Simulation-based training used to train healthcare teams’ skills and improve clinical practice has evolved in recent decades. While it is evident that technical skills training is beneficial, the potential of human factor training has not been described to the same extent. Research on human factor training has been limited to marginal and acute care scenarios and often to validate instruments. This systematic review aimed to investigate the effectiveness of simulation-based training in improving in-hospital qualified healthcare teams’ human factor skills.A review protocol outlining the study was registered in PROSPERO. Using the PRISMA guidelines, the systematic search was conducted on September 28th, 2021, in eight major scientific databases. Three independent reviewers assessed title and abstract screening; full texts were evaluated by one reviewer. Content analysis was used to evaluate the evidence from the included studies.The search yielded 19,767 studies, of which 72 were included. The included studies were published between 2004 and 2021 and covered research from seven different in-hospital medical specialisms. Studies applied a wide range of assessment tools, which made it challenging to compare the effectiveness of human factor skills training across studies. The content analysis identified evidence for the effectiveness. Four recurring themes were identified: (1) Training human factor skills in qualified healthcare teams; (2) assessment of human factor skills; (3) combined teaching methods, and (4) retention and transfer of human factor skills. Unfortunately, the human factor skills assessments are variable in the literature, affecting the power of the result.Simulation-based training is a successful learning tool to improve qualified healthcare teams’ human factor skills. Human factor skills are not innate and appear to be trainable similar to technical skills, based on the findings of this review. Moreover, research on retention and transfer is insufficient. Further, research on the retention and transfer of human factor skills from simulation-based training to clinical practice is essential to gain knowledge of the effect on patient safety.The online version contains supplementary material available at 10.1186/s41077-022-00207-2. Adverse eventsResearch indicates that simulation-based training (SBT) is a safe and effective tool to develop and increase competencies in healthcare . HoweverThis systematic review aimed to investigate the effectiveness of in-hospital simulation-based training as a learning and teaching method to develop qualified healthcare teams’ human factor skills.The AMSTAR 2-criteria (A MeaSurement Tool to Assess systematic Reviews) were used to prepare the review . The revSPICE  , an alteBoolean operators were used, combining keywords and blocks. Furthermore, the databases’ unique thesauri, truncation, phrase searches and proximity searches were included. An experienced information specialist (author TFF) optimised the search. Publications in English, Danish, Norwegian and Swedish were deemed eligible.th, 2021. Search histories are available in The following databases were searched: CINAHL (EBSCO), Cochrane Library, EMBASE™ (OVID), ERIC (EBSCO), MEDLINE® (OVID), PsycINFO (OVID), SCOPUS and Teacher Reference Centre (EBSCO), September 28Covidence , a screeConflicts were resolved through dialogue. LA subsequently selected eligible studies for inclusion by full-text reading, and, in cases of doubt, the consensus was achieved by consulting the authors MLH, ABN, LH and SVS. Each study was scrutinised for validity, reliability, generalisability and replicability of the results using the Critical Appraisal Skills Programme checklists (CASP) , Mixed Mcharacteristics, target population, HFS focus, intervention type and content, type of assessment, outcome, results and limitations, summaries of intervention effects for each study. Due to the variation of the included study types, all assessments and methods were analysed and categorised. Every theme was verified and, where necessary, revised or split into two.Content analysis , 45 was Ethical approval was not deemed necessary because data was from previously published studies, but the study meet(s) the claims of the Helsinki Declaration .The initial search identified 34,846 publications, representing 19,767 unique studies, after removing duplicates. After title and abstract screening, 521 studies were identified for full-text screening, of which 72 were included for data extraction and synthesis. This process is shown in the PRISMA flow diagram  in Western countries. The 72 studies used 51 different assessment methods to measure the outcome of the team training interventions, including pre-tests, peri-tests and post-tests, (un)blinded ratings, self-assessments, surveys and interviews. The methods were validated (n = 30), non-validated or no information about validation (n = 14) and modified versions of validated (n = 9) instrument. The studies reported SBT settings such as simulation centres (n = 36), in-situ training (n = 24) and the use of both centre and in-situ training (n = 7). A broad variation was seen in the size and range of the studies (n = 7 to 675 participants) and represented SBT within seven different in-hospital medical specialisms: anaesthesiology (n = 7), emergency medicine (n = 20), intensive care (n = 9), internal medicine (n = 2), obstetrics (n = 12), paediatrics (n = 6) and surgery (n = 15). A range of teaching methods were used: SBT (n = 30); SBT and didactics (n = 34); SBT, didactics and workshops (n = 6); and SBT and workshops (n = 1).Included studies were published between 2004 and 2021 and were conducted mostly (n = 51), meaning not part of formal educational (n = 18) progress. The participants were either voluntary (n = 35), mandatory (n = 16), randomly selected participants (n = 9) or not stated (n = 12). Participants trained one or more HFS: communication, coordination, decision-making, followership, leadership, situational awareness, task management or teamwork.The courses in the included studies were mostly stand-alone (n = 47). Midwives, nurses and physicians were the most common participants, but 13 different disciplines participated. Mono-disciplinary SBT was seen in 20 studies; physicians (n = 18) were primarily trained separately from other qualified personnel. An extracted summary of included studies is shown in Table Team size varied from two to twenty members, typically training in teams of two to five members. Two-thirds of the studies were of multidisciplinary teams  Training HFS in qualified teams, (2) assessment of HFS, (3) combined teaching methods and (4) retention and transfer of skills. These themes will be elaborated on below.n = 65) of the studies concluded that SBT could develop qualified teams using HFS. In two-thirds of the studies, HFS as the sole focus of the training were seen and associated with enhanced effectiveness . For instance, the increased time could also be due to improvements in the TS and not the HFS. HFS training associated with specific behaviour markers were the most successful assessment , 114. Fin = 21) used video recording and blinded assessors [The rating of markers was either blinded or unblinded by internal or external faculty or assessed by the participants themselves. Self-assessments were used in 31 studies. Self-assessment were used in combination with other methods in 18 studies , 116, whssessors , 114, whssessors , 125.n = 15) only mentioned the HFS in broad indefinite terms such as communication or teamwork [The most frequently trained HFS were communication, leadership and teamwork. The specification of the trained HFS were described in various ways. Eleven studies , 115 desteamwork , 112. CoCommunication and teamwork are both broad terms. Communication and teamwork are not isolated and unequivocal tasks; they depend on and influence each other, like most HFS. The purpose of outlining and dividing the tasks into behaviour markers is to simplify a complex clinical situation, i.e. highlight easily recognisable behaviour for the participants, making it easier to acquire and develop skills , 126. ThSignificant effects on HFS were observed in 32 studies that combined SBT with didactics and workshops, compared to 12 that just trained SBT. The impact on qualified teams’ use of HFS was evident, regardless of whether SBT was combined with didactics and workshops or training HFS on their own or in combination with TS. HFS training was combined with TS training in 30 of the studies, of which 19 showed a significant effect on one or more HFS, equalling 48 of all the included studies. Thus, it appears that the studies in which HFS training was separate from TS training resulted in the most significant improvements in the teams’ use of HFS.The studies that combined HFS and TS training tended to focus more on TS. For instance, Burden et al. and Siassakos et al. covered the results of HFS training with only a few sentences , 125, anRetention or transfer of HFS was explored in 21 of the studies. The retention of HFS were measured from participants’ knowledge, self-assessment, audits and patient outcome. Transfer of enhanced HFS are identified in 20 studies, but in two of these , 104, thThis systematic review demonstrates that SBT is a successful learning tool to improve HFS in-hospital healthcare settings. Unfortunately, we were unable to show the effect level due to the use of all the different assessment tools. More research is required to increase knowledge about the transfer of competencies to daily clinical practice, examining why many studies use non-validated assessment strategies and the barriers to training HFS. While HFS are widely taught, there are gaps in the literature regarding efficacy assessment. There is a need for more long-term studies and studies about how we translate assessment of skills to clinical work. However, there is a lack of knowledge about the transfer and retention of the HFS developed, from SBT to actual competencies in clinical practice. The culture of viewing HFS as innate and complicated to train could be one of the obstacles.Although this review revealed support for training HFS in the clinical setting using SBT, there is a lack of agreement on which tools are best to assess HFS. There are gaps in the literature regarding the assessment of the HFS. More research and consensus on how we assess HFS is needed before the level of effectiveness can be estimated. All assessment methods in SBT should be supported by valid evidence. Several instruments are designed to evaluate the effect of HFS skills through SBT. Still, this review shows that the existing assessment methods are not solid enough to establish consensus on the way HFS are assessed. Although tools exist to assess HFS, methods to study communication and other team-related processes are far from being standardised, making comparison challenging. This raises new questions about training HFS and future directions for research.Cognition is an emergent property of the situation and environment. Knowledge, perceived facts, understanding and predictions within each team member’s mind interact with displayed information, cues and devices in the environment to affect decision-making and situational awareness. Recurrent exposure to these factors can lead to personal, team and institutional learning. Furthermore, the environment can be modified and redesigned to support the team’s improved performance and safety. Cognition is thus an individual and shared mental process within the team in all situations –129. TheThe review also demonstrates that studies in which HFS was trained alone had a more significant effect than those focused on both HFS and TS. However, although the increase of HFS was lower in combined TS and HFS training, HFS was still enhanced in most studies. In SBT research, HFS are often relegated to an add-on to develop procedures, algorithms and associated TS in specific settings. This may be for several reasons: everyday clinical situations involve both HFS and TS, trained together, or it is easier to