Diagnosing a child by newborn screening with classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CAH) causes multiple challenges for the affected parents and the whole family. We aimed to examine the health-related Quality of Life (HrQoL), coping, and needs of parents caring for a child with CAH to develop demand-responsive interventions for improving the psychosocial situation of affected families. In a retrospective cross-sectional design, we assessed HrQoL, coping patterns, and the needs of parents caring for a CAH-diagnosed child using specific questionnaires. Data of 59 families with at least one child diagnosed with CAH were analyzed. The results show that mothers and fathers in this study reached significantly higher HrQoL scores compared to reference cohorts. Decisive for the above-average parental HrQoL were effective coping behaviors and the parental needs being met. These findings verify the importance of helpful coping patterns and rapid fulfillment of parental needs for maintaining a good and stable HrQoL of parents with a child diagnosed with CAH. It is crucial to strengthen the parental HrQoL to build a reasonable basis for a healthy upbringing and improve the medical care of CAH-diagnosed children. The introduction of expanded newborn screening in Germany in 2005, including rare congenital inborn errors of metabolism such as congenital adrenal hyperplasia (CAH), allows for diagnoses in newborns before the onset of symptoms. Therefore, early initiation of therapy can prevent newborns from severe consequences ,2,3.CAH is a rare disease with an incidence of 1:12,000 . It is cCAH is characterized by an increased amount of 17-hydroxyprogesterone, which is crucial for the detection within the screening process. Approximately 94% of all CAH cases are allocated to classic CAH ,6,7,8. CAdditionally, CAH is associated with many long-term implications relating to hormonal replacement therapy, clinical and biochemical monitoring, surgical interventions, fertility issues, and quality of life ,6,7,8. WDiagnosing a child with a chronic disease such as CAH causes multiple challenges for the parents and constitutes a profound change in parental thinking. The parents must understand and accept the disease and realize that the disease is lifelong. Many studies verify an increasing psychosocial burden on the entire family after a newborn is diagnosed with a chronic disease ,12,13,14We know less about the psychosocial situation of parents of children with CAH, particularly those diagnosed by newborn screening. A few studies indicate an increasing strain on these parents, especially shortly after the initial diagnosis ,17,18,19Immediate and appropriate education by medical professionals about the diagnosis is essential in alleviating parents’ psychosocial distress. It is crucial that parents comprehensively understand the information ,21,22. TAlthough there is evidence of increased psychosocial distress among affected parents, there is often a lack of professional support and psychosocial support services . Due to In addition to the psychosocial burden, health-related quality of life (HrQoL) is an essential outcome of successful treatment. HrQoL describes a person’s subjective psychological, physical, mental, and social health-related well-being and functioning ability .Studies examining the HrQoL of parents with chronically ill children reported a reduced HrQoL in parents caring for a chronically ill child due to an increased burden and additional responsibility . ParentsOnly a few studies focus on HrQoL and the psychosocial consequences for the parents of children with CAH. Waldthausen  reportedNevertheless, parents seem to cope with their child’s chronic health condition over time and worry less about the child. 97% of parents of children with CAH aged 4 to 12 years reported being satisfied with their child’s health, and 76% had no fear of a salt-wasting crisis .However, it is crucial to understand the needs of affected families to improve the psychosocial well-being of parents caring for a child with CAH. Gathering the dimensions of the HrQoL, coping patterns, and the specific needs of affected parents allows clinicians and researchers to gain insight into these families and thus provide adequate support. Therefore, our study aims to examine the HrQoL, coping patterns, and special needs of parents caring for a child with CAH.This retrospective cross-sectional study examined the HrQoL, coping patterns, and needs of parents caring for a child with CAH diagnosed by newborn screening in Bavaria, Germany. It was a cooperation project of the Department of Medical Psychology of the University Medical Center Hamburg-Eppendorf (UKE), the Bavarian State Office for Health and Food Safety, and the University Children’s Hospital in Erlangen. In a mixed-method approach, quantitative and qualitative data were analyzed using validated questionnaires and semi-structured telephone interviews. The presented analysis focuses on the quantitative data, aiming to gain knowledge about HrQoL, coping patterns, and the needs of parents of children born with CAH. The Bavarian Medical Association Ethics Committee approved the study in September 2018 (No. 18003).The Bavarian State Office for Health and Food Safety registry identified the families and asked them to participate in this study. Inclusion criteria were: (1) parents of children with classic CAH (21-OH deficiency), (2) children aged up to 18 years, and (3) CAH diagnosis by newborn screening in Bavaria ,36. The Parents were excluded because of (1) missing informed consent, (2) insufficient knowledge of the German language, or (3) other diseases than CAH being the center of attention of the family.The Bavarian State Office for Health and Food Safety sent questionnaires to eligible families via the postal service, including an informative letter about this study, a declaration of consent, and a pre-paid return envelope between September 2018 and September 2019. Parents reported sociodemographics, the child’s health condition, and circumstances regarding the diagnosis process. Based on self-reports, parents provided information about their HrQoL within the last week, coping strategies for dealing with the situation due to their child’s disease, and their current particular needs.Parental HrQoL was measured using the chronic–generic Ulm Quality of Life Inventory for Parents (ULQIE) . The ULQParental coping strategies were assessed using the chronic–generic Coping Health Inventory for Parents (CHIP) questionnaire ,39. The Chronic–generic needs of parents were measured using the Scale of needs for parents of chronically ill children. This questionnaire contains 19 items about the parental need for information, psychosocial care, exchange with others, and support in everyday life. The items are rated on a 5-point Likert scale ranging from 1 to 5: the higher the item’s score, the more intense the parent’s need. The reliability of the Scale of needs for parents of chronically ill children shows internal consistency of 0.95 .t-tests. Multiple linear regression analyses were performed to identify variables that predict parental HrQoL. Sociodemographic and clinical variables, the CHIP total score, and the total score of the Scale of needs for parents of chronically ill children were entered as predictors into the model. The clinical data comprised the child’s age, sex, and current hormonal replacement therapy. Since no data on the pubertal status of the children were reported, we set the age of 10 years, according to Sawyer, Azzopardi [We used the statistic software SPSS, version 25  for data analysis. Descriptive statistics were computed for each subscale of the questionnaires examining HrQoL and coping. Missing values were replaced by the individual mean score for each variable if missing data were random or less than 20.00% of all scale items . We compzzopardi , as the The examined sociodemographic aspects consisted of the parents’ age and sex, number of children, number of children diagnosed with CAH, place of residence, educational level, and employment status in the last 12 months. Further examined aspects were the use of psychosocial consultation and contact with other parents who have children with CAH.t-test. The linear regression model investigates 14 relevant influencing factors to analyze the influence on the HrQoL measured by the ULQIE total value. With the one-sample t-test, the computed ULQIE total value was compared to a reference cohort’s total value.For the confirmatory approach, a Bonferroni adjustment for multiple testing was conducted. Based on an initial significance level of α = 0.05, the significance level was reduced to α = 0.0033. The reduction was justified by simultaneously calculating multiple linear regression analyses and one one-sample Exploratory regression analyses were conducted to investigate the impact of clinical or sociodemographic aspects on the CHIP’s total score, the total score of the Scale of needs for parents of chronically ill children, and each subscale of the ULQIE. In addition, we explored whether the coping behavior or parents’ intensity of needs influenced the ULQIE-subscales.The 120 eligible families received the study information as well as the questionnaires. Of these families, 62 agreed to participate and filled out the questionnaires, resulting in a response rate of 51.67%. Among the 62 families with at least one child diagnosed with CAH, three were excluded due to one or more exclusion criteria, resulting in a final sample size of 59 families .We included 59 families in the final analysis, consisting of 100 parents (59 mothers and 41 fathers). The mean age of the parents was 43.18 ± 7.48 (SD) years, with 42.12 ± 7.50 for mothers and 44.71 ± 7.27 (SD) for fathers. In 41 families, both parents answered the questionnaires, whereas in 18 families, only the mother participated. The mean time of conducting the presumptive diagnosis of the child was 7.79 days after birth. Ten of the fifty-nine families had two affected children diagnosed with CAH, including two families giving birth to twins with CAH . The numt(97) = 9.15, p < 0.01), emotional distress (t(97) = 12.31, p < 0.01), self-development (t(97) = 4.53, p < 0.01), well-being (t(98) = 6.53, p < 0.01), as well as for the ULQUIE total score (t(97) = 8.36, p < 0.01).Parental HrQoL scored in the upper segment of the 0–4 scale, with the highest means for the subscale satisfaction with the situation in the family (3.38 ± 0.59) and the lowest means for the subscale self-development (2.28 ± 0.77) . In compNo statistically significant differences between the HrQoL scores of mothers and fathers were found. The same results were found for parents of one affected child with CAH compared to parents of two CAH children. However, the analyses showed differences in the ULQUIE total score between parents of younger (<10 years) and older CAH children (≥10 years), as well as between parents of CAH girls and CAH boys . Parents = 1.83, p = 0.06, n = 58). The results showed that sociodemographic or clinical factors did not significantly affect the total score of the ULQIE. Nonetheless, the examined HrQoL of the parents depended considerably on the effectiveness of applied coping strategies and the intensity of the needs of these parents. Confirmatory regression analyses showed a significant positive correlation between the total score of the CHIP and the ULQIE total value. Additionally, the data