diabetes, has also been shown to be related to a higher risk of developing AD . Severalin vitro and in vivo. Additionally, teprenone is an antiulcer agent that can inhibit Aβ increase, senile plaque formation, neuronal degeneration, and improve memory. However, a 12-month intervention study in patients with mild to moderate AD who received a combination of donepezil and teprenone did not significantly affect the ADAS-Jcog score (p = 0.861), but did impact the MMSE score (p = 0.044)  .p < 0.05) in patients with AD. There were no significant differences in the group receiving donepezil, suggesting that the effect of the Jiannao Yizhi formula is not inferior to that of donepezil. The Jiannao Yizhi formula had a favorable safety profile, and no serious adverse effects were found (p < 0.01) in patients with mild to moderate AD. No serious adverse effects were observed during the study. The Huannao Yicong formula may prevent neuronal apoptosis in the CA1 area of the hippocampus, inhibit secretase activity, and reduce neurotoxicity caused by Aβ peptide in rat models of AD  employs a variety of herbal medicines to treat various diseases, including AD, and is considered a natural alternative to synthetic drugs. The mechanisms of action of these herbal medicines have been investigated, and it is believed that they may have beneficial effects in the prevention and treatment of AD. Some herbal medicines may reduce inflammation in the brain, protect nerve cells from damage, and improve cognitive function by modulating different signaling pathways such as NF-κB, Nrf2, JAK/STAT, ubiquitin-proteasome pathway, AMPK/mTOR related to the autophagy-lysosome pathway, GSK-3/mTOR, and PI3K/Akt/mTOR, as well as the SIRT1 and PPARα pathways . Herbal re found . Similarls of AD .Our systematic review was limited by the scarcity of studies available for discussion of the findings. However, we presented some of the discoveries obtained during the literature search, which could not be included in the systematic review because their failure to meet the established inclusion criteria.Lithium is considered to be a potential treatment for improving neurotrophic responses and protecting the brain. In patients with amnestic cognitive impairment, treatment with lithium carbonate showed cognitive and functional stability for 2 years, with better performance in memory and attention tests compared to the placebo group . Unlike Insulin not only regulates glucose homeostasis, but it also has functions in the brain. It has been shown to improve synaptic viability, modulate neurotransmitter levels, such as dopamine, and protect against the toxic effects of Aβ peptide . Unlike In the last decade, research has being conducted to evaluate the effect of vaccination and immunotherapy in the treatment of AD . Most ofGiven that pharmacology and nutrition have some points in common, we will also discuss some data we have found regarding the relationship between nutrition and AD. Various nutrients and nutraceuticals have been linked to improvements in cognition and other psychological aspects related to AD  Some exaAD is commonly treated with drugs such as donepezil, rivastigmine, galantamine, and memantine . AlthougZolpidem and Zopiclone have been studied for their use in AD patients with insomnia, as insomnia is a frequent problem in these patients . DepressCompared to donepezil, TCM shows no significant difference in effectiveness for treating AD , althougAD is a common type of dementia that has caused a significant global economic and health burden, and there has been a wide debate on the use of statins as a treatment for this disease. Although a systematic review by Animal studies have suggested that TNF-α inhibitors may improve cognition and behavior. However, human studies have been limited . Sodium Benzodiazepines and related drugs have been associated with an increased risk of AD in old age and adverse events in patients with mild to moderate AD . EszopicAlthough RCTs are methodologically sound according to the JADAD scale, there is still significant variability in the types of interventions used. Only two studies  have invIn conclusion, although a potential improvement in cognitive function has been observed with some of the evaluated drugs, the limited number of available studies necessitates further research to determine their effectiveness and safety in treating cognitive impairments in Alzheimer’s disease.


It was found that paxillin expression is associated with the grade of dysplastic samples (p < 0.001). Conclusion: The present study provides evidence that paxillin may be involved in the pathogenesis of OSCC and the development and progression of dysplastic tissue, since the paxillin expression was higher than that of HK and OLP.Background: Paxillin is a cytoskeletal protein involved in the pathogenesis of several types of cancers. However, the roles of paxillin in epithelial dysplasia (ED), oral squamous cell carcinoma (OSCC), oral lichen planus with dysplasia (OLPD), hyperkeratosis (HK), and oral lichen planus (OLP) have remained unnoticed in the literature. This study aimed to evaluate its attainable functions in the pathogenesis and malignant transformation of potentially malignant oral epithelium and benign lesions. Methods: In this retrospective cross-sectional study, paxillin expression was investigated in 99 tissue samples, including 18 cases of OSCC, 21 ED, 23 OLP, 21 OLPD, and 16 cases of HK. The tissue sections also underwent immunohistochemical paxillin staining using 3,3-diaminobenzidine (DAB) chromogen. The intensity, location, and percentage of staining were examined across all groups. Data were analyzed using the Shapiro–Wilk test, ANOVA, Pearson chi-square, Kruskal–Wallis, and Dunn’s post hoc test. Results: The cytoplasmic percentage and intensity staining of Paxillin expression were evident in the central/suprabasal and basal/peripheral layers of all the obtained samples. The final staining score was significantly higher in OSCC and dysplasia compared to HK and OLP ( Oral squamous cell carcinoma (OSCC), the most prevalent malignancy in the head and neck squamous cell carcinoma category, was reported to rank 11th and 18th globally in 2012 and 2018 ,4. MultiDysplasia refers to abnormal cell growth. The oral epithelial dysplasia (ED) grade helps determine whether a lesion could likely progress to malignancy. The current gold standard for predicting the malignant transformation of OPMDs is the histopathologic evaluation for the presence of oral epithelial dysplasia ,17. The One of the chronic inflammatory disorders of the oral mucosa is oral lichen planus (OLP), which the WHO classifies as a potentially malignant lesion ,23,24,25Paxillin (PXN), first discovered in 1990, is a 68-kDa, adhesion-associated, and phosphotyrosine-containing protein that recruits signaling molecules into a complex. Structurally, it is considered as composed content, mediating protein-protein interactions. The domain-binding site’s contents act as sites for the cell cytoskeleton, tyrosine kinases, GTPase activating proteins, and other adaptor proteins that impress additional enzymes into the complex with paxillin . AccordiIn this cross-sectional study, 99 patients diagnosed with oral hyperkeratosis (HK) in 16 cases, OLP in 23, ED in 21, OSCC in 18, and lichen planus with dysplasia (LPD) in the rest of them (21 cases) were selected based on the clinically archived tissues and their medical records in the Oral and Maxillofacial Pathology Department of Shiraz Dental School, Shiraz, Iran, between 2011 and 2018. Histopathological criteria adopted for definite diagnosis of OLP were: (1) the presence of a well-defined band-like mainly lymphocytic infiltrate that is confined to the connective tissue’s superficial part; (2) signs of keratinocyte apoptosis and vacuolar degeneration of the basal and/or suprabasal cell layers; and (3) epithelial thinning and sometimes ulceration in the atrophic type ,48. In aAll the obtained samples were from a definitive diagnosis, and the related hematoxylin-eosin (H&E) slides were re-evaluated to confirm this diagnosis. After that, erosive and ulcerative OLP samples with no definitive