measure technical outcomes. HFS often play a minor role in the conclusions drawn. In this way, TS “steal” the focus, and the focus is on solving the medical problem at hand (e.g. bleeding or anaphylaxis) rather than improving HFS, which generally are the cause of most adverse events . HFS areThe high amount of studies from acute and high-intensity situations and the paediatric speciality shows that there is awareness of the need for training qualified personnel, that SBT is not only for the students and novices. The training mostly around algorithms is unclear and could be an exciting focus in future research. Nevertheless, the results also show that qualified teams mostly train situations where life is at stake. However, adverse events not only happens in highly acute situations but also in slow situations such as medication administration , receiviAn interesting result is that the training teams mostly were 2–5 members, although critical care teams are more prominent in numerous places in the world. The reasons for this are unclear, but possible explanations include the expense of SBT and a high turnover of qualified healthcare personnel . MoreoveIt is important to understand learning holistically, integrating the individual, brain, body and surroundings . All levThis systematic review demonstrates a strong indication that SBT is an effective learning tool to improve HFS in-hospital healthcare settings. However, HFS are inconsistently described, interpreted, taught and assessed and the lack of real-world assessment or follow-up makes the transfer to everyday practice challenging. This systematic review does not entirely answer if SBT improves HFS in qualified healthcare teams. Still, it highlights the gaps in the literature and underpins the necessity of increasing the focus on HFS or routine care in SBT to improve outcomes. There is a need for more long-term studies and studies about how we translate assessment of skills to clinical work. However, there is a lack of knowledge about the transfer and retention of the HFS developed, from SBT to actual competencies in clinical practice. The culture of viewing HFS as innate and complicated to train could be one of the obstacles. Healthcare, in general, must support the necessity and significance for HFS. Otherwise, the HFS will not be effectively transferred to everyday practice. Also, design issues such as positioning of the equipment, cognitive aids and process changes are needed to support ideal human performance such as not relying on memory or complex decision-making in complex time-pressed situations. More research is required to increase knowledge about the transfer of competencies to daily clinical practice, examining why many studies use non-validated assessment strategies and the barriers to training HFS.A few limitations of this review need to be highlighted. Firstly, three authors screened a vast number of studies, but only the first author did a full-text reading and assessment of the included studies. This increases the possibility of selection bias and influences the internal validity and reliability. The bias was sought to be minimised by bringing any doubts about selected studies to the broader author group. Nevertheless, the intercoder reliability is inevitably affected when human coders are used in content analysis . SecondlIt is evident that SBT can improve qualified teams’ HFS. SBT is an effective learning tool for use with novices and experts, and with unqualified or qualified personnel. A change of focus is recommended for healthcare providers to train emergencies or rare situations and everyday non-emergency situations, such as admission to hospital, rounds, or the unprepared talk with next-in-kind in the hallway. This review shows that even qualified teams’ can develop their HFS significantly through SBT. Using SBT to train the healthcare personnel for everyday clinical practice are essential. Firstly, because the everyday routine takes up most of the performance tasks in the hospitals, the personnel are constantly in different forms of teamwork. Secondly, as learned from Safety II, it is necessary to enhance the ability to succeed (reduce adverse events) under varying conditions . ThirdlyAll human interactions in hospitals need to be efficient and trained just as seriously as TS and clinical procedures because interactions are just as prone, if not more, to errors. Cultural, social and people skills, together termed HFS, are not innate and untrainable. Instead, they are generic and essential in reducing adverse events within healthcare and demands an increased focus on systematic multidisciplinary training of HFS among healthcare teams.Additional file 1. Supplement A–Searches.Additional file 2. Supplement B–Results summary.


Disability poses a burden for older persons, and is associated with poor outcomes and high societal costs. Prediction models could potentially identify persons who are at risk for disability. An up to date review of such models is missing.To identify models developed for the prediction of functional status in community dwelling older persons.A systematic review was performed including studies of older persons that developed and/or validated prediction models for the outcome functional status. Medline and EMBASE were searched, and reference lists and prospective citations were screened for additional references. Risk of bias was assessed using the PROBAST-tool. The performance of models was described and summarized, and the use of predictors was collated using the bag-of-words text mining procedure.Forty-three studies were included and reported 167 evaluations of prediction models. The median c-statistic values for the multivariable development models ranged between 0.65 and 0.76 , and were consistently higher than the values of the validation models for which median c-statistic values ranged between 0.6 and 0.68 . A total of 559 predictors were used in the models. The five predictors most frequently used were gait speed (n = 47), age (n = 38), cognition (n = 27), frailty (n = 24), and gender (n = 22).No model can be recommended for implementation in practice. However, frailty models appear to be the most promising, because frailty components (e.g. gait speed) and frailty indexes demonstrated good to excellent predictive performance. However, the risk of study bias was high. Substantial improvements can be made in the methodology.The online version contains supplementary material available at 10.1186/s12877-022-03156-7. Disability is a key outcome for public health . It is aDecades of research have focused on identifying risk factors for disability in ADL in community dwelling older persons. Key risk factors include, among others, multi-morbidity, frailty, cognition, depression, body mass index, physical activity, and sensory and physical impairments –14. If mOne systematic review, published in 2015, has previously investigated the utility of clinical prediction models for the outcome functional decline .We therefore performed a systematic review to identify models developed for the prediction of functional status in community dwelling older persons. We investigated the types of predictors that were included in the models, and how well the models predicted functional status.A protocol for the systematic review was drafted before the start of the study  or specific aspects of ADL (e.g. washing or mobility). Physical performance outcomes were considered relevant if the reported data related to daily activities, e.g. ability to mobilise. Physical performance related to strength or speed was not considered for inclusion.Predictions could include the prediction of ADL , or decline, maintenance, recovery or improvement in ADL . The prediction model had to measure a single characteristic (univariable model) or a set of characteristics (multivariable model) to estimate a person’s individual prognosis and could include patient, care outcome and care process factors. The models could be presented in any format, e.g. as a statistical model, regression formula with coefficients, web or electronic application, nomogram, or score chart.Studies with binary or survival outcomes had to report the concordance (c) statistic . Studies with continuous outcomes had to report the R2 statistic.We included nested case-control studies, prospective and retrospective cohort studies (including database and registry studies), and secondary analyses of trials.We searched the Medline and EMBASE databases from inception up to March 2022 for eligible studies. After selecting the full text manuscripts, we screened references lists and prospective citations (using Google Scholar) for eligible studies. Lastly, the ICTPR portal was searched for protocols and Web of Science for conference proceedings in order to track full text manuscripts.A search string was drafted using a combination of free text words and MeSH terms. The search terms were grouped according to outcome, prediction models, and setting. We used a validated search string for the terms related to the prediction models . The terIdentified records were collected in an Endnote database. One author screened all titles and abstracts for inclusion in two stages: screening titles and abstracts, and reading full text manuscripts. The second author verified the final inclusion using a standardised checklist. The final selection was based on a consensus decision. Authors were not blinded to the manuscripts’ citation information.Data were collected in an Excel database. The data collection was first piloted in order to standardise the collection process and define uniform terms. The data collection was performed by one author. Data were verified a second time by the same author.The following information was collected: study citation, country, design, setting, sample characteristics, sample size, outcome definitions and measurements, statistical analyses, definition of predictors, purpose and design of prediction models, and the evaluation and performance of prediction models.The PROBAST tool (Prediction model Risk Of Bias ASsessment Tool) was used to assess the risk of bias for the participants, predictors, outcome and analysis for each model . A standWe investigated the discrimination and calibration for models with a binary and survival outcome, and the R2 measure and calibration for models with a continuous outcome . The disSummary tables were drafted to describe the study characteristics, risk of bias and findings of the studies. We originally planned to construct funnel plots to visualize the different performance measures . However, the majority of the studies did not report standard errors or sufficient information to construct confidence intervals. We changed our strategy and described the distribution using scatter plots to visualize the discrimination and R2 of the individual studies, and constructed box plots to describe the central tendency (median) and spread of the data (interquartile range). We further observed substantial differences between studies and models and therefore decided to describe the results within subgroups based on the 1) definition of the outcome , 2) type of summary measure (c statistic or R2), 3) type of model (univariable or multivariable), 4) type of model evaluation . We used the ‘bag of words’ text mining procedure to summarise the clinical predictors included in the models. This procedure was used to create a word cloud to describe the frequencies of the predictors. Analyses were performed using R studio .In addition, we described individual models that demonstrated a good performance in a validation cohort  separately using a narrative synthesis.A total of 11952 titles and abstracts, and 316 full text manuscripts were screened for inclusion. A total of 34 studies were retained for inclusion. , 21–52 An = 19) or Europe (n = 15), and to a lesser extent from Asia (n = 7), or South America (n = 1) or Africa (n = 1). All but one study used data from a prospective cohort study; the one study using data from a randomized controlled trial. The median age across the samples was 76 years, with a