conveyed that parents with intense needs achieved significantly lower HrQoL scores  and the use of psychosocial consultation . Parents who used psychological or social-pedagogic help reported a lower HrQoL, measured by the family satisfaction subscale. The same is true for parents with an older CAH child. Concerning the subscale self-development, regression analyses showed impacts from the parents’ educational qualification, the gender of their child, and their applied coping strategies. The higher the parental educational degree, the lower the HrQoL measured by the subscale self-development .Exploratory regression analyses showed a correlation between particular subscales of the ULQIE and several factors involved. The subscales daily functioning, family satisfaction, and emotional distress seemed to depend on coping strategies and needs in the same way as the total score of the ULQIE . The HrQp = 0.06). The coping strategies influenced the parents’ self-development in the same way as the total score . Maintaining social support, self-esteem, and psychological stability was deemed less helpful than the other subscales. With a mean total score of 2.01 (±0.47), the effectiveness of coping mechanisms of parents of children with CAH was comparable to German reference cohorts ,44. Mothp-values (p > 0.11) on every independent variable, including sociodemographic or clinical particulars for the CHIP total score as the dependent variable within the model.The exploratory regression analyses showed high We measured the intensity of the needs of parents with CAH-diagnosed children using the Scale of needs for parents of chronically ill children. Comparing mothers and fathers, the mean total scores differed by about 0.12 points, resulting from mothers’ mean score of 2.87 (±0.83) and a mean score of 2.75 (±0.76) for fathers. The most frequently indicated needs were primarily information, such as needing more information about therapy options, dealing with departments and councils, diagnostic methods, and dealing with the ill child. Another often-mentioned requirement was having more time for the partner. The three needs least indicated were the need to obtain relief in everyday life from relatives or friends and to conduct problem-centered conversations with friends .p ≤ 0.01). Other factors included in the model did not show any substantial dependences.Furthermore, parent-reported needs showed differences depending on the child’s gender. Exploratory regression analyses indicated that parents of a boy declared their needs more severely than parents giving birth to a girl with a 0.69 unit difference  did not contact other affected families. Parent-to-parent communication is a meaningful intervention to improve the knowledge, self-efficacy, and HrQoL of mothers of ill children . Other sParents in this study did not declare a high need for psychosocial support at the survey time. Altogether, only 16.00% of the mothers and fathers used psychosocial consultation in the past. However, about two-thirds of this group evaluated psychosocial support as helpful or very helpful. Studies have shown that psychological support, e.g., through cognitive behavioral therapy, is highly recommended for parents of children with chronic health issues. Multiple emotional stressors and coping challenges for the families of children with CAH can increase the risk of developing psychopathological symptoms . ImmenseThe clinical practice guideline published by the Endocrine Society in 2010 also recommends regular behavioral/mental health consultation and evaluation for parents to address any concerns related to CAH .We assume that the parents’ need for psychosocial help was no longer present at the time of this survey since, in most cases, many years have passed after disclosing the child’s diagnosis. Another reason could be that there was impeded access to psychosocial consultation. Approximately only every tenth family in the present study received a professional offer of psychosocial support during their first clinical stay after learning of the presumptive diagnosis of their child. Consequently, early psychosocial support could be a valuable topic with scope for improvement.Different dimensions of care should be considered to improve the situation of CAH-affected families. Sensitizing physicians at maternity and pediatric clinics to this rare disease is essential. Medical professionals should be encouraged to consult experts early, such as pediatric endocrinologists, to accompany respective families from the diagnosis process onwards. In addition, our results show that even after a mean time of 11 years after the disclosure of the CAH diagnosis of their child, mothers, and fathers still indicated more information regarding the disease as being their primary need. This knowledge gap implies that with a complex disease such as CAH, new arrival questions, and informational needs are shared continuously.Consequently, improving the mediation of first and ongoing information is essential for improving care for these families. Another critical aspect constitutes the mediation of the (presumptive) diagnosis. Studies show that parents value thorough, timely, and understandable information without too many specialist terms ,18. FurtFurthermore, families should be encouraged to participate in self-help groups early. With the results of this study, the development of demand-responsive, purposeful interventions can be initiated. Family-oriented coping should focus on early interventions to strengthen family solidarity and improve communication. Another leading aspect depicts information-oriented coping. Early and repeated training for managing adrenal crises is desirable to strengthen the mother’s and father’s management ability and improve the situation of CAH-affected families.A child with a chronic disease diagnosis marks an unexpected, extraordinary, and stressful change in the prevailing family-life system. Since CAH constitutes a rare chronic disease with a potentially life-threatening character, parents must overcome additional obstacles in caring for their children. Thus, they are even more at risk of undergoing psychological strain and decreasing their HrQoL ,57,58. POn the one hand, the established parental HrQoL is highly affected by the effectiveness of the mother’s and father’s applied coping patterns. Parents in the present study described their coping strategies as helpful so that effective coping can be assumed. On the other hand, the intensity of needs in parents of a child with CAH significantly influences their perceived HrQoL. Hence, this study verifies the importance of helpful coping patterns and the rapid fulfillment of parental needs for maintaining a good and stable HrQoL of parents with a child diagnosed with CAH.To our knowledge, this is the first study investigating the HrQoL of parents of CAH-diagnosed children. The findings provide important impulses for improving the situation of CAH-affected families since decisive influencing factors on the parental HrQoL were found.Even though the examinations concern a rare disease, many participants could be gathered for this study. Questionnaires were addressed to 83.90% of all registered parents with a child diagnosed with CAH through newborn screening in Bavaria. With a response rate of 51.67%, the sample covers a large number of affected families in this region. Further, contrary to many other studies, mothers and fathers were included in the survey to include the family perspective. A strength of this study is based on the applied methods. Using a Bonferroni adjustment for multiple testing ensures the prevention of possible interference factors to a large extent.Nevertheless, various limitations of the study have to be acknowledged. Since the study format was retrospective and not based on clinical data, recall bias cannot be excluded. Further, even though there was a satisfying number of returns, the parents who did not participate may have struggled with their situation the most and could not answer the survey. An important fact to add is that the children’s ages in this study were spread over a wide range (0.68–18.12 years). Therefore, parents newly confronted with their child’s initial diagnosis and parents who had years to adapt to the new situation filled out the questionnaires, making the study population heterogeneous. The present study also describes a regional sample, including only parents in Bavaria, Germany. However, this study still delivers a profound gain in knowledge about the psychosocial situation of CAH-affected families and elaborates important impulses to improve the provision of care. Further studies should concentrate on accompanying families with CAH-diagnosed children early on and in other federal states and countries. A longitudinal format is suggested.


Noroviruses are a leading cause of acute gastroenteritis (AGE) worldwide. The geographical characteristics of norovirus outbreaks in Beijing and their influencing factors remain unknown. This study aimed to explore the spatial distributions, geographical characteristics, and influencing factors of norovirus outbreaks in Beijing, China.Z-scores and P-values as statistical significance measures with Global Moran’s I statistics and Getis-Ord Gi in ArcGIS. Linear regression and correlation methods were used to explore influencing factors.Epidemiological data and specimens were collected through the AGE outbreak surveillance system in all 16 districts of Beijing. Data on spatial distribution, geographical characteristics, and influencing factors of norovirus outbreaks were analyzed using descriptive statistics methods. We measured spatial, geographical clustering of high- or low-value deviance from random distribution using Between September 2016 and August 2020, 1,193 norovirus outbreaks were laboratory-confirmed. The number of outbreaks varied seasonally, typically peaking in spring (March to May) or winter (October to December). Outbreaks primarily occurred around central districts at the town level, and spatial autocorrelation was evident in both the entire study period and in individual years. Hotspots of norovirus outbreaks in Beijing were primarily found in contiguous areas between three central districts  and four suburban districts . The average population numbers, mean number of all schools, and mean number of kindergartens and primary schools for towns in central districts and hotspot areas were higher than those in suburban districts and non-hotspot areas respectively. Additionally, population numbers and densities of kindergartens and primary schools were influencing factors at the town level.Hotspots of norovirus outbreaks in Beijing were in contiguous areas between central and suburban districts with high populations, and high kindergarten and primary school densities were the likely driving forces. Outbreak surveillance needs to focus on contiguous areas between central and suburban districts with increased monitoring, medical resources, and health education. Noroviruses are a leading cause of acute gastroenteritis (AGE) worldwide, accounting for a large proportion of sporadic AGE cases and outbreaks in recent years . ApproxiA meta-analysis indicated that the prevalence of norovirus in cases of AGE in developing countries was 17% . AdditioIn 2011, a hospital-based surveillance network was established in all 16 districts of Beijing, China for monitoring sporadic AGE cases caused by norovirus and