diagnosis and defective epithelial components were excluded. The patient’s medical records with OLP diagnosis were evaluated, and if the clinical and histopathologic diagnoses were OLP, their slides would be used. The patients with lichenoid reaction diagnosis or no bilateral lesions were excluded.Moreover, poorly stained samples and small-sized ones that lead to a wrong diagnosis were excluded. Demographic data of the included cases, including age, gender, and the histological characteristics of each lesion, were also obtained from the patient’s medical records. There was no record of patients’ oral habits  available. Subsequently, the histopathologic grading of the dysplastic and tumoral specimens was performed to assess the probability of the malignant transformation.The minimum required sample size was calculated to be at least 80 participants (16 in each group) using GPower version 3.1.9.2, considering type one and type two errors to be 0.05 and 0.2, with an effect size of 0.4 based on Cohen’s criteria.The process of decision making on the use of human tissue specimens is usually the responsibility of the Institutional Review Board (IRB), which is also known as the Institutional Ethics Committee (IEC) of Shiraz University of Medical Sciences (SUMS). The Ethics Committee of Shiraz University of Medical Sciences, Shiraz, Iran, approved the study design (IR.SUMS.DENTAL.REC.1398.134). The current study was performed in terms of all the institutional ethical guidelines. The Ethics Committee/Institutional Review Board of SUMS waived the need for informed consent since the research was conducted on tissues already diagnosed by pathologists, which did not cause any serious physical harm to human subjects.The detection of paxillin expression was performed with immunohistochemical staining in terms of the standard protocols. Accordingly, this was followed by serial cutting of formalin-fixed and paraffin-embedded tissue blocks at a thickness of 4 μm. The xylene was used for the deparaffinized sections, graded alcohol series for rehydration, and 3% hydrogen peroxide in methanol, to block the endogenous peroxidase activity. After that, the sections were rinsed with phosphate-buffered saline and then subjected to microwave antigen retrieval in 0.01 mol/L sodium citrate buffer (pH 6.0). Rabbit anti-paxillin antibody  was used as the primary antibody, followed by horseradish peroxidase-streptavidin complex. Finally, adding 3,3-diaminobenzidine (DAB) chromogen visualized the labeled antibody, and all the sections were then counterstained with hematoxylin, which is generally used as background staining. The current study used colorectal cancer cells as the positive control [3 cell populations/each lesion at ×400 magnification. The percentage and intensity of immunoreactivity were assessed to quantify the paxillin expression by modifying Jaafari’s method [The cytoplasmic percentage of positive cells was determined by examining 10s method . The pers method . Some vaData were analyzed using SPSS software  at a 0.05 significance level. Quantitative and qualitative data were presented by mean ± standard deviation and number (percent), respectively. The Shapiro–Wilk test was used for the assessment of the normality assumption. Pearson chi-square, one-way analysis of variance (ANOVA), or Kruskal–Wallis followed by Dunn’s post hoc test was performed for the pairwise comparison of the groups regarding demographic characteristics or the study outcomes.In the present study, 99 patients were eligible to participate, including 57 women and 42 men, with a mean age of 50.7 years old, ranging from 15 to 83 years old. Baseline data, such as age and gender, SCC, and Dysplasia grade, are illustrated in The basal percentage was not significant between any of the study groups. However, the study groups saw significant pairwise differences in suprabasal percentage . In addip = 0.004)  of the paxillin expression among all the focus groups  were statistically significant (= 0.004) .p > 0.05).In the OSCC samples, paxillin overexpression in the basal layer was almost found in all cases (96%), but only 40% of the cases showed paxillin overexpression in the suprabasal layer . The ovep = 0.013). Of note, the paxillin overexpression increased with the progression of dysplastic grade (p < 0.001). Furthermore, 38.1% of them had a high final score. Notably, most of the HK samples had paxillin overexpression in the basal layers (95%), and those with suprabasal layer staining of paxillin had the lowest rate (3%)  C,D. MoreIn the LPD cases, 58% of the obtained samples showed paxillin overexpression in the suprabasal layer A,B. TheiIn all the samples of all the study groups, the basal/peripheral layers demonstrated more prominent staining than the suprabasal layer. On the other hand, the highest staining percentage of the suprabasal layer belonged to the ED samples, and the lowest belonged to the HK samples.p > 0.005, p < 0.005, p = 0.004), respectively.In both the malignant (OSCC) and dysplasia groups , the overall staining intensity of paxillin in basal and suprabasal layers and the mean final score were higher than those of HK and OLP  and dysplasia  compared to HK and OLP. The paxillin expression was also more observed in the tissues with dysplastic changes than in the non-dysplastic tissues. Hence, it can be suggested that paxillin over-expression might play an essential role in developing dysplastic tissues into malignancy. These outcomes align with Alam’s and Mackinnon’s findings ,57. ThesInterestingly, previous studies on urothelial and lung carcinoma claimed that down-regulation in the paxillin expression might affect cell motility and promote invasiveness ,58. AddiOLP is considered a potentially malignant inflammatory lesion with a malignant transformation rate of up to 12% . No studp = 0.001, p = 0.001), respectively. The underlying cause of this finding may be that paxillin plays a role in pathological conditions, such as inflammatory processes [p = 0.001) [Notably, the specimens with OLP manifested a lower paxillin expression than the ED and OSCC samples (rocesses . Corresprocesses . Howeverrocesses . Lower processes . Recent = 0.001) . This ou= 0.001) .In the present study, the level of paxillin increased with the grade of the samples; however, the correlation was not statistically significant, which may be due to the usage of a small number of samples in each group, which is consistent with the investigation of Kandelman et al. . SeveralAdditionally, in the dysplastic groups, paxillin was highly expressed at the advanced dysplastic stages. It is unclear whether paxillin is associated with invasion since it manages focal adhesion kinase (FAK) duty , which iSimilar to the findings of Kandelman et al. and Mackinnon et al. ,57, our Larger samples may be able to show the malignant potential of OLP. However, OLP with dysplastic changes is not a typical lesion, and section preparation for this goal may be difficult.Numerous investigations on the function of paxillin in cells using various methods have shown the same results, indicating that paxillin regulates cell spreading and motility. Nevertheless, this depends on the context. Paxillin could therefore be considered a helpful biomarker for both treatment and prognosis. However, additional research involving a sizable sample size, prospective long-term follow-ups, multiple geographic locations, local lesion biopsies, as well as other molecular analytical techniques may be required to draw a conclusive conclusion regarding the relationship between paxillin and the precise pathogenesis of potentially cancerous disorders and OSCC.In conclusion, the present study provides evidence that paxillin may be involved in the pathogenesis of OSCC and the development and progression of dysplastic tissue since the overall staining intensity of paxillin in both the OSCC and dysplastic groups was higher than that of HK and OLP. In all the groups, the basal layers of the lesion demonstrated more prominent staining intensity than that of suprabasal layers, which may refer to the proliferative activity of paxillin. So, paxillin may be a prognostic marker in dysplastic lesions.