minimum of 66 and a maximum of 85. Eighteen (43%) of the studies recruited persons who were independent in ADL or mobility at baseline. Basic ADL was the most prevalent outcome (n = 15), followed by Instrumental ADL , mobility (n = 5), disability (n = 4), or a composite outcome of ADL and IADL (n = 4). The remaining studies had multiple outcome measurements of ADL, IADL, mobility, or bathing and dressing. Almost all studies evaluated predictions of functional decline (n = 39), two studies predicted a change in outcome score, and two studies predicted the outcome score on a continuous scale. The median incidence of functional decline across the studies was 20%, with a minimum of 5% and a maximum of 59%. The median time to follow-up across the studies was two years, with a minimum of half a year and a maximum of nine years. The 43 studies included 167 evaluations of prediction models. The results will be reported at the level of the 167 evaluations of prediction models. The characteristics are described in table The majority of studies originated from North America n = 9 or Euron = 157) and outcomes (n = 130). However, the majority of evaluations had a high risk of bias on the domains related to recruiting participants (n = 86) and analyses (n = 158). A clear description of the recruitment was often missing or only participants with complete data were selected from the cohort for analysis. Predictors were often selected based on p-values without accounting for overfitting or optimism in the performance, and the influence of right censoring (e.g. due to death) was not estimated.There was a low risk of bias in 13 model evaluations, high risk of bias in 135 evaluations, and there was uncertainty in the remaining 19 evaluations  . GobbensTwo univariable models demonstrated a good to excellent performance in a validation cohort. However, the risk of bias was uncertain for both models. Both models were evaluated in the same cohort by Adachi et al., which observed that a gait speed of <0.8m/s had an excellent discrimination (c statistic 0.91), and a gait speed of <1.0m/s had a good discrimination (c statistic 0.89) for the outcome mobility limitations at two years follow-up .The median number of predictors in the multivariable models that were evaluated was seven, with a minimum of two and a maximum of 26. Six model evaluations included longitudinal repeated measurements of predictors, with the remaining models only included baseline measurements.n = 47), age (n = 38), cognition (n = 27), frailty (n = 24), gender (n = 22), comorbidity (n = 15), grip strength (n = 15), physical activity (n = 15), body mass index (n = 15), IADL (n = 13), balance (n = 12), educational level (n = 12), residential status (n = 12), sarcopenia (n = 12), and ADL (n = 10).A total of 559 predictors were recorded, with 55 predictors being used in at least three evaluations dependence on activities of daily living was the most prevalent outcome for the prediction of functional status. The performance of the models varied substantially, ranging from poor to very good, but was moderate to low on average. The performance of the prediction models was generally lower in validation cohorts. Multivariable models appeared to be slightly better for the prediction of future functional status than univariable models, but this was difficult to assess because most univariable models lacked external validation. Gait speed was the most prevalent predictor, in particular for univariable predictions, and demonstrated a moderate predictive performance . The majority of studies (95%) did not evaluate the calibration of the model.Our results are in line with the previous review on prediction models for community dwelling older adults , 13, thaSpecific suggestions can be made to improve the body of evidence on the prediction of functional status. The majority of studies relied on statistical significance to select predictors, which can result in overfitting and overly optimistic performance measures for the developed model . This opThe results of this review are somewhat discouraging. Nonetheless, the burden of disability remains high and will be an important driver for increasing long-term healthcare costs . We beliLastly, it is important that the impact of models is evaluated in practice. We have additionally searched for studies that implemented disability prediction models in the community setting, but we could not identify any references. However, evaluating if the introduction of a prediction model changes care, e.g. increases physical therapy interventions, and improves outcome, e.g. reduced incidence of disability, will be an important future investigation.Some limitations should be noted. Although both authors screened the included studies independently, titles and abstracts were only screened by one author. However, we included a large number of studies and model which makes it likely that we have a sample that is representative from population of studies.. One author collected the data, and although this process was double-checked, some data abstraction mistakes may have been made. Further, we inferred the performance of the models based on the distribution , but these should not be considered pooled results. The models, and their evaluation, differed substantially from each other and we did not consider it relevant nor appropriate to perform a meta-analysis.Currently available models for the prediction of future functional status in older persons have a low to moderate performance on average. Though multivariable models perform slightly better than univariable models, high risks of bias in the evaluations of prediction models do not allow for any firm conclusions. There is currently no model that can be recommended for implementation in practice, but frailty models appear to be the most promising. Substantial improvements can be made in the methodology of developing and validating prediction models for disability in the community setting.Additional File 1. Prediction Models for Functional Status in Community Dwelling Older Adults: Review Protocol, Search Strategy and Prisma Checklist.


The tool was reliable . This validated, consistent and reliable adapted tool is ready to use in larger scale evaluations of TB-related stigma amongst workers in formal and informal business sectors of Indonesia to develop strategies to eliminate TB-related stigma from the workplace.Workers with tuberculosis (TB) are often stigmatized, negatively impacting their socioeconomic position, mental health, and TB treatment outcomes. There is a dearth of validated tools to assess stigma in the worker population. This study aimed to develop and validate a novel, culturally adapted tool to measure TB-related stigma among workers in Indonesia. We translated, adapted, applied, and internally validated Van Rie's TB-Stigma Scale to the worker population in varying sizes businesses  in Indonesia. Psychometric evaluation using exploratory and confirmatory factor analyses (EFA and CFA) was performed to check the tool's internal consistency and reliability. The translation and cultural adaptation phases resulted in a final 11-item tool. From 172 participant responses, the EFA found two loading factors relating to responses on isolation and exclusion from the workplace. The CFA confirmed that the developed model had moderate fit with R •This is the first tool to measure stigma towards people with tuberculosis, developed for the general worker population.•The tool was adapted from Van Rie's TB Stigma Scale with adjustments and additional items relevant to the worker population.•The tool is valid, consistent, reliable, and ready to use in larger-scale evaluations of TB-related stigma amongst workers. These fTB-stigma can negatively affect people's access to TB services, delay treatment, worsen treatment outcomes, and increase the likelihood of TB transmission within families and communities . In addiThere have been several tools to assess TB-stigma , but mosTo date, there has been no specific tool used to measure stigma towards fellow coworkers in workplaces and, according to our previous review, no intervention developed to address TB-stigma in this specific population . TB-Stig2We performed the study in three phases between February and July 2022: Phase 1—Translation, Phase 2—Cross-cultural adaptation, and Phase 3—Psychometric evaluation. We conducted Phase 1 in two weeks, followed by Phase 2 in three months and Phase 3 in two months  .Fig. 1Fl2.1There is no tool, questionnaire, or scale to measure TB-stigma among workers in non-healthcare settings. We decided to adapt Van Rie's Stigma Scale which originally consisted of two parts: Part A: Community Perspectives towards TB (11 items); and Part B: Patient Perspectives towards TB (12 items). We used Part A for adaptation and validation in the general worker population on the assumption that in settings outside of healthcare this population would be similar to community respondents. Each of the 11 items in Part A of the Van Rie Stigma Scale has four options: strongly disagree (0), disagree (1), agree (2), and strongly agree (3) .2.2The original Van Rie's TB-Stigma scale was translated into Bahasa, the lingua franca of Indonesia. Two independent researchers  fluent in English and Bahasa with previous experience in TB research did the translation separately, resulting in two versions of translated scales. The study team reconciled the two translated versions into one version, which was consolidated before the back translation. The consolidated version was then translated back to English by a contracted translator who was separate from the project team and did not know the original version of the tool. The adapted, back-translated English tool was subsequently reviewed and compared with the original tool by the study team to check for readability and consistency.2.3We adapted the tool to the Indonesian context by (a) inviting local experts to a two-stage panel meeting and (b) pre-testing the tool prior to deployment. We purposively selected and invited thirteen experts with diverse but complementary experience: three occupational medicine specialists, three community medicine specialists, a psychiatrist, a psychologist, two pulmonologists, the Indonesian National TB Program officer, and two TB-related non-government organizations staff. Ten experts joined the first stage panel meeting. In this meeting, we invited suggestions from participants on the content and language of the tool in order to be culturally appropriate to the Indonesian context. Since there was no previous tool specific to the worker population, experts were invited to suggest additional items or delete items . We invited the same experts to the second panel meeting. In this meeting, six experts provided further comments or suggestions to the Pre-final Tool 1 to shape the tool . All panel expert meetings were recorded, and experts verbally consented at the beginning of the meetings.We subsequently further revised the tool and sent to the panel experts to reach a version of the tool ready for pilot implementation (resulting in a Pilot Tool). We then did a cognitive debriefing by pre-testing the tool with 20 respondents in three enterprises in formal sector and one enterprise in informal sector, following the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidance . The fou2.42.4.1For a psychometric evaluation, we first purposefully selected several enterprises in four provinces: East Java, West Java, Banten and Jakarta. We divided the enterprises into formal  and informal  business sectors. The enterprises in the formal sector were manufacturing, wholesale and service enterprises. The small enterprises in the informal sector were the home industry of bag makers, bakers, home chip makers, and local farmers. At each enterprise, we contacted the human resource department  and the owner  to select division(s) or group(s) of workers aged ≥18 years old. We calculated the sample size based on the original study's Cronbach's Alpha of 0.9  and assuWe also asked demographic characteristics of respondents, including