rotavirus . From thNorovirus outbreaks show seasonality, with peaks during winter months . The virOur previous study showed that outbreaks are usually reported in the winter and spring, with 88.89% of outbreaks reported in kindergartens and schools . The risIn recent decades, geographic information systems (GIS) and spatiotemporal techniques have been widely used in the surveillance and investigation of infectious diseases –15. ThesAGE outbreak surveillance was established in Beijing in April 2014, and district-level Centers for Disease Control and Prevention finished the preliminary epidemiological investigation and detection of fecal specimens. Patients with diarrhea, defined as three or more loose stools within a 24 h period, and/or vomiting, defined as one or more episodes, were designated as AGE cases. An AGE outbreak was defined as the occurrence of three or more epidemiologically linked cases of AGE within a 3-day period. A norovirus outbreak was confirmed if more than two AGE cases tested positive for the norovirus. Norovirus was tested by real-time reverse transcription polymerase chain reaction (PCR).In this study, a norovirus outbreak surveillance year was defined as starting on September 1 and ending on August 31 of the following year. Data on norovirus outbreaks reported between September 2016 and August 2020 were collected and imported into the WPS Spreadsheets 2016  for manipulation and graphing. Additionally, the annual incidence of norovirus outbreaks per 100,000 people in each town was calculated.P < 0.05 (two-tailed). The distribution of data was tested using one-sample Kolmogorov–Smirnov (KS) test. Means for different groups were compared using t-tests.Statistical analyses were performed using the SPSS v20.0 software . Statistical significance was assessed using an α level of 0.05 for all analyses and set at The map of Beijing at the town level was purchased and used with permission from the Beijing Institute of Surveying and Mapping. Beijing has geographical coordinates of N39°56' and E116°20', is located in a warm temperate zone, and has a semi-humid and semi-arid monsoon climate . There aData on the 0–14 age group at the district level and the populations of all age groups at the town level were acquired from the open database of the seventh national census, which was held in November 2020, and from the official websites of the 16 districts of the People’s Government of Beijing Municipality. The number of total schools, kindergartens, and primary schools in each town were similarly collected from the official page of the People’s Government of Beijing Municipality.Analyses of the spatial distribution of norovirus outbreaks were conducted using ArcGIS  softwareThe spatial weight matrix file was generated using spatial statistics tools in the ArcGIS toolbox. The K-nearest neighbor method was used to define the conceptualization of spatial relationships. The distance between each element and its neighbors was calculated using the Euclidean distance formula.I index values were calculated and a matrix file was used to define the conceptualization of spatial relationships. When p-values were statistical significant, positive Moran’s I index values indicated a cluster tendency. Otherwise, index values indicated a dispersed tendency.To explore the spatial characteristics of annual norovirus outbreaks, we used spatial autocorrelation to examine whether the distribution pattern was clustered, dispersed, or random. Moran’s Z-scores and P-values as statistical significance measures with Getis-Ord Gi in ArcGIS. High Z-scores and a P < 0.05 indicated hotspots with statistical significance. In this study, we focused on hotspots.The spatial hotspots and cold spots of outbreaks were identified, considering the weighted features of the matrix file, using P < 0.05) in the univariate analysis were included for stepwise multiple linear regression analysis, collinearity statistics was conducted simultaneously, and variables with a variance inflation factor (VIF) above 10 were excluded from the multiple linear regression analysis. Pearson and Spearman correlation tests were used to analyze the relationship between outbreaks and population and population density of the 0–14 age group.We analyzed the association between the annual average number of norovirus outbreaks and variables  one by one using simple linear regression analysis. Variables that showed significance (2) of districts and towns was calculated using the calculation geometry tool in ArcGIS. Population density was defined as the population number divided by area of the town or district, and the density of schools was defined as the number of schools divided by area of the town. Number of schools per population was defined as the number of schools divided by the population  of the town.The area  were laboratory-confirmed as norovirus and 16 (0.82%) were mixed infections with norovirus and other pathogens. In our study, we focused on the 1193 laboratory-confirmed norovirus outbreaks, which showed seasonal peaks in spring  and winter . Of the 1,193 norovirus outbreaks, 580 (48.62%) occurred in kindergartens, followed by 449 (37.64%) in primary schools, 76 (6.37%) in middle schools, 19 (1.59%) in comprehensive schools, 14 (1.17%) in universities, and five (0.42%) in vocational schools. The remaining 50 (4.19%) outbreaks occurred at sites such as hospitals, nursing homes, and companies. A total of 726 (60.85%) outbreaks occurred in six central districts and 467 (39.15%) outbreaks occurred in 10 suburban districts.According to the distribution of the total reported norovirus outbreaks from 2016 to 2020, outbreaks primarily occurred around the central districts, with the same pattern evident for every year of surveillance ; Chaoyang and Tongzhou districts and towns in the north of Tongzhou (14 towns); Fengtai, Fangshan, and Daxing districts and towns in the northwest of Daxing (12 towns); and one town in the central area of Chaoyang district , Dongcheng and Xicheng district (three towns), Chaoyang and Changping districts (three towns), and five towns in the northwestern parts of Chaoyang district. Additionally, hotspots were found in contiguous areas of the Chaoyang and Tongzhou districts (nine towns) and in the northern parts of Tongzhou (five towns)  increased significantly compared with the previous year, distributed in central areas of Haidian district (nine towns) and on contiguous areas of Haidian and Changping (six towns) and Haidian and Xicheng district (two towns). In the contiguous areas of the Chaoyang and Tongzhou districts, 10 towns were hotspots. One town was a hotspot in the contiguous areas of Chaoyang and Changping. We also found hotspots in the north of Tongzhou (three towns), Daxing (one town), and in the middle of Changping (one town)  and four suburban districts , which we separated into four parts. The first part was in the central districts of Beijing, in the contiguous areas of Xicheng, Shijingshan, and Haidian districts, of which 14 towns were hotspots. Second, to the north of the central districts, 14 towns were hotspots in the contiguous areas of the Haidian, Changping, and Chaoyang districts. Third, in southeastern Beijing, on the boundary areas of the Fengtai, Daxing, and Fangshan districts, 11 towns were hotspots. Finally, in the contiguous areas of the Chaoyang and Tongzhou districts, and together for the northern parts of Tongzhou, 19 towns were hotspots. We considered these 58 towns as hotspot areas in subsequent analyses . Compared with the average population in non-hotspot areas (0.055 million), the population in hotspots was considerably higher .The population distribution in Beijing is shown in Fig. 2), density of kindergartens and primary schools (/km2) in central district towns were higher than those in suburban districts. However, number of kindergartens and primary schools per population  in central district towns and hotspot areas were lower than those in suburban districts and non-hotspot areas respectively  and densities of kindergartens and primary schools (/km2)  were influencing factors for norovirus outbreaks on town level. In contrast, density of population  , numbers of kindergartens and primary schools , total number of schools , number of kindergartens and primary schools per population  , number of all schools per population   showed no statistically significant difference. The VIF for densities of all schools (/km2) was 18.907, indicating high collinearity, and this variable was excluded from multiple linear regression analysis. We conducted stepwise regression analysis again without the densities of all schools (/km2), and the coefficients for variables remained unchanged.The influence of each variable was statistically significant in simple linear regression analysis Table . Howevert = 0.176, P = 0.198) and outbreak number  data for 16 districts were normally distributed, and the population density data of the 0–14 age group  was abnormally distributed. There were correlations between outbreak number and the 0–14 age group population  and the 0–14 age group population density , as demonstrated by Pearson and Spearman correlation tests, respectively  were influencing factors in norovirus outbreaks. There were strong correlations between outbreak numbers and the 0–14 age group population and the 0–14 age group population density. These results suggest that kindergarten children and primary school students play an important role in norovirus outbreaks. These children stay in crowded, enclosed classrooms where viruses, such as norovirus, are easily transmitted by person-to-person contact, causing outbreaks [Our study showed that population and densities of kindergartens and primary schools (/kmutbreaks . In addiutbreaks . At the As norovirus is mainly transmitted person-to-person, high population numbers increase the opportunities for transmission. In other provinces of China, a significantly higher number of norovirus outbreaks occurred in southern and eastern China, predominantly in Guangdong and Zhejiang provinces . AdditioOur study had several limitations. First, the map we used contained the administrative region in Beijing in 2012, and several townships were divided in later years, which may possibly decrease or increase the risk level in some towns. Second, there may have been differences in the awareness of epidemic reporting and related management in different towns and districts, which may have influenced the number of reported norovirus outbreaks. Third, our study found that higher population numbers increased the risk of transmission; however, population density was not found to be an influencing factor. As population density was calculated according to the permanent population and areas of towns and the floating population were not included, population density may have been underestimated. Finally, data on age group populations at the town level are not publicly available, and only data on the 0–14, 15–59 and ≥ 60 age group populations at the district level are available.Norovirus outbreaks in Beijing showed spatial autocorrelation characteristics, and hotspots were in contiguous areas between central and suburban districts with high populations, and high kindergarten and primary school densities were the likely driving forces. Outbreak surveillance needs to focus on contiguous areas between central and suburban districts with increased monitoring, medical resources, and health education.