Objectives: The aim of this study was to evaluate the level of hematuria and the presence of clots during retrograde intrarenal surgery (RIRS) and miniaturized percutaneous nephrolithotomy (mPCNL) to predict surgical outcomes. Materials and Methods: The data of patients who underwent RIRS and mPCNL were analyzed separately. A hematuria grading (HG) system was classified into five grades based on the presence of blood clots and any visible stones according to the irrigation settings. Inter-observer reliability of the grading system was assessed using intra-class correlation and Spearman’s rho. Results: The HG system showed high agreement among examiners, with high intra-class reliability and a strong correlation between RIRS and mPCNL groups. The stone density of the Houns-field unit was the most important factor in determining the hematuria across the development and validation groups of RIRS and mPCNL patients. Multivariate logistic regression analysis showed that the HG system was a significant predictor for remnant stones in the PCNL group and the probability of acute pyelonephritis or sepsis in the RIRS group. The high hematuria group showed lower basketing difficulty with the basket with a blue marker instrument than with others. Conclusions: The new HG system shows excellent inter-observer reliability and a correlation with a gradual increase in stone density and surgical difficulty. Nephrolithiasis is a highly prevalent disease worldwide, ranging from 1–5% in Asia, 5–9% in Europe, and 7–13% in North America ,3,4. NepRecently, retrograde intrarenal surgery (RIRS) and miniaturized percutaneous nephrolithotomy (mPCNL) have emerged as safe therapeutic options for managing renal stones, because they can reduce hospitalization time with an acceptable stone-free rate ,7. MoreoBecause of the small caliber of scope and the nature of underwater surgery, hematuria, especially the presence of blood clots during RIRS and mPCNL, makes surgery more difficult. Several factors, including increased intrarenal pressure, distended cavities in the renal pelvis and renal calyces, urothelial injury by direct laser firing, fragmented stones, and endoscopy manipulations, can cause bleeding during procedures. In addition, the high grade of hematuria can lead to prolonged operating time and affect the stone-free rate. Therefore, it may require an additional operation. However, no studies are available on the correlation of the severity level of hematuria with surgical difficulty or surgical outcomes during these operations.Therefore, this study aimed to develop and externally validate an easy and reliable hematuria grade (HG) system to assess the severity of hematuria during RIRS and mPCNL. Because the two surgical methods share the fact that hematuria is a key factor for performing surgery and predicting surgical outcomes, our HG system applied the same HG system to both RIRS and mPCNL. We evaluated the intra-class correlation and the inter-observer reliability of the HG system among examiners and determined between-group differences in surgical outcomes based on clinical parameters.We retrospectively evaluated the medical records of all patients who underwent RIRS and mPCNL at two institutions. The inclusion criteria followed the guidelines of the Urological Association of Asia . We inclThis study was approved by the Institutional Review Boards (IRB) of Institution 1  and Institution 2 . Participants’ waiver of the informed consent requirement was approved by each IRB, considering the retrospective study design involving anonymized data. All experiments were performed following relevant guidelines and regulations.® PC Hydrophilic Guide Wire, Terumo Guide Wire Radifocus) was inserted into the ureteral orifice, and retrograde pyelography was performed using a dual-lumen catheter to place a Superstiff guidewire . If a pre-operative JJ stent was inserted, we retracted and put the Superstiff guidewire into the ureter through the JJ stent. The authors placed the Superstiff guidewire very carefully into the kidney so as not to cause damage, and the tip of the guidewire is usually located in the upper major calyx. Subsequently, an 11/13-Fr ureteral access sheath (UAS) (Boston Scientific Corporation) was placed up to the ureteropelvic junction, and a flexible ureteroscope  and URF-P5 or URF-V  was inserted through the UAS. The use of a UAS may cause a ureter injury to produce hematuria during RIRS, but when we started the RIRS procedure, we saw no hematuria in all cases. After systemic inspection of the renal calyx, we performed Holmium laser lithotripsy with a Lumenis Pulse™ 100 H or 120 H using a 200 nm laser fiber. In the case of a renal stone lodged in the lower calyx, we retrieved the stone from the upper or middle calyx using a stone basket if feasible. Laser power was set to 1.0 to 2.0 W with a 10–30 Hz frequency. Portions of the fragmented stones were removed with a stone basket, and the type of stone basket varied according to the surgeon’s preferences . Remnant stones were completely fragmented (stone size < 1 mm) by the pop-dusting procedure. Following laser lithotripsy, we examined the renal calyx for the presence of stones missed during the procedure. Consistent irrigation flow is necessary for endoscopic stone surgery in order to optimize the endoscopic view. An automated irrigation pump, the FloSteady Irrigation Pump , was used for more consistent flow than irrigation devices that depend on pressure that are manipulated manually with pressure infusion sleeves  and 0.958  for groups of RIRS and mPCNL patients, respectively. Strong correlations  were also found for groups of RIRS and mPCNL patients, respectively.In the development group, results showed high agreement for the HG system among examiners, with intra-class reliability of 0.928 [95% confidence interval, 0.899–0.950; p = 0.037), maximal diameter of stones (p = 0.027), stone volume (p = 0.005), operative time (p = 0.040), and the occurrence rates of acute pyelonephritis and bleeding without transfusion were observed according to the increase in the HG system. In the validation group of RIRS, only the Houns-field unit (p = 0.034) and the occurrence of acute pyelonephritis or sepsis (p < 0.001) showed significant between-group differences. In the development and validation groups of mPCNL, only the Houns-field unit showed significant between-group differences according to the increase in the HG system.Clinical parameters related to stones showed an increasing trend of surgical difficulty with increasing severity of hematuria . The stop = 0.040), the operative times (p = 0.001), and body weight (p = 0.022) were predictors for remnant stones in the RIRS group. However, the HG system (p = 0.009), preoperative creatinine (p = 0.012), Houns-field unit (p = 0.002), number of stones (p = 0.003), operative times (p < 0.001), and body weight (p = 0.010) were predictors for remnant stones in the PCNL group , preoperative creatinine (p = 0.014), and the preoperative glomerular filtration rate (p = 0.023) were significant predictors in the RIRS group. However, preoperative creatinine (p = 0.010), the preoperative glomerular filtration rate (p = 0.022), and female gender were significant predictors in the mPCNL group.Regarding the occurrence of acute pyelonephritis or sepsis, the HG system (p = 0.21). Based on the severity of hematuria, we divided patients into low (HG-zero and HG-one) and high  hematuria groups. There was a significant difference in basketing difficulty between the low and high HG groups. In the high HG group, the surgical difficulty of basketing techniques was lower only in the basket with a blue marker instrument (Skylite) than in others, showing a borderline statistical significance (p = 0.05).Although no significant between-group differences in stone basketing difficulty score were observed , the aveIn this study, we developed an easy and reliable HG system for RIRS and mPCNL that showed a strong agreement among examiners to assess hematuria. We found a significant association of the HGs with the pre- and intra-operative parameters, which can impact surgical outcomes. To the best of our knowledge, this is the first study to demonstrate the effectiveness of an HG system and the importance of blood clots for predicting surgical complications of RIRS and mPCNL.Hematuria is one of the complications that leads to surgical difficulties and longer operative times. It affects the stone-free rate. Surgeons have tried to explain the level of surgical difficulty with intraoperative parameters. However, only the total operation time is a single candidate for explaining the level of surgical difficulty. Therefore, a validated HG system is warranted for clinicians to improve patient counseling and better evaluate surgical outcomes . QuantifPrevious studies showed that stone size, number, and location had been reported as risk factors for low stone-free rates ,19,20. TIn our study, the Houns-field unit, maximal diameter of stones, stone volume, operative time, and bleeding without transfusion were significantly associated with the increasing severity of hematuria. To treat hard and large-volume stones, a larger diameter of laser fiber, UAS, high-power laser settings, and other techniques are frequently used by surgeons. When we use high-power laser settings, tissue around the stone is more vulnerable to injury. That is why the above clinical parameters may cause severe hematuria. The high-power laser settings in our study