sex, marital status, education level, workplace setting (indoor or outdoor), job level , and their monthly income according to the Indonesian National Statistics Bureau's .2.4.2https://redcap.fk.ui.ac.id) by FAH and AF. All tools were provided with a complete written explanation about the study and informed consent. Investigator (FAH) answered, clarified, and explained any questions from respondents regarding the tool.We developed self-administered paper-based and online tools to allow flexibility in data collection. The online tool was developed using REDCap  was sent to remind invitees to fill out the tool. After seven days, we ended the data collection, assuming that we would not receive responses following three consecutive reminders. For enterprises in which online-based data collection were not possible, we deployed paper-based tool to the workers. All responses from the paper-based tool were entered into the 2.4.3We performed Exploratory Factor Analysis (EFA) to assess the internal consistency of the tool. In the Principal Axis Factor analysis, we set a threshold of 0.7 for Kaiser-Meyer-Olkin's (KMO) and 0.05 for Bartlett's test values. We followed the analyses with factor analysis by assessing the Eigenvalues to determine the number of factors or domains. We included factors with Eigenvalues >1 and contained three or more items with a loading of ≥0.4 .We applied a confirmatory factor analysis (CFA) and evaluated the model by calculating Root Mean Square Error of Approximation (RSMEA), Standardized Root Mean Square Residual (SRMR), Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI). RSMEA value of less than 0.05 is considered as fit, while the value of 0.05–0.08 is a reasonable fit. CFI and TFI of more than 0.90 and SRMR of less than 0.08 were set as thresholds of model fitness. We also tested the reliability by assessing Cronbach's Alpha, with a Cronbach's Alpha coefficient of 0.80–0.90 being considered reliable . CFA was2.5This study received ethical approval from the Research Ethics Committee of the Faculty of Medicine, Universitas Indonesia – Cipto Mangunkusumo Hosital, Jakarta, Indonesia I think that coworkers with TB have limited capacity to work 2.I think that coworkers with TB negatively impact the enterprise's finances The study team proposed four main changes in translating and consolidating the tool. First, changing the subject in all statements, from "some people" to "I" because of the first-person perspective. In the original tool, people with TB were asked how they perceive the community's attitude toward them or people with TB. In this study, we asked workers about their attitudes toward people with TB so that using "I" is more relevant, contextual, and understandable. Second, we proposed the additional wording "coworkers" to replace "friends". These two changes reflected different perspectives from the original version—for example, from "Some people may not want to eat or drink with friends who have TB" to "I do not want to eat or drink with coworkers who have TB." Third, we proposed to delete one item, “Some people may not want to eat or drink with relatives who have TB” because it was not relevant for workers in their workplaces. Fourth, we proposed two additional items to explore whether people with TB were stigmatized in the workplace due to the perception that they were detrimental to their enterprise . In addition, one item, “I keep my distance from coworkers with TB” , was deleted because this item was represented by other items about keeping distancing, for example, ‘do not want to eat or drink with coworkers with TB’, 'feel uncomfortable around coworkers with TB’, and ‘behave differently around coworkers with TB’. This first stage panel meeting resulted in 11 items . In the second stage (May 2022), there were no additional or deleted items, but some suggestions on the use of specific words, for example, changing ‘disgusting’ to ‘shameful’ and ‘afraid' to ‘worry’ for better understanding  decided not to join the study, and 29 (11.9%) did not complete the tool. All responses from the paper-based tool were complete. Therefore, we entered 172 responses into the analysis.Of 172 respondents, most were female (56%), married (68%), low-level staff (55%), worked in formal sectors (78%) and indoor settings (76%), and had low to moderate monthly income  . Most of3.4p<0.001). Following on from these findings, further analysis identified two loading factors: isolation  and exclusion from the workplace   . The tooX2(pdf) = 105.58 (43), which was statistically significant  chi-square for our model was  p<0.05, . The RMS4We culturally adapted Van Rie's TB-Stigma Scale to develop a new TB-stigma tool to be applied to the worker population in Indonesia. The tool was considered comprehensive, had good content validity and internal consistency, and included some adapted and additional items relevant to the worker population.This is the first tool developed to measure TB-Stigma among the non-healthcare worker population. This suggests that, despite people with TB anecdotally reporting stigmatization and discrimination in the workplace , such stAdaptation and validation of the tool followed the ISPOR's guidelines for adapting a tool to a new context. The experts involved in this study were medical specialists, psychologists, and professionals who work with people with TB, all of whom were well-informed on how stigma can develop in workplaces. Their involvement, alongside the participation of both formal and informal sector workers, also helped to refine the tool by formulating appropriate item wording from multiple diverse perspectives, adding, and deleting items to be more relevant to the context, and ensuring that every statement was understandable for the target population.In adapting to a new context and population, we decided to ask the respondents items to consider in the first person “I” as opposed to third person "some people". Using the third person's perspective is generally applied to ask sensitive questions. In this context, besides improving the respondents' understanding of the statement, it was vital to capture their personal perceptions towards people with TB. We also replaced ‘people with TB’ with ‘coworkers with TB’ to highlight that the stigma being assessed was towards their coworkers.The EFA showed two main factors running throughout the 11 items: isolation and exclusion from the workplace. These two factors are similar and may even intersect. However, isolation indicates perception and attitudes towards coworkers with TB who continue to work in the workplace. Conversely, exclusion from the workplace is a perception that coworkers with TB negatively impact the workplace and, therefore, should be excluded.These two factors are helpful in identifying the roots of TB-Stigma in working place and how to tackle it. Isolation may be closely related to the misconception of TB development, spread, infection, and risk. Therefore, improving TB-related knowledge would significantly reduce TB-Stigma when the TB-related scores in this factor are high. Exclusion from the workplace may be related misconception of to the effects of TB. Workers with TB, especially those seeking care, may have impaired health, higher absenteism, and, therefore, may be assumed to be less productive or even costly for the enterprise. Enterprise managers may also not understand that people with pulmonary TB are generally non-infectious after 14 days of appropriate anti-TB therapy and therefore should be able to return to work after proper assessment. When the score is high for this ‘isolation’ factor, improving the perception of TB early detection, prompt treatment, evaluation, and enabling non-punitive sick leave is essential, particularly for those in a high-level position in the enterprise. Stronger legislation and social protection for those living with TB are also imperative to protect them from unnecessary job and income loss.Two statements were added to this tool to capture exclusion from the workplace, “I think that coworkers with TB have limited capacity to work” and “I think that coworkers with TB negatively impact the enterprise's finances”. These statements showed relatively high loading factor values and were shown to be valid, internally consistent, reliable, and contributed to the overall internal consistency and reliability of the tool. These statements are also critical since TB-Stigma related to these statements can create health inequality for the stigmatized group. TB-Stigma, in this case, tends to keep people away (disease avoidance). In the workplace, stigmatization from the more powerful group  to the less powerful group will create inequality in socioeconomic and health .Despite the valuable findings, this study has several limitations. First, the respondents were those working on Java Island, which is characterised as a densely populated urban area with good access to information, including online information. The tool may not be generalizable to other areas including rural regions. Indonesia also has a wide variety of cultures that may affect the interpretation of question items and findings. Therefore, the items will need to be reviewed and refined prior to any wider implementation. Checking the wording and verifying the understanding of the statements among target respondents would help to optimize consistent and valid responses in future deployment. Second, the participation bias resulting from the high rejection rate among respondents receiving online tools may underestimate or overestimate the findings. Almost all respondents rejecting to join the study left the tool on its first page. We did not provide questions to explore the reasons for rejection, which can also be ethically problematic data to collect. Third, the proportion of respondents from the high-level position was low. Although we could assess the stigma related to exclusion from the workplace, it may not necessarily capture such stigma among males and those in a high-level position, who have more power to decide workers' employment status .5We successfully adapted Van Rie's TB-Stigma Scale into a tool to measure TB-Stigma amongst working people in Indonesia. The adapted tool is valid, internally consistent, reliable, and ready for wider external validation among workers in both formal and informal business sectors in Indonesia and beyond. Our identification of isolation and exclusion from the workplace as two significant loading factors may support the design and development of interventions, policies, and legislation to address the root causes of TB-Stigma in the workplace.10.13039/501100006378Universitas Indonesia , Indonesia(Grant No. NKB-1104) and the 10.13039/501100000683Royal Society of Tropical Medicine and Hygiene, United Kingdom (Grant No. 19590206), received by Ahmad Fuady. Tom Wingfield is supported by grants from the 10.13039/100010269Wellcome Trust, UK (209075/Z/17/Z), the 10.13039/501100000265Medical Research Council, 10.13039/501100002992Department for International Development, and 10.13039/100010269Wellcome Trust, United Kingdom , and the 10.13039/501100009187Medical Research Foundation, United Kingdom .This study had funding from PUTI Q1 Grant, The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.The Ethical Committee of Medicine, University of Indonesia approved this study with the ethical approval number KEP – 60/UN2·F1/ETIK/PPM.00.02/2022 and protocol number 22-01-0023.Informed consent was given to each respondent in this study. Respondents were also informed that they could resign or refuse if they were unwilling to participate in the study. In addition, they were informed that all information provided would be kept confidential.Conceptualization: FAH, DS, AF; Data curation: FAH, DS; Investigation: FAH, DS; Formal analysis: FAH, AF; Study management: FAH, AF, AS; Methodology: FAH, DS, AF, AK, MM, TW; Supervision: AF, AK, RAW, FY, AS, MM, TW; Validation: AF, AK, TW; Visualization: FAH, AF; Writing—original draft: FAH, DS, AF; Writing—review and editing: FAH, DS, AF, AK, RAW, FY, AS, MM, TW; Funding acquisition: AF, AS, TW.