With the increase in aging and cardiovascular risk factors, the morbidity and mortality of atherosclerotic cardiovascular disease (ASCVD), represented by ischemic heart disease and stroke, continue to rise in China. For better prevention and intervention, relevant guidelines recommend using predictive models for early detection of ASCVD high-risk groups. Therefore, this study aims to establish a population ASCVD prediction model in rural areas of Xinjiang using survival analysis.Baseline cohort data were collected from September to December 2016 and followed up till June 2022. A total of 7975 residents  aged 30–74 years were included in the analysis. The data set was divided according to different genders, and the training and test sets ratio was 7:3 for different genders. A Cox regression, Lasso-Cox regression, and random survival forest (RSF) model were established in the training set. The model parameters were determined by cross-validation and parameter tuning and then verified in the training set. Traditional ASCVD prediction models (Framingham and China-PAR models) were constructed in the test set. Different models' discrimination and calibration degrees were compared to find the optimal prediction model for this population according to different genders and further analyze the risk factors of ASCVD.After 5.79 years of follow-up, 873 ASCVD events with a cumulative incidence of 10.19% were found (7.57% in men and 14.44% in women). By comparing the discrimination and calibration degrees of each model, the RSF showed the best prediction performance in males and females  0.791 , C statistic 0.780 , Brier Score (BS):0.060, female: AUC 0.759  C statistic was 0.737 , BS:0.110). Age, systolic blood pressure (SBP), apolipoprotein B (APOB), Visceral Adiposity Index (VAI), hip circumference (HC), and plasma arteriosclerosis index (AIP) are important predictors of ASCVD in the rural population of Xinjiang.The performance of the ASCVD prediction model based on the RSF algorithm is better than that based on Cox regression, Lasso-Cox, and the traditional ASCVD prediction model in the rural population of Xinjiang.The online version contains supplementary material available at 10.1186/s12889-023-15630-x. Atherosclerotic cardiovascular disease (ASCVD), which mostly involves heart attacks and strokes caused by atherosclerosis, is one of the main causes of death worldwide . RelatedTherefore, domestic and foreign ASCVD prevention guidelines recommend using the ASCVD risk prediction model and early detection of high-risk groups to develop interventions for reducing the risk of ASCVD in the population , 5. TradLocated in northwestern China, Xinjiang is a multi-ethnic gathering area composed of individuals from the Uygur, Han, and Kazakh ethnic groups and other ethnic groups. Previous studies have demonstrated that the prevalence rates of ASCVD risk factors, such as metabolic syndrome, hypertension, and obesity, are high in Uygur and Kazakh people in rural areas of Xinjiang, leading to an increased risk of ASCVD in this population –14. The Survival analysis is a statistical analysis method that considers the outcome of an event and the time taken for the occurrence of the result as the observation outcome . CurrentTherefore, this study used the Uygur population of Xinjiang as an example to establish a prediction model based on survival analysis suitable for ASCVD risk, early identification of high-risk groups for ASCVD, and provide a theoretical basis for the effective prevention of ASCVD in the future in rural areas of Xinjiang. This study has great practical significance for the comprehensive prevention and control of ASCVD in the communities in this region.n = 4195), the patients with ASCVD at baseline (n = 502), those lost to follow-up, and those with incomplete information (n = 141), 7975 people were included in the final cohort , body obesity index (BAI) (HC / height 1.5—18), pulse pressure difference (SBP—DBP), and waist-to-hip ratio (WHR) (WC [cm] / HC [cm]). A family history of diabetes was defined as a history of diabetes in at least one parent or sibling; the same criteria were used for a family history of ASCVD. Current smokers were defined as participants who had smoked for more than 6 months [Data were collected using questionnaires, physical examinations, and laboratory tests. The questionnaires were administered face-to-face. Trained professionals measured anthropometric data, such as height, weight, waist circumference (WC), HC, blood pressure, and B-ultrasound. For each participant, blood pressure and heart rate were measured three times using a mercury sphygmomanometer after a 5-min sitting rest, and the mean values were calculated. Hypertension was defined as a systolic blood pressure (SBP) of ≥ 140 mmHg or a diastolic blood pressure of (DBP) ≥ 90 mmHg. Prehypertension was defined as 140 > SBP ≥ 120 mmHg or 90 > DBP ≥ 80 mmHg . The com6 months . Alcohol6 months . Fasting6 months  was defi6 months . We alsoIn this study, hypertension , diabeteThe Cox proportional hazards regression model, also known as Cox regression, is the most widely used traditional modeling method for survival analysis . The appP values were greater than 0.05, indicating that the data were evenly distributed in the training and testing sets. The database contains 61 variables, including demographic characteristics, questionnaire information, and serological indicators. If all variables are used in model construction, the computational burden will increase, and the model will easily lead to overfitting, affecting the final predictive performance. Therefore, different screening methods were used for the variable screening. Selecting meaningful features through different variable screening techniques can effectively reduce generalization errors. The methods commonly used in machine learning include regularization, feature selection, and feature extraction based on the RSF algorithm. L1 regularization satisfies the sparsity of weights, that is, the weight of most feature vectors is 0, and the sparsity of weights can reduce the complexity of the model. The RSF algorithm can measure the importance of features by the average impure decay of all survival trees and then rank the features according to their importance, selecting the top-ranked features to build a machine-learning model. The traditional model mainly selects variables by single and multiple factors of Cox regression. This study will use L1 regularized Cox regression, RSF algorithm, and Cox regression analysis to select meaningful characteristic variables.First, the datasets were divided into a dataset of men and a dataset of women according to the different genders. Each dataset was randomly divided into a training set and a test set at a ratio of 7:3. The K-S test was conducted on the training and testing sets of different genders. The 2 statistic  [Using different subsets of variables, Cox regression, Lasso Cox, and RSF models were constructed in the training set, and parameters were selected through cross-validation to determine the final model parameters. Furthermore, we compared the discrimination and calibration degrees of the China-PAR and FRS models with the model constructed in this study in the test set to determine the most suitable prediction model for this population  , 36 for t-test and chi-square test, respectively. The statistical analyses were performed using SPSS, version 26.0, or R language 4.0, and all data were analyzed separately for men and women. A two-tailed P < 0.05 was used to indicate statistically significant differences.There are some missing values in the database, and directly deleting the missing values will lead to a loss of sample information. As there are a few missing variable values in this study, the mean value is used to fill continuous variables, and the mode is used to fill categorical variables. The continuous variables are expressed as the mean ± standard deviation, categorical variables are expressed as the pass rate and constituent ratio, and differences between the measurement data and count data were analyzed by the P < 0.05), suggesting that there were gender differences in various risk factors, and risk prediction models should be constructed according to gender.A total of 7975 people were included in this study . During a median follow-up of 5.79 years, 873 ASCVD events were observed, with a cumulative incidence of 10.19% (7.57% in men and 14.44% in women). After the Kaplan–Meier curve adjustment was performed, the 5-year ASCVD incidence observed in women was higher than in men. The baseline characteristics are shown in Supplementary Table P > 0.05). The discrimination between the China-PAR and FRS models in this population was moderate , but the calibration was poor , as shown in Table We used Cox multivariate analysis, Lasso regression, and RSF to rank the importance of permutation variables in the different gender databases to select the predictor variables. We constructed a prediction model based on the selected variables. Detailed information on the variables is provided in Supplementary Tables 2 > 20, P > 0.05). In the population of women, the AUC and C-statistics of the Lasso–Cox, RSF, and China-PAR models were similar to and higher than those of the Cox regression and FRS models, respectively. The cNRI and IDI of the Cox regression, Lasso–Cox, and RSF models were compared, and the differences between the three models were not statistically significant. The calibration curve results demonstrate that the numbers of patients with ASCVD predicted by the Cox regression, Lasso–Cox, and RSF models in the population of women were 156.68, 155.84, and 179.68, respectively. The corresponding ASCVD events/objective ASCVD events predicted by the Cox regression, Lasso–Cox, and RSF models were 0.92, 0.91, and 1.04, respectively.In the population of men, the AUC and C-statistics of the Cox regression, Lasso–Cox, and RSF models were similar to and higher than those of the China-PAR and FRS models, respectively. Further comparisons of the cNRI and IDI between the Cox regression, Lasso–Cox, and RSF models and the net reclassification ability and comprehensive discrimination ability between the RSF, Cox regression, and Lasso–Cox models demonstrated statistically significant differences. Taking the comparison between Lasso–Cox and RSF as an example, the cNRI value was 0.323 , and the IDI value was 0.021 , indicating that the predictive ability of Lasso–Cox model was higher than that of the RSF model. Correct classification and comprehensive discrimination abilities improved by 32.3% and 2.1%, respectively. The calibration curves demonstrate that the three models had good calibration  and uric acid (UA), VAI, BAI, and WHR, which reflect the degree of obesity, were also important predictors of ASCVD in men. In the population of women, in addition to traditional risk factors such as age and systolic blood pressure, HC, VAI, and LAP reflecting human obesity and lipid metabolism indicators such as APOB and AIP are also important predictors of ASCVD, as shown in Figs. The results of this study demonstrate that the cumulative incidence of ASCVD in populations in rural Xinjiang is 10.19%, which is a cumulative incidence of ASCVD that is similar to that in European and American Caucasians  and thatThe predicted incidence of ASCVD was higher in women than in men. A pilot study demonstrated that the prevalence of diseases, such as obesity, metabolic syndrome, and hypertension, is higher in women than men , 41. RelThe comparison of ASCVD risk models in this population demonstrated that the discrimination of the RSF model in the population of men was similar to that of the Lasso–Cox and Cox regression models and higher than that of the China-PAR and FRS models. The comparison between the cNRI and IDI demonstrated that RSF was better than the other models. The results indicated that the RSF model could accurately distinguish between the population of men with ASCVD and the population of men without ASCVD. The calibration results demonstrate that all models have good calibration, and the results of the BS demonstrate that the RSF model is slightly better than those of the other models. In the population of women, the discrimination of all models demonstrated that AUC and the C-statistics of all models were similar and that there was no difference between the cNRI and IDI of the RSF, Lasso–Cox, and Cox regression models. Still, they were all higher than those in the China-PAR and FRS models. The calibration analysis results demonstrated that the performance of the RSF model in this population of women was better than that of the other models. Based on the discrimination and calibration results, the RSF model had the best predictive performance in this population.The RSF model is an extension of random forest in survival analysis. Unlike the traditional Cox regression model, which needs to satisfy many assumptions, the RSF model is completely nonparametric, does not require restrictive assumptions, and can automatically evaluate the influence of all variables. Therefore, it is widely used in constructing prognostic models for heart failure, arrhythmia, multiple myeloma, and other diseases , 46, 47.A comprehensive analysis of the importance of variables in different gender prediction models demonstrated that the most important predictors of ASCVD in men were age and high-density lipoprotein cholesterol, which is a finding that is consistent with the conclusions of many previous studies , 8. APOBAlthough we believe that the included population represents the general Uygur population, this study has some limitations. First, only the traditional risk factors were considered. With the deepening of omics research, a large amount of data were entered into the clinical prediction model research. The relevant data based on genomics and metabolomics were not included in this study, which may have a certain impact on the model's predictive performance. Second, this study lacked an independent, external validation population. Although we divided the training and test sets and conducted cross-validation in the training set, the predictive accuracy and robustness of the established model extrapolated to other ethnic populations need to be explored further. Finally, only baseline measurements were used for modeling in this study, and the time effect was not considered in the model construction process. Subsequent studies should incorporate relevant omics data and multiple follow-up data for the modeling analysis and validation in independent external populations.In this study, the performance of the ASCVD prediction model based on the RSF algorithm was better than that of those based on Cox regression, Lasso–Cox, and the traditional ASCVD prediction model in the rural population of Xinjiang. In addition to the traditional risk factors for predicting ASCVD, lipid metabolism indicators, such as APOB, AI, and AIP, and obesity indicators, such as BMI and BAI, are considered important factors for predicting the incidence of ASCVD in this population.Additional file 1:Supplementary Fig. 1. Flow chart of data analysis in this study. Supplementary Table 1. Parameters of two risk equations used in this study for men and women. Supplementary Table 2. Comparison of research objects between man and woman. Supplementary Table 3.1. Screening variable subsets based on Cox regression in man. Supplementary Table 3.2. Screening variable subsets based on Lasso-Cox regression in man. Supplementary Table 3.3. Screening variable subsets based on RSF in man. Supplementary Table 3.4. Screening variable subsets based on Cox regression in woman. Supplementary Table 3.5. Screening variable subsets based on Lasso-Cox regression in woman. Supplementary Table 3.6. Screening variable subsets based on RSF in woman. Supplementary Table 4. C statistic of different models on training and test sets.