are typically altered as follows. For RIRS, the initial laser power is usually 0.5 J, but it is usually increased to 1.0 or 1.2 J. For mPCNL, the initial laser power is usually 2.0 J, but it is sometimes increased to 2.5 J.The high HG system group was a significant predictor for remnant stones in the PCNL group and the probability of acute pyelonephritis or sepsis in the RIRS group. The probability of acute pyelonephritis in the RIRS group can be increased by high-speed irrigation to clear the visual field. Thus, high HG system cases may lead to intraoperative high intrarenal pressure, which affects postoperative urinary tract infection ,22. In tRenal stone complexity based on stone number and location was significantly correlated with hematuria based on the HG system in our study. In addition, the present study showed that the high HG system of three and four with blood clots was another critical factor to consider in predicting the poor stone-free rates, because the blood clot can attach to the stone, and the surgeon can miss the stones inside the clots. Therefore, the surgeon needs to melt the clots or fragment the hidden stone fragments with a laser. We used long pulse laser emission to dissolve the clot, which reveals the chink in the clots and exposes the stone’s surface. In an additional way, surgeons can perform basketing techniques constantly after laser emission to see the maximal size of the stones. With these techniques, surgeons should be careful not to use high temperatures with continuous emission of a long-pulse laser for a long time. Therefore, with the above delicate surgical settings, our novel HG system successfully represented the importance of blood clots for high stone-free rates and the severity of operation difficulty with the HG system.There was no significant between-group difference in basketing difficulty measured by a modified visual analog scoring system. However, a higher score was noted for the HG-three group. Interestingly, in the high hematuria subgroup with HG of three and four, the basket with a blue marker showed a trend for better performance than other instruments. In the usual setting of RIRS, stone basketing was performed by the first assistant. Although operators could use their hand–eye coordination for orientation, the first assistant measured the stone and basket distance through the direction of the eyes. In the high hematuria grade, complementary color contrast (green to blue) might aid in basket orientation, supporting better identification of structures already accepted for background sheet color during microsurgery . In thisThis study had several limitations. Firstly, there were no patients and one single patient with an HG-four grade score in the RIRS and mPCNL groups, respectively. This could be attributed to the stringent HG-four criteria, in which severe hematuria posed difficulty in proceeding with the operation. The rare occurrence of HG-four suggests RIRS and mPCNL as safe procedures in terms of bleeding. Therefore, we may consider removing HG-four from this grading system. However, we believe that surgeons might gain experience in managing HG-four levels of hematuria by handling such patients’ cases in rare situations. Secondly, this study was performed in a retrospective manner. Thus, it might not be free from selection bias. Lastly, the different types of flexible ureteroscope utilized may affect visibility. Different visibility may have an impact on HG evaluation. However, the HG system is based on the reaction of the surgeons regarding how to react with regard to the hematuria during surgery. Surgeons in this study thought that the type of ureteroscope might not be a detrimental factor in finding targeted stones in a bleeding situation .Despite the shortcomings of this study, we successfully developed and validated the reliability of a novel HG system for RIRS and mPCNL. The new HG system showed significant associations with pre- and intra-operative parameters. Additionally, we found interesting evidence for optimal basket selection in severe hematuria conditions.We developed a novel HG system for predicting surgical complications of minimally invasive stone surgery based on simplified and easily applicable parameters, including the presence of a blood clot, any visible stone, and characteristic hematuria in irrigation fluid. The new hematuria grading system shows excellent inter-observer reliability and a relationship with a gradual increase in surgical difficulty. The hematuria grade with clots was one of the significant predictors for remnant stones. The appropriate surgical technique is necessary to increase surgical outcomes with the condition of hematuria. In addition, the surgical difficulty of basketing techniques might be lower with the basket with a blue marker instrument than with others in the high hematuria group.


Pisum sativum L.) hold significant value for producers, researchers, and ingredient manufacturers due to their wealthy composition of protein, starch, and micronutrients. The protein quality in peas is influenced by both intrinsic factors like amino acid composition and spatial conformations and extrinsic factors including growth and processing conditions. The existing literature substantiates that the structural modulation and optimization of functional, organoleptic, and nutritional attributes of pea proteins can be obtained through a combination of chemical, physical, and enzymatic approaches, resulting in superior protein ingredients. This review underscores recent methodologies in pea protein extraction aimed at enhancing yield and functionality for diverse food systems and also delineates existing research gaps related to mitigating off-flavor issues in pea proteins. A comprehensive examination of conventional dry and wet methods is provided, in conjunction with environmentally friendly approaches like ultrafiltration and enzyme-assisted techniques. Additionally, the innovative application of hydrodynamic cavitation technology in protein extraction is explored, focusing on its prospective role in flavor amelioration. This overview offers a nuanced understanding of the advancements in pea protein extraction methods, catering to the interests of varied stakeholders in the field.Yellow field peas ( Field peas are cool-season legume pulse crops globally grown for use in human and animal nutrition. In Canada and other countries, field peas are crops of economic interest and are used as export commodities. The most common field pea is the yellow cotyledon species, which is followed by the green cotyledon species and a few other species . Pea seeWhile pulse crops are the most popular protein sources for human consumption in tropical and subtropical countries, their utilization is still in its infancy in Western nations ,3. UntilThe nutritional value and functional properties of proteins are dependent on the quantity and quality of the protein. Pea proteins have a high potential to be utilized as ingredients in the food industry because of their relatively balanced amino acid profile when compared with other plant proteins like soybeans . HoweverYellow field peas, like other pulses, are a leguminous crop grown mainly for the consumption of dry seeds which are rich in macromolecules  and micromolecules  but low in fats. The chemical composition of pea protein is affected by the cultivar , growth conditions, and the protein extraction methods used to produce concentrates and isolates. In addition, pea protein contains residual antinutritional substances  and natural pigments . Maharjan et al.  analyzedThe chemical composition of yellow field pea flours as determined by Millar et al.  showed tThe crude protein content in a pea protein isolate obtained by alkaline extraction coupled with isoelectric pH precipitation (AE-IEP) was reported to be 83.33–84.67% , but there were no significant differences between the protein content of isolates extracted at pH 8.5, 9.0, and 9.5 . HoweverAs shown in The colors of pea protein isolates differ and are dependent on the cultivar, as determined using the International Commission on Illumination (CIE) L*a*b* method. An analysis of 12 of the 2S proteins showed a range for L* (87–91), which signifies lightness; a* (−0.5–3.5) for the green cotyledon color; and b* (19–24), which is the yellow color.  In anothSoybean is an oil seed with approx. 20–30% lipid content depending on the cultivar . The majAs shown in The different protein fractions  vary in amino acid composition, and the major non-essential amino acids in globulins are asparagine, glutamine, glycine, arginine, isoleucine, leucine, phenylalanine, lysine, and threonine, while albumins are rich in tryptophan, lysine, and threonine ,41. ProtThe quality of any food protein is assessed by the amino acid composition and protein digestibility. The protein-digestibility-corrected amino acid score (PDCAAS) is an assessment model that has been in use for over 20 years, and it is based on the assumption that all amino acids have the same digestibility as crude protein and calculated using fecal digestibility. However, proteins are mostly digested in the small intestine, and an accurate way to determine amino acid release and availability is using ileal digestibility in a procedure called digestible indispensable amino acid score (DIAAS) . The PDCE,E)-2,4-heptadienal, acetophenone, 1-octen-3-one, and 3-isopropyl-2-methoxypyrazine are reported to be responsible for off-flavor in peas . ,73. 