Giant ovarian cyst itself is defined as a cyst >10 cm in diameter from radiological- examination or the size of the cyst exceeds the umbilicus. Extra-large benign and malignant cysts of the ovary are uncommon and involve diagnostic and management challenges. We present the case of a 20-year-old nulliparous woman who was referred to our center with complaints of abdominal pain and heavy breathing. She benefited from a salphingo-oophorectomy laparotomy procedure. Benign and malignant gynecologic and non-gynecologic etiologies are included in the differential diagnosis of an abdominal mass. Because of the infrequent occurrence or absence of distinctive clinical presentation of the giant ovarian cyst, accurate preoperative diagnosis is challenging. A fluid-filled sac in the ovarian tissue is known as an ovarian cyst. A cyst is defined as a fluid-filled sac that is bigger than 5 cm in diameter , 2. GianIn general, in the younger population, the goal of management is conservative, with observation and resolution of symptoms, prevention of complications, and, when necessary, proper treatment of malignant tumors while maintaining ovarian structure and function .2.A 20-year-old woman, G0P0A0, came to Hospital’s with complaints of tightness and difficulty in breathing because her abdomen is increasingly enlarged and hardened. Complaints were already present for three years ago, but she never sought medical attention until now because she started feeling short of breath. The patient also complained of generalized abdominal pain with a VAS score of 8. On physical examination, the patient appeared toxic but fully concious (GCS E4M5V6). Measurement of vital signs are as follow: blood pressure 130/80 mmHg; heart rate 89, regular; respiratory rate 22 breaths per minute, regular; axillar temperature 36C; and oxygen saturation 99%. The patient weighs 67 kg with 156 cm height  . Bowel sCT scan examination of the abdomen revealed a giant septal and lobulated cyst (30.7 cm × 30.72 cm × 31.67 cm), oval-shaped, located in abdominal and pelvis and abdominal cavity . The patWe hereby report a case of a 20-year-old woman suffering from giant ovarian cyst. Ovarian cysts are seen in girls and women of all ages. Extra-large benign and malignant cysts of the ovary are uncommon and involve diagnostic and management challenges. Many problems are linked with surgical care of these giant ovarian cyst tumors, including severe hypotension, heart failure, respiratory failure, intestinal distention, and hypovolemic shock .The many of mucinous tumors were benign mucinous cystadenomas (85%). These tumors can grow to a very large size. They usually occur as large multicystic masses containing mucus and fluid, usually appearing in women in their 20 to 40 s. Its large size itself can be a sign of mucinous histology . Our patOvarian cyst frequency increased with age as adolescence progressed, ranging from 3.8%–31.3%. With a rate of 31.3 percent, the peak age for ovarian cysts was 15 years , which allows accurate identification in approximately 90% of cases. It has the advantage of being available, inexpensive, easy to perform , and has no ionizing radiation .This patient had an ultrasound examination, which indicated an adnexal mass on the right ovary, and a CT-scan was performed to further analyze this mass. A cyst may be classified as benign if at least one ultrasound feature of a benign mass  is present, and none of the ultrasound features of malignancy . Blood tTo estimate the risk of malignancy, ultrasound features without CA-125 levels have been shown to have high sensitivity, specificity, and likelihood ratios. Malignant ovarian cysts account for over 10% of all gigantic ovarian cysts, and their signs and symptoms, especially in the early stages of the disease, are ambiguous and non-specific, necessitating the exclusion of this possibility in all cases of ovarian cysts , 14.The surgical management of giant ovarian cystadenoma must pay attention to various factors, especially in the case of adolescents, where the operative strategy is to cure, and also maintain fertility in the patient. And during surgery, do not take the part where there is no cyst, and only do a cystectomy . The manLaparoscopy can be used as an option for diagnostic purposes. It can be useful in the differential diagnosis between ovarian tumors and other intra-abdominal cystic masses when imaging evaluation cannot determine the organ of origin. In addition, the tumor can be inspected and, when there are signs of malignancy , the surgeon may change the procedure to an open laparotomy. Laparoscopically in giant ovarian cysts, especially those that reach the umbilicus, there is a risk of perforation when the trocar is inserted . In thisI have reported a case of ovarian cystadenoma in a 20-year-old woman who underwent a left salpingo-oophorectomy, while the right adnexa  are still maintained, and the organ condition is good. So that the reproductive function is still possible to get pregnant.Extra-large benign and malignant cysts of the ovary are uncommon and involve diagnostic and management challenges. The most ovarian cysts occur during the hormonally active stages of growth of childhood and adolescence. Abdominal pain, distension, bloating, constipation, and vomiting are common symptoms caused by the compressive action of a giant ovarian cyst. The management approach is determined on the size of the cyst, the equipment available, and the surgeon’s level of skill. In this case report, open salpingo-oophorectomy was done, without any perioperative complications.


Gonimbrasia cocaulti (GC), a saturniid caterpillar, is a delicacy in some communities in Africa, yet there is no information on its nutrition profile to provide insight on their contribution to rural household nutrition. This study provides in-depth knowledge on the nutritional composition of the edible larval stage of G. cocaulti and the pupal life stages of the domestic silkworm (Bombyx mori) and Eri silkworm (Samia Cynthia ricini). The results showed that the edible stage of GC had significantly high levels of linoleic acid, minerals , vitamins  and crude fiber. The crude protein content of the larval and pupal stages of the various insects ranged between 50 and 62%. It is evident that the developmental life stage of GC and silkworms have adequate nutrients that could allow them to be utilized as ingredients in food fortification.Despite edible insects being possible future food sources, studies on the nutritional properties of some of the insects are still limited. Gonimbrasia cocaulti (GC) for the first time, while exploring the potential nutrient content of the pupal life stages of the domestic silkworm  and the Eri silkworm . The three insects were analyzed for fatty acids, minerals, proximate composition and vitamins. Among the fatty acids, linoleic, a polyunsaturated fatty acid, was approximately threefold higher in GC than in the silkworms. The Ca, Fe and K contents were highest in GC. However, the Zn and Na contents were highest in BM, while Mg content was predominant in SC. The crude protein content of the various developmental life stages of the edible caterpillars and pupae ranged between 50 and 62%. Further, the fiber content of GC was substantially higher compared to the pupal stages of the two silkworm species. The vitamin  levels of the two insect life stages were considerably high. These insects are comparably rich in nutrients with potential suitability to be utilized in food fortification and thus ease pressure on the over-reliance on animal and plant-based sources, which are becoming unsustainable.This study aimed to provide information on the nutrients of the edible larval stage of  With the world population expected to surpass nine billion by 2050, there is an urgent need to increase our current food production by almost 70% to feed this hungry population . HoweverAmong the many alternatives, edible insects stand out as the most sustainable and innovative source of food and feed. Conventional nutritional sources  have economic shortfalls in their production and have more negative effects on the environment. For instance, livestock rearing contributes close to 36% of global agricultural greenhouse gas emissions , whereasGlobally, over 1900 insect species form part of human diets, with others being used as animal feed, an indication that entomophagy is widely practiced . From a Gonimbrasia cocaulti, a saturniid caterpillar, is a delicacy in some communities in Kenya and in other parts of Africa [G. cocaulti was first described in Africa in 1992 [Gonimbrasia species and their considerable contribution to the rural economies in Africa [G. cocaulti and the silkworm pupae of Bombyx mori, and Samia Cynthia ricini are nutritionally dense and could serve as functional food ingredients in food fortification for fighting against possible future food insecurity in east Africa.f Africa , yet the in 1992 , previoun Africa ,22,23. T2, B9, B5, B12 and B6 standards, nicotinic acid, nicotinamide, alpha-tocopherol, beta-tocopherol retinol, potassium hydrogen carbonate, ethanol, potassium hydroxide, hexane, methanol, tetrahydrofuran, tert-butyl methyl ether, ammonium acetate, α- and γ-tocopherol standards and methyl acetate were all sourced from Sigma–Aldrich .All chemicals and solvents were of analytical grade unless stated otherwise. Hydrochloric acid, nitric acid, hydrogen peroxide, phosphate buffer, acetonitrile, vitamins BS. cynthia ricini and B. mori) were sampled from the sericulture rearing unit at the Animal Rearing and Containment Unit (ARCU) at icipe. At icipe, captive populations of the Eri (S. cynthia ricini) and domestic (B. mori) silkworms were reared on castor (Ricinus communis L.) and mulberry  leaves, respectively, which are the primary host plants [G. cocaulti under field conditions, reported by Kusia et al. [Vachellia tortilis, which is commonly called the umbrella thorn acacia or Israeli babool. A field survey on this medium to large, canopied tree yielded over 900 G. cocaulti caterpillar larvae in Machakos County. This collection was randomly divided into groups of 300, resulting in three groups (samples).The domesticated species of two silkworms  were kept separately in standard nonwoven bags (12 × 16 inches) and frozen at −21 °C in a chest freezer. While the caterpillar (G. cocaulti) samples collected from the field were packed in cool boxes that contained flaked ice (4–7 °C) and transported to the International Centre of Insect Physiology and Ecology (icipe) for taxonomic confirmation. The raw insect samples were then weighed into composite samples of 700 g, thawed and oven-dried  at 60 °C for 24 h to a moisture content of below 15%. The samples were ground in a three-speed Waring laboratory blender  before being screened through a 0.1 mm stainless steel laboratory sieve. They were then vacuum-packaged in sterile Ziploc bags, labeled and stored in a deep freezer (−21 °C) until further analyses.The silkworm pupae  using a 7890A gas chromatography coupled to a 5975 C mass spectrometry selective detector  ). To metThe mineral contents were assessed by inductively coupled plasma emission spectrometry (ICP-AES). Each sample (5 g) was incinerated at 450 °C until its ash turned a grey to reddish-brown color. The ash was then dissolved in an acid mixture of hydrochloric and nitric acid and hydrogen peroxide  as per the published protocols in . The samThe proximate components of the samples were analyzed using the protocols of AOAC . The dryThe fat- and water-soluble vitamins in the various samples were analyzed following the methods described by Maiyo et al.  and BhatFor the fat-soluble vitamins, analyses were performed using reverse-phase HPLC  linked to a SPD-M2A detector. The injection volume of each sample was 10 µL with a total flow rate of 0.4 mL/min for 10 min. Standards for retinol and α- and γ-tocopherol were prepared at four different concentrations each and used for the calibration curve. Peaks were identified by their retention time and the absorption spectra were compared to the standardized spectra. Vitamin concentrations were calculated by comparing the peak area of samples to the peak area of the standardized spectra.Three replicate samples per species were analyzed for each parameter. Two statistical programs (R and PAST) were used in the statistical analyses. ANOVA and Tukey’s multiple comparisons tests (HSD) from the package “agricolae” were used to compare the assayed parameters between species. A nonmetric multidimensional scaling (NMDS) plot was completed in the PAST program , to highlight the interspecies variation in free fatty acids. Box plots, bar graphs and a plot of means were completed in R v3.6.2 , the facp < 0.05) (p = 0.0259). Azelaic acid was significantly higher in BM than in SC and GC, both of which had comparable values . Myristic and pentadecanoic acids were high in GC, while in the silkworm pupae they were low and