The current study was carried out to assess the toxicity of CdSe QDs after intravenous injection in Wistar male rats (230 g). The rats were given a single dose of QDs of 10, 20, 40, and 80 mg/kg and were kept for 30 days. Following that, various biochemical assays, hematological parameters, and bioaccumulation studies were carried out. Functional as well as clinically significant changes were observed. There was a significant increase in WBC while the RBC decreased. This suggested that CdSe quantum dots had inflammatory effects on the treated rats. The various biochemical assays clearly showed that high dose induced hepatic injury. At a dose of 80 mg/kg, bioaccumulation studies revealed that the spleen (120 g/g), liver (78 g/g), and lungs (38 g/g) accumulated the most. In treated Wistar rats, the bioretention profile of QDs was in the following order: the spleen, liver, kidney, lungs, heart, brain, and testis. The accumulation of these QDs induced the generation of intracellular reactive oxygen species, resulting in an alteration in antioxidant activity. It is concluded that these QDs caused oxidative stress, which harmed cellular functions and, under certain conditions, caused partial brain, kidney, spleen, and liver dysfunction. This is one of the most comprehensive in vivo studies on the nanotoxicity of CdSe quantum dots.Cadmium selenium quantum dots (CdSe QDs) with modified surfaces exhibit superior dispersion stability and high fluorescence yield, making them desirable biological probes. The knowledge of cellular and biochemical toxicity has been lacking, and there is little information on the correlation between  Nanoparticles have demonstrated wide applications because of their small size and large surface-to-volume ratio attributes . The las2+ ions into the surrounding medium.10 These Cd2+ ions in turn stimulate the generation of ROS that in turn affects cellular metabolism and may initiate apoptosis [The small size of CdSe QDs assists them to easily cross the cellular membrane and internalizing in the cytosolic space, specifically in lysosomes –13. The poptosis , 14. Addpoptosis –17. The poptosis , 19.in vivo remains somewhat poorly understood. Reports suggest that coating QDs with capping agents such as BSA, PEG, or glutathione makes them less toxic and drastically reduces ROS generation [2+ ions from Cd-based nanoparticles can cause hepatic injury by specifically binding with sulfhydryl groups of mitochondrial proteins [2+ ions in the concentration range of 100–400 nmol/mL are potentially toxic and lead to cell death [in vivo environment and underlying reactions. The exposure to human tissues is also increased by the use of CdSe QDs in imaging, diagnosis, and drug delivery. When these nanoparticles are exposed to an in vivo system, it is crucial to determine their in vivo toxicity, biodistribution, and clearance profiles. Additionally, the properties and mechanisms of toxicity of QDs can vary significantly in vivo and in vitro systems. While some studies reported a direct correlation between cadmium accumulations concerning time after intravenous injection [Due to their consistent fluorescence characteristics, cadmium-based QDs have attracted a lot of interest in the past due to their potential in both biomedical and clinical applications. Due to the significant impact that size, shape, and composition have on QD properties and subsequent toxicity behavior, although studies have correlated the toxicity of such QDs concerning size and surface coating, the determination of the influence of these QDs on the biochemical and genotoxicity parameters neration , 20, 21.neration , 23. Preproteins  and thatll death . Previounjection , other snjection .in vivo study impart sufficient novelty to the work reported.Hence, it is imperative to determine the toxicity of CdSe QDs before ascertaining their biological applications. We have used CdSe quantum dot-Wistar rat (8–10 weeks old) as the model system to investigate the bioaccumulation-induced biochemical toxicity after intravenous administration. Considering the potential use of quantum dots in pharmaceutical formulations, the aforesaid study is of relevance. Further, the depth and breadth of the present The prepared QDs were characterized by UV-visible absorption, fluorescence spectroscopy, X-ray diffraction, transmission electron microscope, and EDAX techniques to determine their morphology, size, and crystallinity parameters. The details are provided in our earlier work . In brieAs per the study, increasing doses of CdSe QDs were administered to the rats and assays were performed at regular intervals. Administration of CdSe QDs did not produce significant changes in the feed and water intake of Wistar rats. No unusual response, behavioral changes, or death of the animal were observed throughout the experiment period. No weight loss was observed in the treated group of animals. No major changes in the food and water uptake were found in the treated group of rats as can be observed in Figures CdSe QD concentration was also estimated in urine and feces samples of the rats by using AAS analysis. For this, all the control and treated animals were kept in metabolic cages and the samples were collected daily. Further, AAS analysis of Cd concentration in the collected urine and feces was performed. As can be seen from Figures μg/g of tissue weight. The order of bioaccumulation of Cd was as spleen>liver>kidney>lungs>heart>brain>testis. At maximum, for CdSe dose (80 mg/kg), the spleen showed the highest bioaccumulation (120 μg/g) and the testis, the least (10 μg/g). Bioaccumulation has also been observed in lower doses in different organs. However, those changes were not statistically significant to report. Additionally, we estimated the concentration of Cd in the blood of the treated groups. As can be observed in μg/mL Cd was estimated after 12 hours of treatment with QDs. The concentration of Cd was found to decrease thereafter and was minimal after 21 days of treatment.Bioaccumulation of nanoparticles occurs when the rate of uptake is greater than the rate of clearance. However, the route of administration, its biopersistence, and nanoparticle properties also affect bioaccumulation . Cd concrd and 4th), the count was almost the same as that of the control group. This signifies that administration of CdSe induced immunogenic changes in Wistar rats, but with time body adapted to such changes. Similarly, we observed a decrease in WBC count with increasing dose in the first week of administration, and not much variation from the control group was found thereafter. RBC count decreased from around 7.7 million/cumm (control) to 6.9 million/cumm, while WBC increased from 11,500 million/cumm (control) to around 14,000 million/cumm (80 mg/kg CdSe). Thus, dose-dependent decrease in RBC along with a concomitant increase in WBC count suggested the toxic effects of these QDs on the rats.The different hematological parameters  were analyzed at weekly intervals, and the results have been shown in Figures p < 0.05) were found at 10 mg/kg CdSe concentration, the changes were more prominent (p<0.001) at 20, 40, and 80 mg/kg CdSe concentration. Likewise, bilirubin concentration that provides a direct indication of liver functioning also showed a very significant (p < 0.001) increase in 40 and 80 mg/kg of CdSe QDs-treated groups. The results are presented in Analysis of various biomarkers that serve as markers for kidney and liver functioning was conducted. We analyzed the levels of bilirubin , aspirate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP), which give indications of liver damage. In all the cases, significant changes were observed in the treated rat group. The level of ALT, AST, and ALP increased significantly in the experimental group. While significant changes  in the liver, spleen, and brain catalase activity was observed compared to the control set. At a higher dose of CdSe, the reduction was very significant (p < 0.001) indicating the capability of CdSe QDs to inhibit the catalase activity in a dose-dependent manner. However, we noticed an enhancement in kidney catalase activity compared to the control set. Thus, the QDs induced oxidative stress which was evident from the marked reduction in GPx, catalase, SOD levels, and enhanced lipid peroxidation. It is well known that the generation of ROS  instigate a series of cellular responses such as inflammation, DNA damage, and cellular apoptosis [Nanoparticles are known to exert toxic effects on cells by the generation of free radicals, which then induce oxidative stress –33. As tpoptosis .in vitro and in vivo [QD has become a promising tool for cell tracking and diagnostic purpose both  in vivo ; howeverOur results suggest that QDs did not affect the feed and water intake of animals. These results are in accordance with our previous study in iron oxide nanoparticles (IONPs) where administration of nanomaterial did not induce any significant changes in the eating or behavioral changes in the treated animals .Clearance profile suggested that QDs were able to excrete out from the body of the animals efficiently after the administration in a few days only. Although the variations were also observed based on the individual animals, excretion analysis suggested that QD nanomaterials were excreted out of the body of the animals through urine and feces. The elimination process seems to be connected with the distribution of nanomaterials in different organs of the body. Our results are in accordance with previous studies which indicated a higher concentration of NPs in faces , 37. NonBiodistribution of NPs to different organs results from systemic circulation, and NPs may get delivered to the same organs despite different administration routes. Through systemic circulation, NPs reach various organs such as the liver, kidney, spleen, testes, lungs, heart, and brain . Bioaccu2+ ions that in turn lead to immunogenic and hematological changes. This affects WBC, platelets, and hemoglobin and interferes with the maturation of RBC [The administration of NPs leads to their circulation in the blood where interaction with immune cells and plasma protein may occur. The interaction may result in the progression of oxidative stress, reduced level of antioxidant system, increased number of immunological cells, and reduced numbers of blood cells. The present study suggests that the inflammatory response is generated through induction of immunological changes, i.e., alteration in blood cell counts after the administration of different doses of QDs. The administration of nanomaterials leads to the circulation in the blood where NPs interact with blood cells and plasma protein. These interactions may result in several possible pathways to begin such as hemolysis and complement activation. The report suggests that different QDs have been observed to show hemolytic activity in RBCs . It has n of RBC . Thus, tn of RBC . They poThe liver and kidney are considered to be the first-line organs to protect them from any xenobiotic components. In the present study, therefore, we measured the liver and kidney profiles. The results from the biochemical panel of assays suggested that the QDs induce the generation of liver and kidney biomarker metabolites implying QD-induced hepatic and nephrotoxic damage at both acute and subchronic levels . Thus, aNPs may involve in ROS induction and generation of oxidative stress which eventually results in alteration in the antioxidant system , 49. MetCdSe quantum dots were synthesized from the precursors CdO and elemental Se using a protocol with slight modifications , 53. In Male Wistar rats (8–10-week-old with body weight of approx. 