7,73g) usage . During g) usage . Overallg) usage .Wet fractionation is a conventional protein extraction method with the potential of producing high-purity (up to 95%) and high-yield ~60–90%) protein ingredients depending on the source  Table 4Table 4. % proteinAlkaline solubilization coupled with isoelectric pH precipitation is a popular wet fractionation technique mainly because of the high-purity protein ingredients obtained . This meConditions reported to affect AE-IEP protein extraction are the temperature, flour-to-solvent ratio, alkaline solution concentration, and processing time, and these conditions can be optimized to maximize protein yield and recovery ,97. The Also, amino acid and chemical scores in wet-fractionated protein were reported to be higher than those in dry-fractionated pea protein . This waUltrafiltration processing is a non-thermal, pressure-driven, and membrane-based separation technique with applications in protein fractionation, concentration, desalting, and clarification ,103,104.Membrane UF is used in combination with other techniques during protein extraction to produce ingredients with high native content and functionality. A comprehensive review of the application of the ultrafiltration technique in food applications was published by Ratnaningsih et al. . An earlLimitations to UF technology are membrane fouling and concentration polarization, which decrease permeate flux . FoulingMicellar precipitation (MP) is a mild extraction method that produces proteins with a high native structure content. In this method, proteins are extracted in a salt solution at a neutral pH, and the insoluble materials are separated using centrifugation. Subsequently, the proteins are recovered through precipitation and the formation of micelles by the addition of cold water to the high-salt protein extract at different ratios. Micelles form in water as nanosized aggregates where the polar heads orient with the outer environment and the hydrophobic moieties are within the core. Another variation of this method is the reverse micellar precipitation which forms nanostructured aggregates of surfactant molecules in a non-polar environment containing water at the core of the structure. A thorough review of the process and applications of this method was carried out by Sánchez-Velázquez et al.  and MondAlthough the MP technique has been reported as an efficient extraction method for proteins, the literature has scanty information about its use for pea protein extraction. A study by Yang et al.  showed tThe salt extraction method employs the basic salt-in (solubilization) and salt-out (concentration) principles of proteins . The conWater extraction is a mild fractionation method that uses water with or without the adjustment of pH. This technology has the potential to produce proteins with high native structure content, but like all the methods discussed so far, there are limitations, which include low protein yield and recovery, low purity, and high water consumption. Geert et al.  showed tEnzyme-assisted methods are green and environmentally friendly techniques ,113. TheDifferent extraction and processing techniques have been used at the laboratory scale where process controls are relatively easy to manipulate. Scaling up these techniques requires high optimization of the processes at larger scales to maintain proper exposure to processing conditions and the purity, yield, and quality of the end product. Although scale-up is essential for industrial production, the information in the literature about pilot plants and industrial-scale pea protein extraction methods is very scanty. However, a few recent studies have reported some progress in the scaling up of pea protein extraction methods. Hansen et al.  determinThe functional properties of pea proteins are the qualities exploited for food formulation and processing, and these properties are closely related to the physicochemical properties of the protein. To effectively use pea protein in food applications, some form of pretreatment is required to improve flexibility, surface properties, digestibility, and flavor attributes. These methods can be classified as chemical , physical , and biological . In this section, the common functional properties of pea protein will be discussed along with conventional or cutting-edge technologies that have been employed in the modulation of the physicochemical properties and, consequentially, the functionalities. Also, we will discuss some novel processing methods already in use in soybean protein processing as potential techniques in pea protein processing.Solubility is a measure of protein–solvent and protein–protein interactions and is largely dependent on a combination of factors such as the surface properties (charge and hydrophobicity) and non-covalent interactions of the protein. Karaca et al.  reportedAnother factor that affects the solubility of pea protein is variations in the ratio of the different subunits. Going by Osborne’s classification, globulins are weak-salt-soluble, albumins are water-soluble, prolamins are alcohol-soluble, and glutelins are acid-soluble. Vicilin proteins are more soluble than legumins because they have a low molecular weight (LMW), are glycosylated, and contain no disulfide linkages (increased flexibility), while the α and β subunits of the legumin proteins are linked together by disulfide linkage, which contributes to structural rigidity ,126. Conw/v) with high pressure at 600 MPa for 5 min and heat treatment at 95 °C for 15 min was reported to impair its solubility [A study was carried out to bridge the functionality gap between commercial and laboratory-prepared pea protein isolates by the treatment of the commercial protein with high-pressure homogenization (HPH) at 205 and 500 psi . The reslubility . Phospholubility . A >50 klubility . This walubility .The WHC and OHC represent the total amounts of water and oil, respectively, that 1 g of a protein powder can absorb without expulsion. These properties are related to the texture, mouthfeel, and flavor retention of products and are based on the interactions of the protein with water or oil and other solutes ,131. WHCAspergillus oryzae, Rhizopus oryzae, Rhizopus oligosporus, Lactobacillus plantarum, and Bacillus subtilis strains significantly improved both WHC and OHC due to the optimal exposure of polar and non-polar groups [Treatments to improve WHC and OHC of pea protein aim at structural modulation of the protein to expose the hydrophilic and hydrophobic groups, respectively. High energy media mill (HEMM)-treated pea dietary fiber (PDF) improved the WHC (37%) and OHC (123%) of a pea protein beverage because the treatment increased viscosity and steric properties . High-inr groups . Additior groups . This isr groups . Howeverr groups . Anotherr groups .Foams are two-phase dispersion systems of air cells separated by a thin continuous liquid layer, the lamella . FoamingThe processing environment and pretreatment techniques influence the foam properties of proteins. For example, treatment of PPI at 90–100 °C and pH 5.0 (isoelectric point) significantly reduced the foaming ability as both conditions reduced surface properties and increased electrostatic attractive forces . The unf°C for 30 min improved the foam capacity by approx. 105% when compared to the untreated pea vicilin (73.53%) while foam stability was not different from the control. During controlled heating, soluble aggregates could be formed, β-sheets were converted to α-helices, and the surface properties  were enhanced [°C for 30 min) and at different pH values coupled with membrane UF (>50 kDa MWCO), especially at pH 3.0, 7.0, and 9.0. Another study showed that the addition of tea saponin to PPI (50 mg/mL) improved foam capacity (210%) when compared with PPI alone (113%), while stability was improved at a lower protein concentration (10 mg/mL) [Chang et al.  treated enhanced . Similarenhanced  reported0 mg/mL) . A high 0 mg/mL) . The com0 mg/mL) . Also, S0 mg/mL)  showed tEmulsification properties are the most widely studied functional properties of pea proteins, and the reason is that oil-in-water (O/W) emulsions are common in several food applications . Emulsifiers are required to reduce the surface tension at the oil–water interface to stabilize the emulsions, and pea proteins have been identified as potential natural emulsifiers because of their physicochemical properties. Research has shown that commercial pea proteins have limited use in emulsification as functionality is reduced due to greater denaturation and protein aggregation resulting from harsh processing conditions ; hence, pretreatment is required ,153. Pre°C for 30 min also improved emulsification properties compared to those of the unheated pea protein, and higher proportions of vicilin and the basic subunit of legumin became adsorbed to the oil–water interfacial layer of the emulsions [°C produced PPI with smaller protein aggregates and enhanced solubility and emulsification properties compared to those of the continuous sheet-like morphology formed by conventional hot air drying at 60 °C [°C for 10–20 min) were enhanced at pH 7.0 due to improved solubility [The literature is replete with studies on different pretreatment methods used to modulate the emulsification properties of pea protein. Just to mention a few, a study showed that grinding PPI to powder for 10–20 min significantly reduced the particle size of the droplets, increased the surface charge, and improved