comparable . On the other hand, palmitoleic acid was significantly higher in BM in comparison to SC and GC .Edible insects are known as a valuable source of fatty acids, whose properties have been considered to be closer to plant than animal oils ,38,39,40 < 0.05) . In thisp < 0.0001) and linoleic  acids were low and comparable in the silkworms, but substantially high in GC. Elaidic acid  differed considerably between the three insects, while nonadecanoic  was low in CS but high and similar in BM and GC. Moreover, eicosanoic acid was recorded highest in BM, but low and comparable in SC and GC . Our findings are in agreement with fatty acid spectra reported on other edible insects [The contents of both heptadecanoic , heptadecanoic and pentadecanoic . In contThe three insects exhibited different accumulation patterns of minerals , which ip < 0.0001), iron  and calcium  were high in GC (p = 0.00423) and zinc  were found to be high in BM  compared to the other two insects  and crude fiber  were both highest in GC and lowest in BM, nevertheless, the crude fiber values in the silkworms were comparable. The silkworm BM possessed the highest values in both the dry matter  and fat content , while GC had the lowest values, even though the fat content values in GC and SC did not differ significantly. The protein content  was noticeably higher in SC compared to the other two insects. However, it is important to note that all three insects had extremely high-protein content (>50%). The highest moisture content  was recorded in GC and lowest in BM.The findings of proximate nutrients analyzed separately on a dry matter basis are given in Protein content was dominant in all three insects, followed by total fat. These findings are comparable to those reported by Arasakumar et al.  on the pThe fat content of insects has been reported to vary between 10 and 70% on a dry matter basis, which is within the range reported in the current study ,64,66. HThe ash content levels agree with those reported by other authors investigating various edible insects ,68,70,72p < 0.05) and 0.92 (p < 0.001), respectively  and with moisture content . Fiber had a positive association with moisture (0.62), though this association was not significant (p = 0.077). These associations show that some of the proximate components are related and that an increase in one may lead to a decrease in the other and vice versa. For instance, if there is more fat content then one should expect less protein and ash in the studied insects, since they are inversely associated.There were high-positive associations between the ash content with fiber and moisture contents of 0.76 . Further, the insect species had a significant influence on vitamins B9  and B12  both of which were highest in GC but were lowest in the silkworms. Vitamin B6  was recorded lowest in BM, while its values for GC and SC samples were high and comparable. Retinol  was only present in the silkworms, though it was higher in BM than SC. Alpha-tocopherol was higher in GC compared to the two silkworms, while gamma-tocopherol was highest in BM and lowest in GC. The observed differences in the vitamin contents between the studied insects could be due to variation in the diet eaten by the insects [Vitamins B insects ,62.Any feed or food needs to contain sufficient quantities of vitamins, as they facilitate the development of proper and healthy body functions. Moreover, vitamins contribute to the development of the immune system, while also helping in the digestion of other nutrients ,82. The Gonimbrasia spp., which opens new opportunities for future efforts.In addition to macro- and micronutrients, edible insects are rich in natural bioactive compounds, which includes peptides and phytochemicals ,86. ThesIt is also important to note that most of the aforementioned silkworm pupal bioactivities have only been tested in vitro, hence in vivo assays either in animal models or human are needed. Despite the huge potential of edible insects as food and feed or medicine, their safety needs to be evaluated, both for toxicological safety and for allergic reactions. For instance, though insect oils are high in unsaturated fatty acids, they are not recommended for direct human consumption due to the presence of triacylglycerols, which if consumed may increase the risk of heart related diseases . In addiThe overall nutrient profile of the edible stage of GC was comparable to that of the silkworm pupae, which were comparable to, or surpassed, those of the conventional animal and plant-based products in some cases. The high content of mono- and polyunsaturated fatty acids, vitamins, minerals and protein in the targeted edible stage of GC and silkworm pupae showed that they could be explored as a food additive for tackling nutritional deficiencies. However, further studies on protein digestibility, amino acid profile, antinutrients and antioxidants would be necessary. With the ongoing challenges of an expanding global population, climate change, scarcity of land and water and the ever increasing undernourished populations in developing countries, novel food production strategies are required. The rearing of edible insects for food and feed has the potential to bridge these gaps in an environmentally sustainable manner.


Anatomical variations in the location and position of temporal bone-related vasculature are routinely encountered in clinical practice, contributing to clinical syndromes and complexities in ear-related and neurological surgeries. Pneumatization of the temporal bone (TB) is one of several factors that have been hypothesized to influence the variabilities and variations of these vessels. This study aimed to investigate the association between the degree of pneumatization and the morphologies of some TB-related vessels, as well as their morphometrical relationship with ear regions. Observational retrospective chart review of 496 TBs computed tomographic scans were examined. Different degrees of pneumatization were observed, with hyper-pneumatization being the most common and hypo-pneumatization being the least. Various anatomical variants of the sigmoid sinus (SS), jugular bulb (JB), and internal carotid artery (ICA) were observed. Distances of SS and JB to ear regions were observed to have significant differences (p < 0.05) in laterality. These distances increased relative to increased air cells, showing a significant association (p < 0.05). A significant association (p < 0.001) was also observed between the degree of pneumatization and variants of JB and ICA. High JB, JB dehiscence, and ICA dehiscence were significantly associated with increased pneumatization, while flat JB was significantly associated with decreasing pneumatization. However, no significant association  was observed between the degree of pneumatization and morphologies of SS. This study concludes that the degree of pneumatization influences only the jugular bulb variants and ICA dehiscence, as well as the distances of SS and JB to ear regions. Its anatomical complexity poses a challenge in interpreting anatomical findings and diagnosing various pathological conditions affecting this skull region3.The anatomy of the temporal bone  involves a complicated relationship between critical structures2.The temporal bone (TB), though relatively small, contains the middle and inner ear structures, along with several cranial nerves and major vessels, all within a relatively small space6. The pneumatization of the TB has been reported to be responsible for these variabilities8. This was also indicated in the study of Singh et al.9, highlighting how pneumatization of the TB influences the morphology of the SS.The location, as well as the size and shape of these vasculatures, such as sigmoid sinus (SS) and jugular bulb (JB) , is highly variable, including a significant difference in laterality11. For instance, high JB has been seen to occur in 6–20% of the population11. Other reports found variations in the incidence of high JB, with some citing as low as 3.5% and others reporting high incidences up to 65%14.Anatomical variations of these vasculatures and their anomalies, such as protrusive SS, dehiscence SS, high or high riding JB, and JB dehiscence, are not rare in the TB15. The variations also impact the complexity of neurotological surgeries and are a vital pitfall encountered in TB and ear-related surgeries16. For example, injuries to these vessels due to surgical trauma have been mostly observed after mastoidectomy procedures11. Their significance, even in relatively minor otological surgery, was highlighted in a case of a myringotomy in a 10-year old boy with acute otitis media16. The myringotomy of a dark-blue tympanic membrane led to massive bleeding and subsequent death of the child following thrombosis of an iatrogenically injured dominant SS16.These variations of the SS and JB are frequently encountered in clinical practice, affecting the middle and inner ear functions and causing tinnitus, vertigo, and/or hearing loss22. Most TB and ear-related surgeries, depending on the approach, require a good knowledge of the degree of TB pneumatization and the relationship between SS, JB, the external acoustic canal (EAC), the middle ear (ME), and the internal acoustic canal (IAC) in order to avoid intraoperative complication2. For instance, the SS is one of the most familiar landmarks used during trans-mastoid and posterolateral skull base approaches24. It can also be used as a reference structure when evaluating the degree of mastoid pneumatization25.Acute otitis media requiring, minor otological surgeries and TB-related fractures resulting in surgical intervention are not rare in South Africa, sub-Saharan Africa, and other regions of the world.23 and Dai et al.26 that hypothesized possible influences of mastoid pneumatization on the position of SS, observable and measurable data concerning the influence of TB pneumatization on the morphology of TB-related vessels and their morphometric relationship with ear-related structures/regions remain scarce. Hence, this study sets out to investigate any possible influence TB pneumatization may have on the morphology and morphometry of its related vasculature by measuring the shortest distances between selected vasculature (such as SS and JB) and EAC, ME, and IAC, evaluating their vascular variants, and analyzing for any possible association with the degree of pneumatization of the TB.Since the studies of Ichijo et alThe present study was an observation and retrospective review of 496 TBs computed tomography (CT) images of 248 head and neck/brain CTs of patients retrieved from the Picture Archiving and Communication Systems (PACS) of public hospitals in Durban and Pietermaritzburg, Kwazulu-Natal, South Africa. The three population groups identified in the study were South African Blacks, South African Indians, and South African Whites.These include high-resolution multi-detector CT images acquired with 0.6 mm collimation, images without observable signs of abnormal pathological processes in the TB, and absence.The CT images were acquired using Multi-Detector row Computed Tomography (MDCT) Scanners . The scans were performed in a craniocaudal topographical direction using 140 kV, modulated mAs ranging between 280 and 400 mA  with 30% dose reduction and ASIR-V application in a bony algorithm with a window width of > 3000 hU and a window level of 500 hU. The axial view was reconstructed parallel to the orbito-meatal line using slice thickness of 0.625 mm, detector coverage of 20 mm, and a PITCH of 0.5. Voxel size of images is isotropic.Using digital imaging and communication in medicine (DICOM), TB CT images retrieved from the PACS of public hospitals selected for this study were transferred to a Workstation, and all morphological and morphometrical analyses were carried out using IntelliSpace Portal (ISP) Version 11.1 . Prior to the morphologic and morphometric analyses of images selected for this study, a pilot study was initially conducted on 20 TB CT images in other to ascertain specific landmarks for analysis of vascular variants, degree of pneumatization, and distant measurements. Also, 50 randomly selected temporal CT images (both left and right) were analyzed by a first, second, and third observer  for inter-observer reliability testing. This was done to achieve the accuracy and repeatability of measurements.The shortest distances between the selected TB-related vessels (SS and JB) and ear regions  were achieved as described in Fig. ½SS-Width), Protrusive type (SS-Diameter > ½SS-Width), and Saucer type (SS-Diameter < ½SS-Width). SS-Diameter and SS-Width were achieved as described in Fig. The variants of the jugular bulb analyzed in the study are as follows: high jugular bulb (when the bulb's dome rises close to the tympanic membrane’s annulus), jugular bulb dehiscence (when HJB extends into the middle-ear cavity due to dehiscent sigmoid plate), and flat jugular