230 g) were used for CdSe QD toxicity study. The rats were obtained from the Central laboratory for animal resource (CLAR) Animal House, JNU, New Delhi, India for the study. The animals were kept in the animal house under stress-free, controlled temperature (21 ± 3°C), hygienic atmosphere at 12 hours day/night cycle and were supplied with food pellet and water. The animals were divided randomly into four groups of six animals in each. CdSe QDs were intravenously injected in the caudal vein and kept for 30 days. The QDs were used at doses of 10, 20, 40, and 80 mg/kg of particles. One group was injected with phosphate buffer saline (PBS) and was considered the control. However, other four groups were treated with the different doses of QDs, i.e., 10, 20, 40, and 80 mg/kg NPs. All the experiments were performed as per the guidelines and approval of Animal Ethics Committee of JNU, New Delhi, India.Sampling was done by withdrawing 1 mL of blood from retroorbital sinus via a heparin-coated capillary and was collected in a tube containing 20 mg/mL EDTA to prevent coagulation. Prior to sampling, animals were anesthetized using 0.3 mL/250 mg ketamine/xylazine. Sampling was done at weekly interval from both the control and treated groups of animals. The collected blood sample was subjected to centrifugation at 2000 g for 15 min. The serum was collected and stored at −20°C, and the pellet was used for hemolysate preparation.The pellet obtained was washed thrice with PBS buffer, centrifuged at 2000 g for 15 min at 4°C, and thereafter mixed with ice cold distill water (1.9 mL) and packed cell volume suspension (0.1 mL). The hemolysates was stored at −20°C for further analysis. Automated hematological analyzer  was used for various hematological analysis such as red blood cells (RBC), hemoglobin concentration (HGB), hematocrit, white blood cells (WBC), platelets count (PC), mean corpuscular volume (MCV), and for the determination of percentages of lymphocytes and monocytes.Several biochemical assays related to the liver, kidney, and brain functions was conducted on Biochemical Autoanalyzer . Different liver and kidney marker tests were also performed. Antioxidant stress markers such as superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), and lipid peroxidase (LPx) were analyzed using respective enzyme-based kit method.The animals (control and treated) were scarified by overdose of anesthetic ether and cervical dislocation. Thereafter, body weight of all groups of animals was recorded. Organs  were removed, and weight was recorded immediately. Coefficient of organs was then calculated by taking the ratio of organ wet weight (mg) to body weight (g). Experiments were performed in specifically designed metabolic cages in order to collect the urine and feces of the Wistar rats. Cd concentration was estimated in the collected urine and feces so as to determine any changes in the metabolic activity after treatment with the QDs.Quantitative measurement of Cd was performed by removing and burning the organs at 200°C for around 20 minutes. Atomic absorption spectroscopy (AAS) analysis was performed using 1 g of the organ power. AAS analysis was performed after complete digestion of the samples and readings were taken against standard Cd stock solutions. Cd concentration in the spleen, liver, kidney, testis, brain, heart, and lungs was determined to understand the bioaccumulation rate. Metabolic rate of the treated and control groups of Wistar rats was recorded at regular time intervals to monitor any variations brought about in the normal metabolic activity after administration of the QDs.t-test comparing the control and treated groups. The significance level of 0.05 (95%) was ascribed. Results are presented as mean and standard deviation of six independent replicates.Statistical analysis was performed via one-way analysis of variance (ANOVA) followed by 2-sample, 2+ ions induced alteration in red blood cell number, bringing about decrease in cellular antioxidants, thereby enhancing the oxidative stress. In conclusion, the results of this study suggest that high doses of CdSe QDs may be toxic. However, the QD concentration used for the analysis of bioimaging is typically lower than the concentration we used for the evaluation of toxicity. Consequently, the effectiveness of CdSe QDs in bioimaging applications should not be completely disregarded.The administration of CdSe QDs in Wistar rats did not induce major changes in the food and water intake. The spleen showed the greatest accumulation of CdSe particles, whereas the testis showed the least accumulation. In addition, Wistar rats treated with high concentrations of QDs experienced changes in their hematological and biochemical indices. Additionally, as QDs degraded over time, Cd2+ ions were released, which in turn caused immunogenic changes that damaged the kidneys and liver. The generated Cd


Retraction is a significant consequence of scientific research, resulting from various factors ranging from unintentional errors to intentional misconduct. Previous reviews on retracted publications in obstetrics and gynecology have identified “article duplication,” “plagiarism,” and “fabricated results” as the main reasons for retraction. However, the extent of retracted articles in the literature on medically assisted reproduction (MAR) remains unclear. This systematic review aimed to assess the number and characteristics of retracted articles in the field of MAR.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for this study. A comprehensive literature search was conducted on the PubMed database from 1993 to February 2023, limited to English articles and including all 283 terms from the International Glossary on Infertility and Fertility Care. To identify retracted studies, a specific query combining the 283 terms from the glossary with a retraction-related keyword was used. Only studies focused on MAR and involving human subjects were included.n = 16), 15.4% were reviews (n = 6), and 10.3% were retrospective studies (n = 4) or prospective studies (n = 4). Most of the retractions occurred shortly after publication, with “plagiarism” being the most common reason for retraction, followed by “duplicate publication.”The electronic search yielded a total of 523,067 records in the field of infertility and fertility care. Among these, a total of 2,458 records were identified as retracted. The citation retraction rate was found to be 0.47% , and the citation retraction rate for randomized controlled trials (RCTs) was 0.20% . A total of 39 retracted articles specifically related to MAR were identified. Among these, 41.0% were RCTs (The issue of retraction exists within the field of infertility and fertility care, including MAR. Our findings indicate that scientific misconduct, particularly plagiarism and duplicate publication, are the primary causes of retraction in MAR. Despite finding that the proportion of retracted citations is low, promoting scientific integrity should be a priority. The consequences of article retractions have significant implications for patient care and the scientific community. Hence, it is crucial to prioritize thorough screening of manuscripts before publication to maintain research integrity.https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=185769, PROSPERO, identifier: CRD42020185769. Retraction of flawed publications is a measure that safeguards scientific literature, assuring readers the accuracy of published data and the validity of the conclusions. Journal editors, peer reviewers, and the authors themselves are called to responsibly evaluate the studies prior to publication.The retraction represents one of the most serious penalties in scientific research, used to punish serious violations, such as plagiarism, data falsification or fabrication (image manipulation), undisclosed conflict of interest, lack of ethical approval, fraud or suspected fraud, errors  and redundant publications. In 2019, the Committee for Publication Ethics (COPE) updated their guidelines, redefining standardized criteria for manuscript retraction, aiding editors and all those involved in these processes  and data falsification (21.0%) as the main reasons for article retraction . HoweverAlthough Chambers and co-workers identified 16 of the 176 retracted studies belonging to the field of reproductive endocrinology and infertility , the numTherefore, the aim of this systematic review was to investigate the number of research retractions in the field of MAR, specifically examining their characteristics with particular emphasis on trends and reasons for retraction.The study was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . The proInitially, a literature search was conducted from 1993 to February 2023, and only English records were identified using all 283 terms listed in the International Glossary on Infertility and Fertility Care , using RSubsequently, in order to perform our systematic review and identify retracted studies, a bibliographical search was conducted using this query “Term[Title/Abstract] AND ((retracted publication[Publication Type]) OR (retraction of publication[Publication Type])) AND English[lang]“ in which the keywords were all 283 terms listed in the International Glossary on Infertility and Fertility Care  Supplem. FollowiTwo investigators (MZ and VP) independently reviewed titles, abstracts, and full text articles, and selected the studies. Any disagreements were resolved by discussion with a third author (SMi) until a consensus was reached.We used descriptive statistics to characterize retracted MAR publications. No risk of bias was undertaken as the scope of this review was to report the number and characteristics of retracted MAR articles and not to assess the quality of the studies.Each retracted paper was thoroughly investigated and the following data were extracted from each study: (i) Title (PMID and DOI); (ii) author characteristics ; (iii) journal and journal IF; (iv) type of study; (v) publication date; (vi) retraction date; (vii) number of pre-retraction and post-retraction citation; (viii) retraction reason, and (ix) the authors of the retraction notice.A total of 523,067 unique records in the field of infertility and fertility care were obtained from the electronic search, excluding any duplicate entries. Among these, 3,169 records were identified as retracted. After removing 711 duplicates, we identified 2,458 retracted studies. The citation retraction rate of included records was 0.47% . To determine the citation