emulsion stability . Combinimulsions . In addiat 60 °C . High-inat 60 °C . The intat 60 °C . PPI–κ-cat 60 °C . Likewislubility .Gels are formed when large molecules crosslink to form a 3D structure that is an intermediate between a solid and a liquid; these structural changes can be induced by heat, chemical, and enzymatic treatments. The ability of proteins to form gels is evaluated as the least gelation concentration (LGC), which is the lowest protein concentration required to form a self-supporting gel; the lower the LGC, the better the gelation ability of the protein. During gelation, various steps occur, including denaturation, aggregation, and formation of a protein network. Functional groups such as the sulfhydryl are exposed when the structure is unfolded, and irreversible aggregates are formed through disulfide bridge, hydrogen bond, hydrophobic, and/or van der Waals interactions . The for°C) will denature and form large insoluble aggregates through disulfide bonds, while vicilin forms smaller aggregates stabilized by non-covalent interactions [°C for 1–2 h to form gels [Gelation is influenced by factors that include the extraction method; relative ratio of protein subunits; solubility; protein content; and other cellular materials like carbohydrates, lipids, and fiber ,70,165. ractions , and theractions ,120,166.ractions ,164. Howractions . The rheorm gels . A unifoorm gels .Haematococcus pluvialis residue (HPR) at 10–40 g/100 g; HPR gave the extrudate a reddish meat color and a loosened layered fibrous structure [°C by the addition of κ-carrageenan (0.5%) and a low protein concentration (7.5%) [An earlier work by Sun and Arntfield  reportedtructure . Anothern (7.5%) . The surn (7.5%) . Addition (7.5%) . The nutritional quality of a protein is defined by the FAO/WHO based on the amino acid content and in vivo bioassay digestibility (FAO/WHO/UNU 2007). The FAO/WHO proposed the description of the nutritional quality of protein using digestibility based on individual amino acids  rather than digestion based on the whole amino acid composition  . A factoThe presence of naturally occurring antinutritional materials such as antigenic proteins, protease inhibitors, α-amylase inhibitors, lectins, alkaloids, saponins, and tannins would reduce the digestibility of pea proteins and nutrient availability in the gut . Other cLactobacillus plantarum reduced the activity of protease inhibitors, but digestibility was reduced at the 11th hour from 67.0% to 54.6% due to a reduced score of sulfur amino acids [°C, and the result showed that digestibility was enhanced and there were improved levels of glutamine, cysteine, and methionine. Limiting the SCAA level in pea protein will influence digestibility, which is another reason for the lower digestibility in plant proteins than in animal proteins [Another study evaluated the effect of different processing treatments on the antinutritional materials and digestibility of the same cultivar of yellow field peas grown around four different locations in Saskatchewan . The resno acids . On the no acids  fermenteproteins , and digproteins . The solproteins .The food industry is one of the highest consumers of water and energy, and for this sector to remain in business and maintain sustainable growth, the use of processing techniques that offer increased efficiency and reduced water and energy consumption must be employed . HoweverOur discourse so far has been based on processing technologies that have been applied in the extraction and structural modulation of pea protein. Under chemical treatments, techniques like glycation, acylation, phosphorylation, and pH shifting have been widely used in pea protein processing. Other common methods are the biological class  and physical class . However, our search reveals some physical methods  that have been used in the processing of soybean protein but have not been applied to pea protein processing. A study showed that the application of hydrodynamic cavitation  to soybean glycinin aggregates dissociated the aggregates and enhanced the physicochemical and functional properties of the protein . AnotherThis literature review indicates a notable gap in research related to the utilization of pressure-assisted protein processing technologies to augment yield and functionality. A promising avenue for future investigation is the exploration of the impacts of high pressure (HP) and abrupt pressure changes in hydrodynamic cavitation (HC) on the yield and quality of pea protein, as both methodologies are harmonious with the wet fractionation technique. Additionally, HC technology can offer controlled heating, which is crucial for the inactivation of the lipoxygenase enzyme responsible for the oxidation of polyunsaturated fatty acids and resultant off-flavors in pea proteins. Initial studies have demonstrated the positive influence of HP treatment, within 50–125 MPa, on soybean protein extraction yield, with conditions for HP attainable through high-pressure homogenizers (HPH) at pressures exceeding 35 MPa . HoweverPlant-based proteins like PPI are taking center stage in research and food formulations for several reasons . Using pea proteins as ingredients in food and beverage formulation was well captured in a review by Boukid et al. . The funNowadays, there is a surge in the consumption of plant-protein-based meat or seafood analog products. Pea proteins can create HME fibrous-textured extrudates to mimic meat products ,167,192.Research in the replacement of other protein sources with pea protein in the production of beverages is progressing and yielding positive outcomes. The application of different plant proteins  in fermented beverages showed that the product from pea protein exhibited the highest viscosity and coagulum strength with no syneresis . Klost aw/w) cholecalciferol/canola oil to improve the stability of vitamin D when fortified in food formulations such as milk and juices. Nanoemulsions that carried 20 μg vitamin D/mL exhibited superior water holding, foam, emulsification, and antioxidant properties when compared to the PPI prepared by ultrasound treatment [PPI has been widely used as a carrier in nanoencapsulation technology to preserve and transport labile nutrients and nutraceuticals. Akkam et al.  preparedreatment . The addreatment .Yellow field pea is a high-protein crop with variations in chemical composition from different cultivars, and even when the same cultivar is grown in the same environment, the harvest and storage conditions are important factors. Extensive work has been carried out on optimizing the functional properties of pea proteins for applications in the food industry. The major challenges in using pea protein as an ingredient are the intrinsic and extrinsic factors . These lead to discrepancies and gaps in the functional properties and flavor output of the ingredient. Notably, laboratory-prepared field pea proteins maintain most of their native functionality, while commercial pea ingredients mainly have high degrees of denaturation because of conventional extraction methods like AE-IEP and spray drying conditions. Research has shown that the existing conventional extraction methods (dry and wet fractionation) do not provide optimal results  alone and may be more effective when used as a hybrid model. Dry fractionation could produce protein concentrates with preserved native properties, but their purity is low (40–50% protein content), while protein isolates obtained from wet fractionation have high purity but are denatured with impaired functionalities. The purity of dry-fractionated proteins could be improved by ~15% using electrostatic methods in combination with or as an alternative to air classification. Milder wet or aqueous fractionation methods  have been used either as a standalone technology or in combination with the AE-IEP method to produce proteins with superior yield, purity, and functionality when compared to conventional methods. A divide exists between the functional properties of laboratory-prepared and commercially prepared pea protein products because of the harsh extraction methods used for the latter. This gap can be effectively bridged using milder technologies  to maximize yield, purity, and protein functionalities. In addition to the choice of the appropriate extraction method, research has shown that the use of chemical, physical, and enzymatic methods to modulate the complex conformation and improve the organoleptic and nutritional properties of pea protein have great potential to produce proteins with a high quality that is suitable for industrial use and consumer acceptability. This literature review indicates a notable gap in research related to the utilization of feedstock pretreatment technologies to enhance pea protein extraction in terms of yields and functionalities. For example, cavitation technology, based on ultrasonication or hydrodynamic pressure changes in the flow stream, is widely accepted for cell disruption. It has been applied in the extraction of soybean protein and should be explored for pea protein extraction. The authors are currently working on a project to utilize hydrodynamic cavitation for the pretreatment of yellow peas for protein extraction. The impact of abrupt pressure changes produced by hydrodynamic cavitation on the yield and quality of pea protein will be explored. The economic advantages of the pretreatment technologies and hybrid methods inspire industry interest in commercial implementation.