bulb (no bulb or absence of the dome) Fig. d. Finall.25, the degree of TB pneumatization was analyzed by evaluating the air cells around the sigmoid sinus on an axial CT image. This involved the application of three parallel lines in the anterolateral direction angled at 45° on the axial CT section, where the malleoincudal complex appears as an ice-cream-cone shape. These lines were applied at positions in which each crossed the most anterior point of the sigmoid sinus at the junction with the petrous bone, the most lateral aspect along the transverse plane of the sigmoid groove, and the most common posterior point of the sigmoid sinus, respectively  and the National Health Research Committee of the KwaZulu-Natal Department of Health (NHRD Ref.: KZ_202102_026). All methods were carried out in accordance with the University of KwaZulu-Natal standard-approved guidelines and regulations, as well as all experimental protocols in accordance with the declaration of Helsinki.All continuous and categorical data were presented as the median and interquartile range (IQR) and percentage (%). A total of 248 patients with 496 HRCT TB scans (right and left sides) were included in this study. The median age of the patients was 13.0 years . Of the patients, 115 (46.4.5%) were females, and 133 (53.6%) were males , where pneumatization extends beyond the arbitrary line drawn at the most posterior point of the SS. However, females were more likely to have hyper-pneumatization , while males were more likely to have hypo-pneumatization . Also, hypo-pneumatization was observed to have a higher incidence on the left, while moderate and good pneumatization had higher incidences on the right. In most patients, the degree of pneumatization was observed to be the same on both sides of the TB, with a significant association at p < 0.05. The results are detailed in Table The degree of pneumatization was achieved by evaluating air cells around the sigmoid sinus, according to Han et al.tization 40, 37.9%The average distances of SS to EAC, ME, and IAC and JB to EAC, ME, and IAC were observed to be greater on the left. According to laterality, the Wilcoxon rank test showed a significant difference in average distances of SS-EAC, SS-ME, SS-IAC, JB-ME, and JB-IAC (p < 0.01) except for JB-EAC, which showed no significant difference (p = 0.55) Table . For sexAs presented in Table The incidence of anatomical variations and morphologies of the sigmoid sinus, jugular bulb, and internal carotid artery in the selected study population is summarized in Table 2, p = 0.199) dominance on the left TB . Protrusive SS was observed to have an incidence of 126 (35.0%) with a non-significant  dominance on the right TB . The half-moon type of SS was observed to have the lowest incidence (4.2%). For sex, the saucer-shaped SS was observed to be higher in males with an incidence of 123 (66.8%) and non-significant dominancy on the left for both sexes , Fisher’s, p = 0.148; female left- 50 (56.2%), Fisher’s, p = 0.659). While, the protrusive SS was observed to be higher in females with an incidence of 72 (40.9%) and dominancy on the right for both sexes , Fisher’s, p = 0.659; male right- 31 (35.6%), Fisher’s, p = 0.148).Overall, the saucer-shaped and protrusive types of SS were more common, with the former having a higher incidence. Saucer-shaped SS was observed to have an incidence of 219 (60.9%) with a non-significant (XJugular bulb variants observed in the study were FJB- 25 (6.9%) , with males having an incidence of 7 (3.7%) and females having an incidence of 6 (3.4%). The incidence was also more dominant in the right ear (right TB) in the overall incidence and with sex at p < 0.05.For both right and left, vascular variants in the shape of SS analyzed in this study were observed to occur in the different degrees of pneumatization, with the most occurrence of half-moon-shaped SS in patients with hypo-pneumatized TB. In contrast, protrusive and saucer-shaped SS occurs more in hyper-pneumatized patients. However, there was no significant association between the incidences of these variable shapes of SS and the degree of TB pneumatization .For the analyzed JB variants in the study, HJB was observed in the different degrees of pneumatization but with a high incidence in patients having hyper-pneumatized TB on both sides  with a significant association at p < 0.001. JB dehiscence was also observed to have a significant association (p < 0.001) with hyper-pneumatization on both sides, mostly occurring in patients with HJB. However, more incidence of FJB was observed in patients with hypo-pneumatized TB with a significant association at p < 0.001.Lastly, the incidence of ICA dehiscence was observed only in patients with hyper-pneumatized TB on both sides, showing a significant association of p < 0.01. The results are detailed in Table11. However, observable and measurable data relating this to different degrees of pneumatization of TB remains scarce. Moreso, previous studies have highlighted that there is still a paucity of data to ascertain the association between different degrees of pneumatization of the TB anatomical variations of its related vessels and their relationship with ear regions Dai et al.26 and Singh et al.9.The degree of TB pneumatization has been implicated as one of the factors influencing the relative morphology and location of its related blood vessels in relation to the ear regions.25 was utilized by evaluating air cells around the sigmoid sinus and classifying the degrees of TB pneumatization into hypo-, moderate-, good-, and hyper-pneumatization. All degrees of pneumatization existed in the present study population regardless of age or population group. Overall, hyper-pneumatization had the highest incidence (37.9%), and hypo-pneumatization had the lowest incidence (15.2%), which is the same as reported by Tan et al.27 in the Singapore population. Bronoosh et al.28 also identified hyper-pneumatization as the most common pattern occurring in 30.9% of their study subjects in an Iranian population.In this study, the classification of Han et al35. No significant difference was observed with age or among population groups. However, the present study identified the distances between SS and JB and the selected ear regions, i.e., EAC, ME, and IAC, to vary significantly between right and left, with the left significantly higher than the right for all distances .Generally, the position and location of TB-related vasculature to ear regions vary greatly among individuals and between right and left ears which corresponds to the findings from the present study.36, mastoid surface areas and volume follow a linear correlation. This implies that an increased pneumatization denotes an increased surface area, which increases the distances observed between these vessels and ear regions as pneumatization increases.All distances measured were highest in patients with hyper-pneumatized TB. Significant associations  existed between the different degrees of pneumatization and all distances measured. This was because distances between SS and JB and the selected ear regions increase as pneumatization extends across each of the three parallel lines anterolaterally applied at angle 45°, which was utilized to classify the degree of pneumatization in this study. According to Lima et al37. These, of course, are encountered in routine clinical practice and may pose dangers in ear-related and mastoid surgeries in which surgeons need to avoid such pitfalls38. The SS and its variant shapes were observed in the different degrees of pneumatization for right and left. Although in the reviewed literature, the half-moon-shaped SS had been ascribed to a healthy mastoid and was seen as the most common type of SS39, the present study identified the SS as more saucer-shaped in the study population with no significant association with the degree of pneumatization. In contrast, half-moon-shaped SS was found more in patients with hypo-pneumatized TB; however, there was no significant association.The present study also analyzed the incidence of some variants of vessels such as SS, JB, and ICA relative to TB structures, which have implications for the development of pathologic abnormalities, such as encroachment on the structures of the middle ear or eroding into the inner ear.4 and Kawano et al.38, who reported high incidences of HJB to be 23% and 16%, respectively, and supports the claims of Friedmann et al.8 and Park et al.40 that HJB is the most common JB variant not rare in a population. This, however, is significantly associated (p < 0.001) with increasing pneumatization. This implies that, as pneumatization extends the three parallel lines, most significantly where pneumatization extends beyond the arbitrary line drawn at the most posterior point of SS (hyper-pneumatization), increase in the incidence of HJB was observed. Although JB abnormalities are rarely encountered during ear surgeries, a high jugular bulb remains a recognized problem that can lead to brisk venous haemorrhage if the bulb is inadvertently opened41. Hence, ENT surgeons should watch out for the possibility of a high-riding jugular bulb in patients with hyper-pneumatized TB.For JB and its anatomical variants, HJB was found to be the most common variant of JB. This high incidence conforms with the studies of Aslan et al42, HJB becomes a dehiscent JB when the sigmoid plate between high-riding JB and the middle ear is missing, allowing the JB to bulge into the middle ear cavity. This means that an individual with hyper-pneumatized TB is at risk of having a dehiscent JB in the absence of the sigmoid plate, which is one of the common causes of pulsatile tinnitus43.Like HJB, this study also observed a significant association between hyper-pneumatization and JB dehiscence. The similarity in the significant association observed for HJB and JB dehiscence follows their anatomical relationship. According to Gaillard.16, who documented a higher incidence of FJB. A significant association between decreasing pneumatization and incidence of FJB was observed, especially when pneumatization is limited to the first anteromedial line, i.e., hypo-pneumatization or nothing near this line. In this case, the mastoid contains more marrow than air cells (diploic) or contains mainly dense bone45, which could inhibit the formation of the bulb.In addition, a lower incidence of flat JB was observed in this study. This contradicts the report of Vachata et al46. The transition of the bony petrous into air cells in an extensive pneumatized could result in dehiscence of the ICA due to the loss of bony elements.Furthermore, ICA dehiscence as a vascular variant was considered in this study. The dehiscence of ICA was observed to occur with an incidence of 3.5% from the analyzed scans, which was only seen in the TB to be significantly associated with hyper-pneumatized TBs with extensive pneumatization. An extensive pneumatization is when pneumatization spreads to the petrous apex (and even beyond), where the ICA is seen to exit the carotid canal into the foramen lacerum to enter the skull47. Although middle ear disease such as chronic otitis media is one common cause of hearing loss, high jugular bulb (HJB), for instance, when associated with diverticulum or dehiscence high-riding JB, has been reported to result in sensorineural hearing loss, conducting hearing loss, and Meniere-like syndrome (a disorder of inner ear that can lead to dizzy spell and hearing loss common to the left ear) due to compression of the inner ear52. The high incidence of HJB and JB dehiscence reported in this study due to increased pneumatization (hyper-pneumatization- 37.9%) could also contribute to hearing loss in children, teenagers, and adults.Importantly, in ENT and its related surgeries, most of these vascular variants can result in ear disturbances and dysfunction, as well as diagnostic and surgical difficultiesThis study investigated the association between the degree of pneumatization and TB-related vasculature in terms of their morphologies and morphometric relationship with ear regions/structures. Hyper-pneumatization was more common in the study population and significantly associated with HJB, JB dehiscence, and ICA dehiscence, while hypo-pneumatization was least common and significantly associated with FJB. No significant association between the degree of pneumatization and SS variants. Furthermore, distances of SS and JB to ear regions increase as the degree of pneumatization increases. Hence, this study concludes that TB pneumatization is a factor that influences the relative morphological variants of JB and ICA only and the distances of SS and JB to different ear regions. Awareness of these will contribute significantly to predicting and avoiding relative morphological variants and the location of these vessels, which are recognized pitfalls that could become distressful or cause complications during ear-related surgeries.