retraction rate of included records specifically for randomized controlled trials (RCTs), we identified 93 retracted RCTs out of a total of 45,616 RCTs in the field of infertility and fertility care, resulting in an RCT retraction rate of 0.20% .n = 27 papers were excluded due to irrelevance in clinical and laboratory practices related to MAR, and a total of 39 studies were included in the systematic review , 15.4% were reviews (n = 6), 10.3% were retrospective studies (n = 4), and prospective studies (n = 4), 7.7% were letters (n = 3), and case reports (n = 3). Two articles were case-control studies while one was a meta-analysis . The highest and currently available IF of a journal with a retracted study is 96.22 (2021) of the British Medical Journal (BMJ) while the lowest is 0.58 (2021) from Medical Acupuncture. Most of the considered papers were retracted within ~2 years of publication  and the median number of times that a retracted article was cited was 3 , followed by China (n = 7), the Republic of Singapore (n = 4), Italy (n = 3), and Turkey (n = 3). For this analysis, we considered only the affiliation of the first author as primary authorship.Egypt recorded the highest number of retractions , duplicate publication (published same data more than once), and errors in data . Other reasons for retraction included fraud or suspected fraud (data or images manipulation), no ethical approval , undeclared conflict of interest and breach of editorial policy  and compromised peer review process. In some cases, articles were retracted for a combination of different reasons. In line with our findings, Chambers et al.  reportedRCTs were the most retracted study type. Most of these retractions occurred following the publication of the study by Bordewijk et al.  which suMany concerns arise from the number of citations after retraction occurred. Previous studies found that many retracted articles continue to be cited as if they were still applicable  while otRetraction notices are signed by authors, journals, editors, and/or publishers. Our study showed that although mainly editors release retraction notices, these are not elaborative and, hence, not insightful.There are several limitations associated with our study. First of all, we determined the overall citation retraction rate within the field of infertility and fertility care by utilizing the 283 keywords from the Infertility Glossary . Due to Nevertheless, to the best of our knowledge, this is the first study to explore retractions in MAR field. The inclusion of all keywords from the Infertility Glossary  made it per se can be significant. It is the responsibility of the scientific community to ensure proper execution of research that meets specific scientific standards but also to identify misconduct when reviewing the research of peers. Initial screening and subsequent thorough investigation of a manuscript during review is indeed a crucial step before publication and training those researchers who engage in peer review to adhere to instructions and guidelines should be a priority. Likewise, the editorial board of a journal is also significantly responsible for ensuring the absence of plagiarism in all published manuscripts. The advent of online manuscript submission systems has made plagiarism checking less challenging compared to the era of hard copy submissions. In this regard, a reliable web-enabled plagiarism detection tool is a valuable tool for the Editorial Board. Besides authors, editors, and publishers, whose role is to guarantee compliance with COPE guidelines, the institutions affiliated with the research should promote a scientific integrity culture among their researchers by providing training and monitoring of all relevant activities. Considering the collateral negative impact of individual invalid publications on systematic reviews, meta-analyses, guidelines and, eventually, clinical practice, promoting scientific integrity in MAR should be paramount (This systematic review has the definitive aim of drawing attention to research misconduct and raising awareness throughout the MAR scientific community. Kemper et al.  highligharamount .The original contributions presented in the study are included in the article/AA conceived the idea for this review. MZ, SMi, and VP performed the literature search. MZ, DM, VP, and SE extrapolated the data. SMi, MZ, SMa, and AA collaborated in writing the first draft of the manuscript. MCo, MCa, and EP contributed to critical revision. All authors critically reviewed the article resulting in a revision of several drafts, read, and approved the final version of the manuscript.


The aim of this study was to produce an eco-innovative gluten-free bread with a pleasant taste and a unique formulation that includes the highest quality grains and pseudocereals ; and okara; a by-product of soy milk production. The mixture of pseudocereal and cereal flour contained buckwheat flour 45%, rice flour 33%, and millet flour 22%. Three gluten-free breads; each containing different contents of gluten-free flour ; okara ; and a control sample (without okara); were prepared and subjected to sensory evaluation. The okara-enriched gluten-free bread with the highest sensory score was selected for further analysis of physico-chemical  and functional properties . The highest sensory scores were obtained for 30% okara-enriched gluten-free bread including taste; shape; odor; chewiness; and cross-section properties; classifying this bread in the category of very good quality and excellent quality . This bread was characterized by a high content of dietary fiber (14%), the absence of sugar; low content of saturated fatty acids (0.8%), rich source of proteins (8.8%) and certain minerals ; and low energy value . Total phenolic content was 133.75 mgGAE/100g FW; whereas ferric reducing power; ABTS radical cation; and DPPH radical scavenging activity were 119.25 mgAA/100g FW; 86.80 mgTrolox/100g FW; and 49.92 mgTrolox/100g FW; respectively. Okara addition in gluten-free bread production enables the formulation of high-nutritive; good antioxidative; low-energy bread; and better soy milk waste management. Gluten-free bread, according to its composition and method of preparation, belongs to the group of dietary foods  and is pIn the preparation of gluten-free bread, starches from gluten-free grains (corn and rice) and hydrocolloids of natural origin are most often used, as well as buckwheat and rice flour ,7. In a Rice flour contains ~90% total carbohydrates , ~6–10% protein  ~1–2% fat, and about 1% minerals . Millet However, the production of gluten-free bread is a technological challenge due to several drawbacks compared to gluten-rich bread, such as worst texture, less tasty, and lower nutritional quality due to a higher content in lipids and sugars, and a lower content in protein, dietary fiber, and mineral elements . To overThe application of okara can have a significant effect on the structure of the gluten-free matrix and the volume of the bread. The high content of dietary fiber and protein can affect the rheological properties of bakery products . In addiIt has been shown that okara could be successfully used in the formulation of meat products, biscuits, filled pasta, drinks, candies, gluten bread, and nutritional flour, as well as edible packaging and biodegradable materials ,25,35,36Thus, the aim of this study was to produce soy okara-enriched gluten-free bread based on buckwheat, rice, and millet with high nutritional and low-energy values while achieving maximum sensory quality. Three gluten-free breads, each containing different contents of okara, and a control sample (without okara), were prepared and subjected to sensory evaluation. The bread with the highest sensory score was selected for further analysis of proximate composition and antioxidant properties. The new formulated bread can enable the diversification of gluten-free products on the market and increase a higher utilization of okara, food waste by-product, contributing to environmental protection.Knowing that gluten-free products are considered as products with poor sensory properties , sensory2) and produces bread with a larger loaf volume and better rheological and textural characteristics [It is very interesting that the bread containing 30% okara received a very high score for the shape (4.55), as well as for the marks related to the cross-section structure (4.20), considering that it does not contain gluten. Namely, from the technological aspect, the first problem that occurs in the production of gluten-free bread is the possible absence of desirable rheological and textural characteristics of the dough and the final product. Most common breads are made from wheat flour, water, salt, and yeast, with bread making relying on the ability of hydrated gluten to develop a viscoelastic network that traps gas . This may be the effect of added guar gum to the dough, since it is known that all gluten-free breads contain hydrocolloids to improve dough behavior . Namely,Statistically significant differences were registered between the ratings of the sensory quality of the control sample and all samples enriched with okara, for all parameters of the sensory analysis, except for the smell. Among gluten-free bread samples, the sensory quality ratings between samples with 10% okara and samples with 20% and 30% okara differed for all quality parameters, except for the smell. Comparing the statistically significant differences for the sensory quality scores between the gluten-free bread enriched with 20% and 30% okara, the shape and taste scores were statistically different between the two samples.In addition to similar mean quality scores, the samples differed according to the scores for individual parameters of sensory characteristics B. GlutenThe obtained ratings (0–5) by consumers  confirmeBased on the obtained results of the sensory analysis, both trained evaluators, and consumers, rated the gluten-free bread enriched with 30% okara as the most acceptable for consumption. For this reason, this sample (with 30% okara) was selected as the most appropriate gluten-free bread enriched with okara for further analyses.The proximate composition of gluten-free bread containing 30% okara is presented in Dietary fibers are poorly absorbable or non-absorbable in the human gastrointestinal tract and play a significant physiological/nutritional role in human metabolism . NumerouIn addition to a high content of dietary fiber, gluten-free bread enriched with 30% okara has a very low sugar content  0.05%; . Okara iIn addition to being a good source of dietary fiber, okara is also a good source of protein. The analyzed sample of gluten-free bread contained 8.80% of total proteins . This isSeveral important things must be considered when proteins are added to gluten-free bread. First, the functionality of added proteins is important since added proteins cannot replace the role of gluten in the dough. Second, the nutritional quality, allergenicity and origin (if it is a product intended for vegans), and price are very important aspects . The addChecking