Many reports have focused on cigarette smoking and internet gaming disorder (IGD), with widespread alterations of resting-state functional connectivity (rsFC) in the reward and memory circuits, respectively. Epidemiological studies have also shown high comorbidity of cigarette smoking and IGD. However, the underlying mechanisms are still unknown. Therefore, this study investigates the comorbidity and interaction effects between smoking and IGD from the rsFC perspective.Resting-state functional magnetic imaging data were collected from 60 healthy controls (HC), 46 smokers, 38 IGD individuals, and 34 IGD comorbid with smoking (IGDsm) participants. Voxel-wise rsFC maps were calculated for all subjects with the ventral tegmental area, rostral hippocampus, and caudal hippocampus as regions of interest, respectively.Significant interaction effects between smoking and IGD were mainly involved in the reward and memory circuits; that is, the rsFC between the ventral tegmental area and right nucleus accumbens, between the rostral hippocampus and bilateral nucleus accumbens, sensorimotor areas, and left middle temporal gyrus. Specifically, in these circuits, smokers showed decreased rsFC compared to the HC group, while IGDsm showed increased rsFC compared to smokers and IGD individuals. The IGDsm and HC groups showed no significant difference. The altered rsFC also correlated with clinical measures.These findings indicate that lower rsFC in smokers or IGD individuals increases under the effect of another type of addiction, such as smoking and IGD, but only increases to the normal state, which might explain the comorbidity and interaction between smoking and IGD from the perspective of functional circuits. Accumulating evidence showed that cigarette smoking is associated with respiratory and vascular diseases and even increases the risk of cancer, especially lung cancer . There iSmoking and IGD are typical representatives of substance and behavior addiction and many studies have found that the brain changes caused by smoking and IGD both involve the ventral tegmental area (VTA) and the hippocampus. For example, structurally, smokers showed significantly smaller volumes, as well as greater volume loss with increasing age than non-smokers in the bilateral total hippocampus and multiple subfields . IndividThe VTA is the starting brain region of the reward dopamine mesolimbic circuit , which iTo test our hypothesis, we recruited four groups of healthy controls (HC), smokers, IGD, and IGD comorbid with smoking (IGDsm) individuals using resting-state functional magnetic resonance imaging (rs-fMRI) to investigate the rsFC alterations among addicts and the interaction effects of rsFC between smoking and IGD in reward and memory circuits with the VTA, rostral hippocampus (rHip), and caudal hippocampus (cHip) as the regions of interest (ROIs).A total of 62 HCs, 50 smokers, 39 IGD subjects, and 34 IGDsm subjects were recruited in our study (age: 16–29 years). The Mini International Neuropsychiatric Interview  was usedThe study procedures were carried out in accordance with the Declaration of Helsinki and were approved by the Medical Ethics Committee of Ren Ji Hospital, School of Medicine of Shanghai Jiao Tong University. All subjects were informed about the study and all provided informed consent.See Considering the reward and memory circuits involved in smoking and IGD, the VTA and hippocampus were selected as ROIs . In addit-test on rsFC maps with significant results saved as masks for the further two-way analysis of (ANCOVA) to test the interaction between smoking and IGD, both with a primary voxel determining threshold of p < 0.001 and FWE cluster-corrected (p < 0.05) to protect against false-positive findings. After that, the rsFC value of the significant cluster was extracted by averaging the rsFC values of all the voxels in the cluster and then performing one-way ANCOVA and post hoc comparison with Bonferroni’s correction (p < 0.05/5 = 0.01). To test the relationship between the altered rsFC and smoking as well as IGD-associated characteristics, a step-wise multiple linear regression analysis was performed with rsFC among groups as dependent variables, demographic features , smoking-related variables , CIAS and other questionnaire scores  as independent variables. A p-value of less than 0.01 was considered significant (uncorrected).To test demographic and clinical group differences, the Chi-square test was performed for the gender data and the two-way analysis of variance for other variables. As part of the following rsFC analysis, age, gender, years of education, and mean frame-wise displacement were used as the controlling variables and the statistical procedure included a voxel-wise one-sample The detailed demographic and clinical information were the same as in our previous study  and are t-test was performed. The one-sample t-test results can be seen in The rsFC between the whole brain and three ROIs of each subject were calculated, respectively, and then a one-sample F-values, and cluster sizes can be seen in After correction, the ANCOVA results showed that significant interaction effects between smoking and IGD were mainly involved in the rsFC between the VTA and the right NAc  as well Post hoc comparison of rsFC values among the four groups also showed significant results when the VTA, cHip, and rHip were used as the ROIs. Specifically, when the VTA was the ROI  = 22.67, p = 4.04 × 10–6]. The rsFC of smokers was significantly lower than that of the HC group (p = 1.27 × 10–6), but the rsFC of the IGDsm group was higher than that of smokers (p = 2.86 × 10–7). No significant difference was found between the IGD and HC groups (p = 0.22), while the rsFC of IGDsm was higher than that of IGD individuals, but it did not pass the Bonferroni’s correction (p = 0.04). No significantly different rsFC was found between the IGDsm and HC groups (p = 0.30). the ROI , the intF = 18.37, p = 3.01 × 10–5] and post hoc comparison among groups (p = 0.0005), but the rsFC of the IGDsm group was significantly higher than that of smokers (p = 7.76 × 10–5). No significantly different rsFC was found between the IGD and HC groups (p = 0.06), but the rsFC of the IGDsm group was significantly higher than that of the IGD group (p = 0.009). No significant difference in rsFC was found between the IGDsm and HC groups (p = 0.31).Although the rsFC between the cHip and the left NAc did not pass the Bonferroni’s correction at the cluster level, we still extracted the cluster and performed one-way ANCOVA . The significant results of rsFC between the rHip, NAc, and the rSM were the same as between VTA and NAc, and the significant results of rsFC between the rHip and lSM were the same as between the cHip and NAc, except for the specific p-values, which can be seen in p = 0.02, did not passed the Bonferroni’s correction), but the rsFC of the IGDsm group was significantly higher than that of smokers (p = 0.0009). The rsFC of the IGD group was significantly lower than that of the HC group (p = 0.006), but the rsFC of the IGDsm group was significantly higher than that of the IGD group (p = 0.0003). No significantly different rsFC was found between the IGDsm and HC groups (p = 0.17).When the rHip was the ROI, the interaction effects between smoking and IGD were significant [t = 2.936, p = 0.006, t = −2.853, p = 0.008, The stepwise multiple linear regression analysis found that the rsFC between the rHip and rSM in the IGD group could be predicted by the SDS score  and NAc in smokers. The cHip is an important substrate for nicotinic effects on working memory function . The assRepetitive drug administration can be associated with progressively increasing effects on drugs, that is, drug sensitization , which iIn addition, we found significant interaction effects of rsFC between the rHip and the sensorimotor area as well as the lMTG, which may be a reminder that these brain regions are also involved in the regulation in addiction. It has been documented that compared only to the drug itself, the cues related to the action of drug use are more likely to activate the sensorimotor area and promote a range of learning and plasticity processes associated with the hippocampus . These pThere are several limitations to this study. First, the possible impacts of poorly matched age, gender, or education among the groups could not be eliminated completely, although they were incorporated into the statistical design as covariates. Second, gender differences were not investigated in this study. Men and women seem to have different neurophysiology and performance during the addictive procedure, which needs to be explored in further approaches. Third, although we limited the time to approximately 1 h between the last cigarette and MRI scanning in smokers, concentrations of carbon monoxide were not applied to quantitatively assess whether all subjects were in the same state, which might affect the results and requires further approaches to verify these results. Fourth, we failed to assess the number of cigarettes per day consumed by the smokers, and its relationship with rsFC, therefore, could not be elucidated in this study and will require further research. Fifth, while most subjects self-reported no or very little daily alcohol consumption, we could not have known if they were lying. Therefore, the possible effects of alcohol consumption on the interaction between smoking and IGD need to be studied in the future.In conclusion, our study found significant interaction effects of rsFC between smoking and IGD, which specifically manifested as a decrease in rsFC in a single type of addiction, which may be related to the increase in the reward threshold in the reward circuit caused by chronic addiction or the negative reinforcement of stress regulation. Instead, increased rsFC in the comorbidity of IGDsm group compared to a single type of addiction group might be due to drugs being much more potent at stimulating DA-regulated reward circuits than natural reinforcers. The lack of difference in rsFC between the IGDsm and HC groups might be related to the transition from taking drugs in order to feel “high” to taking them just to feel normal. In summary, our findings provide valuable fMRI evidence for the principle of chronic addiction, relapse, and comorbidity of two types of addiction from the perspective of functional reward and memory circuits.The original contributions presented in this study are included in the article/The studies involving humans were approved by the Medical Ethics Committee of Ren Ji Hospital, School of Medicine of Shanghai Jiao Tong University. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.XQ: Formal analysis, Methodology, Validation, Visualization, Writing – original draft, Writing – review and editing. XH: Data curation, Writing – review and editing. YW: Data curation, Writing – review and editing. WD: Data curation, Writing – review and editing. YS: Data curation, Writing – review and editing. HL: Conceptualization, Writing – review and editing. YZ: Data curation, Funding acquisition, Writing – review and editing. FL: Conceptualization, Funding acquisition, Project administration, Supervision, Writing – review and editing.