While Alzheimer's disease (AD) can cause a severe economic burden, the specific pathogenesis involved is yet to be elucidated. To identify feature genes associated with AD, we downloaded data from three GEO databases: GSE122063, GSE15222, and GSE138260. In the filtering, we used AD for search keywords, Homo sapiens for species selection, and established a sample size of > 20 for each data set, and each data set contains Including the normal group and AD group. The datasets GSE15222 and GSE138260 were combined as a training group to build a model, and GSE122063 was used as a test group to verify the model's accuracy. The genes with differential expression found in the combined datasets were used for analysis through Gene Ontology (GO) and The Kyoto Encyclopedia of Genes and Genome Pathways (KEGG). Then, AD-related module genes were identified using the combined dataset through a weighted gene co-expression network analysis (WGCNA). Both the differential and AD-related module genes were intersected to obtain AD key genes. These genes were first filtered through LASSO regression and then AD-related feature genes were obtained for subsequent immune-related analysis. A comprehensive analysis of three AD-related datasets in the GEO database revealed 111 common differential AD genes. In the GO analysis, the more prominent terms were cognition and learning or memory. The KEGG analysis showed that these differential genes were enriched not only in In the KEGG analysis, but also in three other pathways: neuroactive ligand-receptor interaction, cAMP signaling pathway, and Calcium signaling pathway. Three AD-related feature genes  were finally identified. The area under the ROC curve of these AD-related feature genes was greater than 0.7 in both the training and the test groups. Finally, an immune-related analysis of these genes was performed. The finding of AD-related feature genes  could help predict the onset and progression of the disease. Overall, our study may provide significant guidance for further exploration of potential biomarkers for the diagnosis and prediction of AD. Alzheimer's disease (AD) refers to the onset and development of age-related cognitive and functional decline and specific neuropathology, which Alois Alzheimer first described in 1906 . In these three datasets, there were 249 AD samples and 250 normal samples. Among the AD samples, 56, 176, and 17 corresponded to datasets GSE122063, GSE15222, and GSE138260, respectively. All 499 samples were included in this study. Normal samples were used as control throughout all the study to be able to perform pooled analyses and validate the final model. Moreover, we conducted model verification after its construction. In our method, we merged the datasets GSE15222 and GSE138260 and used the merged data as a training group to build a model. Then, we used dataset GSE122063 as a test group for model validation. A flow diagram of the study is shown in The fusion of datasets GSE15222 and GSE138260 was constructed with the R package termed “sva”. The conditions for screening differential gene expression were set as logFC > 1, FDR < 0.05. According to these stringent criteria, 111 genes were screened and selected for subsequent analysis.The Gene Ontology (GO) analysis can identify genes closely related to the origin, development, and phenotypic expression of the disease. In our GO enrichment analysis, three components were included: Biological Process (BP), Molecular Function (MF), and Cellular Component (CC). On the other hand, the Kyoto Encyclopedia of Genes and Genome Pathways (KEGG) enrichment assessment enables systematic gene function analysis by linking genomic and functional information. These two methods were employed to analyze the 111 differential genes obtained before. The R packages involved in the GO and KEGG analysis were “DOSE”, “org.Hs.eg.db”, “clusterProfiler” . Briefly, the first step was to cluster samples and then check whether they contain outliers due to human or other reasons. Then, a corresponding weighted correlation coefficient was obtained by measuring each gene, and an adjacency matrix was constructed accordingly. Here, gene similarity should be reflected at both the expression levels and the network topology. However, noise and false positives can affect the adjacency matrix alone. To minimize these issues, in a second step, the adjacency matrix was transformed into a topological overlap matrix (TOM). After that, the genes that had similar expression levels were clustered in modules to be used in subsequent analysis. In a last step, we aimed to identify gene modules associated with AD using Pearson's correlation analysis. This association was adjusted by setting the values of gene significance (GS) and module membership (MM) to 0.4 and 0.8, respectively. The gene modules thus calculated were used as hub genes. Finally, three modules were found to be highly correlated with AD: yellow, green, and magenta.http://bioinfo.life.hust.edu.cn/HumanTFDB#!/) database.After taking the merged dataset as a training group, the screening conditions were logFC > 1, FDR < 0.05, and 111 differential genes were extracted. Then, the genes from the three AD-related modules found in the WGCNA analysis were assessed for intersection. Six matches were obtained  and subsequently filtered by LASSO regression to obtain 3 AD characteristic genes: SST, MLIP, and HSPB3. Lastly, the three were again submitted to validation using the Test group, and all showed high reliability as AD-related feature genes. In addition, we also performed transcription factor analysis of AD-related feature genes, which was done through the HumanTFDB  was performed to quantify the expression of AD-related immune cell subgroups and immune function in normal and AD groups. Then, a correlation analysis was performed between the screened AD-related feature genes and the immune cells.We combined datasets GSE15222 and GSE138260 as a training group to build a model, and then used dataset GSE122063 as a test group to evaluate model accurateness. In the training group, the genes common to the two datasets were screened out, and the expression levels of each sample were combined into a matrix. The combined dataset had a total of 399 samples to be included in the model for subsequent analysis. Of them, 193 were AD-related and 206 were normal samples. For its part, the validation group had 66 AD samples and 44 normal samples in its gene expression matrix. The merged dataset was normalized using the “limma” package, and then we clustered the samples to avoid significant outliers. All samples in the combined dataset were included in our study .In the AD merged data, a total of 111 differential genes were detected, of which only 16 were up-regulated. The global results are presented in a volcano plot . The expThe results of the GO and KEGG enrichment analysis performed on the previously obtained 111 differential genes are depicted in R2 = 0.86) (P = 5e-19), −0.41 to the green module (P = 6e-18), and 0.38 to the magenta module  . The corA total of 6 AD key genes were found by intersecting the 111 differential genes with the 51 module core genes obtained in the above WGCNA analysis  SST, MLIP < 0.001, After screening out AD-related feature genes by the LASSO regression, the difference boxplot of the Training group was constructed. This boxplot showed that the AD-related feature genes SST, MLIP, and HSPB3 had significant differences between the AD group and the normal group (P < 0.001). In line with the Train group, the evaluated genes were all down-regulated . The abscissa of this violin plot denoted the name of each immune cell, and the ordinate, the content of each immune cell. The blue in the figure represented the samples of the normal group, while the red represented those of the AD group , which passed the verification in the Test group. These three genes may serve as AD markers and effective indicators for AD treatment.Currently, immune analysis for neurodegenerative diseases is gradually entering the big academic picture. The common notion is that immune cells cannot quickly access a healthy brain, which is true most of the time. However, recent research in humans and other species has found that immune cells not only can access a still-healthy aging brain, but can also reach the precise cerebral areas where new neurons are generated. This unlocks new directions for neurodegeneration research. Various neurological diseases have a close interaction with the immune system. In the human meninges, the boundary of the central nervous system, both innate and acquired immune cells are abundant. A different cytoimmunological situation is observed in the brain parenchyma. For the immune response to function properly, the brain parenchyma often adopts another strategy: considerable lymphocyte infiltration.Interestingly, multiple studies have demonstrated that interventions on the immune system in the meninges can modulate the nervous system function and behavior. This regulation depends on neuron-specific receptor signaling, for instance, on T cells and their secreted cytokines  were identified by WGCNA analysis and subsequent LASSO regression. Somatostatin (SST) is released in the hypothalamus and, as the name suggests, inhibits growth by preventing the release of growth hormones from the pituitary gland. A previous study on the SST gene revealed that the content of somatostatin in the cerebrospinal fluid of patients with vascular dementia was significantly lower than in a healthy person. We compared the data of patients with cognitive impairment and found that both diseases are accompanied by a decline in this gene, which would be one of the causes of dementia in patients with cerebral infarction.In the present study, the content of SST was also decreased in the AD group. Thus, the down-regulation of this gene may contribute to the occurrence and development of AD. Nevertheless, more evidence is needed to support this hypothesis. In addition, related studies have proposed that SST is an important neuromodulator in the dentate gyrus, and disruption of the associated signaling system may significantly impact hippocampal function. The latter may have established a more vital link between this gene and AD.On the other hand, the MLIP gene is often reported to be associated with muscle, and enriched in class A lamina-interacting protein. This is a unique protein required for normal cardiac muscle adaptation to stress . HSPB mutations may have serious consequences, such as peripheral neuropathy caused by point mutations in HSPB1 and HSPB8. Thus, HSPB3 research requires special attention. In addition, a new missense mutation in HSPB3 (R7S) has been recently identified in axonal motor neuropathy. A further article that employed bioinformatics methods also identified HSPB3 as a central gene associated with AD ; the Natural Science Foundation for Youths of Shanxi Province, China (20210302124301); the Provincial Science and Technology Grant of Shanxi Province (20210302124588); Changzhi Medical College Innovation Team (CX202001).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.