the possible presence of residual gluten in the formulated bread, 14.41 ppm was obtained. Considering that the FDA  prescribThe sample of gluten-free bread with 30% okara was characterized by a low content of total lipids (3.80%) and a very low content of saturated fatty acids 0.08%; , Such a The content of table salt in the sample of gluten-free bread enriched with 30% okara was within the limits indicated in the literature 0.80%; . ŠmídováBased on the obtained results, it can be concluded that the major drawbacks of commercially available gluten-free bread from nutritional quality aspects can be improved by the addition of 30% okara in the rice/buckwheat/millet flour mixture . The resThe total phenolic content and antioxidant properties of gluten-free breads enriched with 30% okara are presented in 3+) to ferrous-iron (Fe2+) by antioxidants [The antioxidant properties of gluten-free bread were evaluated by three assays: FRP, ABTS, and DPPH. The reasoning is that different studies apply different methods and calculations of antioxidant properties; in addition, the combinations of different constituents in the formulation of bread are practically unlimited. In the case of complex food matrices, since there are many different potential antioxidants, of which have different mechanisms of action, it is recommended to use several different antioxidant screening assays . The ABToxidants . All throxidants . There aoxidants  estimateoxidants  indicateSodium (4677.08 µg/g) was registered as the most abundant macro-element in the gluten-free bread followed by phosphorus (2821.19 µg/g) and potassium (2002.04 µg/g), as well as sulfur (1374.72 µg/g). Additionally, the presence of calcium and magnesium were registered  and zinc (17.42 µg/g), but a significant content of manganese was also recorded (8.91). Iron as an integral part of specific proteins  plays a central role in the transport of oxygen, as well as in the transport of electrons in the respiratory chain and participates in energy metabolism . In addiThese results indicated a very favorable composition of macro- and micro-elements of the gluten-free bread. Ibidapo et al.  analyzedThe presence of potentially toxic elements was registered in analyzed samples: boron (5.82 µg/g) and aluminum (4.15 µg/g). Namely, boron plays a role in the synthesis of uridine-diphosphate-glucose, by affecting the reaction of glucose-1-phosphate into uridine-triphosphate and affects the activity of dehydrogenase and oxidoreductase enzymes. In larger amounts, boron will damage the brain. Aluminum is important in the activity of the nervous system, participates in cellular respiration, and activates B complex vitamins. However, aluminum can have a harmful effect on the central nervous system, kidneys, and bone marrow. For these reasons, food should always be checked for the presence of these potentially toxic elements . The preProsopis nigra flour. However, the same authors obtained lower values for the coverage of daily protein needs by examining gluten-free bread (portion 50 g) for men and females, which were 7–8%. The daily need for protein between men and females would be met by a portion of gluten-free bread (50 g) enriched with okara in the value of 9 to approximately 13% depending on age  [A serving of gluten-free bread enriched with okara would meet the daily carbohydrate needs in the value of 11% for children, men, and females of all ages. However, the portion of analyzed gluten-free bread with okara would meet the daily needs in dietary fiber in a significantly higher percentage: for children aged 1–3 years ~37%, for children aged 4–8 years 28%, for men and females from 18 years to approximately 27%, depending on gender and age . Such a  10–16%) .A portion of 50 g of analyzed gluten-free bread enriched with 30% okara would satisfy significant daily needs for macro- and micro-elements .In conclusion, there are several benefits of producing and consuming the formulated gluten-free bread enriched with 30% okara:This bread does not contain gluten; thus, it is a suitable food for people who are intolerant to gluten and suffer from celiac disease. Studies have shown that 1% of the world’s population suffers from celiac disease and the only solution is to consume a gluten-free diet .The high content of dietary fiber and the absence of sugar allow people with insulin resistance and diabetes to consume this bread. The range of products with these characteristics is significant since 442 million people in the world live with diabetes and that number is rapidly increasing . By 2030This bread is a source of nutritionally valuable proteins, which distinguish it from other gluten-free breads on the market and makes it suitable for athletes’ nutrition. For example, prolonged daily training can increase the need for proteins, not only because they encourage good muscle work but also regenerate damaged tissues .A very low content of saturated fatty acids in the tested bread is desirable. It is known that different saturated fatty acids  contribute differently to increasing the level of LDL cholesterol in the blood, and that a complex food system (which can significantly affect the digestion of lipids and their absorption) has a major impact ,80. TodaThe low energy value makes this bread suitable for use in diets for treating obesity. Worldwide, more than 1 billion people are obese—39 million children, 340 million adolescents, and 650 million adults—and these numbers are increasing . WHO 8383 estimaThe presence of phenolics in the tested bread contributes to the antioxidant properties of this product. Thus, gluten-free bread enriched with 30% okara is a source of natural antioxidants, which is increasingly important in food preparation and nutrition. Namely, since about 1980, natural antioxidants have been used as an alternative to synthetic antioxidants. The toxicity of synthetic antioxidants was extensively studied indicating caution in their use. Therefore, in this sense, natural antioxidants represent nutritionally healthier and safer compounds compared to synthetic antioxidants ,85.Good sensory characteristics, above all good taste, provide the possibility of using this food by a wide group of consumers, who do not have metabolic and health problems, and want to eat healthy. Considering that bread is practically the most common food item in the diets of many people, and the low price of this product, it can be available to many consumers.A potentially wide range of biologically active components , minerals, and dietary fibers give this bread the properties of a “functional food”. The functional food sector in the food industry, with an annual growth rate of 7.4%, has experienced significant growth in recent years. The reason for such large growth in this area is not only due to technological progress in the food industry, but also due to the formulation of new products that will meet the needs of consumers who today are increasingly aware of the need to consume nutritionally/bioactive compound rich food to act preventively and preserve health .Finally, but not in the least, the production of this bread is in accordance with the principles of a sustainable and circular economy, as well as procedures for proper waste handling in the food industry.Regardless of the efforts made in the food industry, the production of gluten-free bread still presents significant technological problems. This confirms the poor quality of gluten-free bread currently available on the market ,88. The Buckwheat, rice, millet flours, sunflour oil, yeast, guar gum, and salt were purchased in the local markets. The soybean variety used in the production of okara was “Olga” selected by the Maize research Institute Zemin Polje . Transglutaminase was provided by the Purtos Group in Serbia .Okara was obtained according to the procedure proposed by Stanojevic et al. , with moGluten-free flour composed of buckwheat flour 45%, rice flour 33%, and millet flour 22% was mixed with okara in the ratios of 90%:10%; 80%:20%, 70%:30%, respectively. The ingredients necessary for quality dough were therefore added to the mixture of gluten-free flour and okara: vegetable oil (4%), yeast (4%), guar gum (0.03%), transglutaminase (0.01%), salt (1.8%), and water (160%). Sucrose was not added during the preparation of the dough. After preparing the dough and pouring it into molds, fermentation  and baking  of gluten-free bread were followed. The control bread was prepared in the same procedure but without adding okara.Sensory evaluation of bread was carried out 24 h after baking by 8 trained expert panelists, according to the procedure by Purić et al.  as well Using the “hedonic scale” in evaluating the overall acceptability of gluten-free bread enriched with 30% okara, consumers were required to give their opinion by choosing one of the 9 offered sensory feelings:  .Evaluation with both the point system and the “hedonic scale” was performed in two repetitions. The consumers were non-smokers, and the sensory analysis was performed anonymously. None of the evaluators was informed about the composition of the samples before the evaluation. Samples were served on glass trays, with random number labels.Total protein content was determined by Kjeldahl method  with a 6The total energy value was calculated from the proximate composition using the content of protein, lipid, and carbohydrate, multiplied by their combustion equivalents in the body  . The res•+ and DPPH• scavenging activity (ABTS/DPPH) according to Milinčić et al. [The antioxidant properties of gluten-free bread enriched with okara was tested using three different tests: ferric reducing power assay (FRP), ABTSć et al. . The resPercentage of the dietary reference intakes of nutrients (%DčRI) was calculated according to Martos and López  for chilPooled std) of two replicates. In statistical data processing, Pearson’s correlation coefficients and Tukey’s test at p < 0.05 were applied.Statistica software version 8.0  was applied for statistical analysis. Data are expressed as mean and standard deviation of three replicates, or as mean and pooled standard deviation  of soy okara has the potential to be a source of carbohydrates, especially dietary fiber, high-value proteins, phenolic compounds, and macro- and micro-elements that are valuable in human health. The analyzed bread showed good antioxidant properties and high sensory scores, obtained for taste, shape, odor, chewiness, and cross-section properties. Gluten-free bread enriched with 30% okara can potentially meet significant values of the daily needs for carbohydrates, dietary fiber, protein, macro- and micro-elements of children, men, and females. In addition to its high nutritional value, this bread was distinguished by its low energy value, thus it can be suitable in diets intended for the treatment of obesity.In addition, the production of this eco-innovative bread was in accordance with the sustainable method of production, circular economy, and proper waste management in food production, which is one of the important goals of modern life from an economic and ecological aspect.