Disease-related stress can trigger the occurrence of herpes zoster (HZ). Fatty liver disease (FLD) can have adverse effects on the human body and may induce stress in affected individuals. In this study, we investigated whether FLD is associated with an elevated risk of HZ.For this study, we utilized data from the National Health Insurance Research Database, patients with FLD from 2000 to 2017 were observed (follow-up until 2018). Patients were considered to have FLD if they had at least two outpatient visits or at least one admission record with a diagnostic code of FLD. Patients with FLD were matched 1:1 by age, sex, comorbidities, and index year with control patients. Additionally, the FLD was further categorized into non-alcoholic fatty liver disease (NAFLD) and alcoholic fatty liver disease (AFLD) groups. Multivariable Cox proportional hazards model was used to calculate the incidence rate and adjusted hazard ratio (aHR) of HZ for FLD and AFLD and for various age groups, sex and comorbidities. Cumulative incidence curve for HZ was plotted through the Kaplan–Meier method, and p-value was calculated using the log-rank test.After 1:1 propensity-score matching, each cohort comprised 62,418 patients. The FLD cohort was further divided into NAFLD and AFLD groups, which respectively comprised 55,709 and 6709 patients. The FLD cohort had a risk of HZ significantly higher than that of the control cohort . Additionally, the NAFLD group exhibited a significantly higher risk of HZ than did the AFLD group . Among patients without any comorbidities, those with FLD had a higher risk of HZ than did those without FLD .Patients with FLD are at an increased risk of HZ development. Additionally, NAFLD is associated with a higher risk of HZ than AFLD. Therefore, patients with NAFLD should be informed of their increased risk of HZ. Fatty liver disease (FLD) is caused by the storage of excess fat in the liver. Alcoholic fatty liver disease (AFLD) is caused by heavy drinking. Wong et al. reported that 4.3% of 34,423 respondents to the 2001–2016 National Health and Nutrition Examination Survey had diagnose of AFLD [Herpes zoster (HZ) presents as a painful rash caused by reactivation of the varicella-zoster virus (VZV). In an analysis of 69 studies, van Oorschot et al. determined the incidence rate (IR) of HZ was between 5.23 and 10.9 per 1,000 person-years . Thus, tDisease-related stress can trigger the reactivation of VZV. Infectious disease, including those are bacterial  or viralInternational Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).The National Health Research Institutes of Taiwan have been promoting the use of the National Health Insurance Research Database (NHIRD) since 2000, which contains the medical records of nearly all Taiwanese people and is a valuable resource for academic research. For this study, we utilized data from the NHIRD, specifically from the year 2000. The disease coding for this study was based on the ICD-9-CM diagnostic code of 571.0 or 571.8 or an ICD-10-CM diagnostic code of K70.0, K75.81, or K76.0. Additionally, the FLD was further categorized into NAFLD  and AFLD  groups. Patients diagnosed with FLD were meticulously matched in a one-to-one ratio with control individuals, with the matching criteria encompassing age, sex, comorbidities, and the index year. Patients with HZ  prior to the index date were excluded. Comorbidity refers to the presence of additional medical conditions alongside an index condition throughout an individual's lifetime [In this cohort study, patients with FLD from 2000 to 2017 were observed (follow-up until 2018); the study population comprised individuals aged between 20 and 100 years. Patients were considered to have FLD if they had at least two outpatient visits or at least one admission record with an lifetime . In ordeCategorical variables such as age group, sex, and the presence of various comorbidities are expressed in term of number and frequency, and the chi-square test was employed to detect differences between the FLD and control groups. Continuous variables such as age and follow-up duration are expressed as means and standard deviations, and the t-test was used to detect the differences. Multivariable Cox proportional hazards model was used to calculate the IR and adjusted hazard ratio (aHR) of HZ for FLD and AFLD and for various age groups, sex and comorbidities. Additionally, HZ risk with and without FLD was calculated with adjustment for age, sex, and comorbidities. Cumulative incidence curve for HZ was plotted through the Kaplan–Meier method, and p-value was calculated using the log-rank test. A two-sided p-value < 0.05 indicated statistical significance. SAS software version 9.4  was used for all statistical analyses, and R Studio was employed for the creation of the graph.Table Table Table We observed that patients with FLD had an increased risk of HZ development. In addition, NAFLD is associated with a higher risk of HZ than AFLD. Alcohol consumption exerts an impact on both innate and adaptive immunity in humans. Persistent heavy drinking is linked to a lower count of lymphocytes and an elevated susceptibility to bacterial and viral infections. In contrast, moderate alcohol consumption is associated with decreased inflammation and enhanced vaccination responses . SchmidtMost of our patients (nearly 90%) had NAFLD. Therefore, our discussion focuses on NAFLD. A meta-analysis of 24 studies involving 35,599 patients discovered the prevalence of NAFLD in patients with DM to be 59.67% . In a meNAFLD increases the incidence of CKD. One study demonstrated that the odds of CKD were significantly higher in patients with NAFLD than in controls (OR = 1.95) . Le et aNg et al. reported a risk of depression for individuals with NAFLD was 12% higher than that for those without NAFLD . In anotIn addition to DM, CKD, and depression, our analysis revealed that CAD, cancer, and obesity were associated with a higher risk of HZ compared to individuals without these conditions Table . NeverthThis study has some limitations. The NHIRD only contains information related to health insurance benefits, and thus does not include patients’ data such as those on disease severity, lifestyle , or self-funded medical treatment. Thus, our research is potentially subject to bias. In addition, the quality and reliability of the data may be limited by differences among medical institutions, variations in medical behavior, and incomplete data collection. However, the NHI Administration has a rigorous review system, and severe penalties are imposed for improper diagnoses and prescriptions. Therefore, the results of our empirical analysis of big data from the NHIRD can be used by clinicians as a reference.Patients with FLD are at an increased risk of HZ development. Additionally, NAFLD is associated with a higher risk of HZ than AFLD. Therefore, patients with NAFLD should be informed of their increased risk of HZ.