Aim. To investigate the diagnostic yield and etiologies of patients with obscure gastrointestinal bleeding (OGIB) using capsule endoscopy (CE) or double-balloon enteroscopy (DBE). Method. We studied the data of 532 consecutive patients with OGIB that were referred to Xinqiao Hospital in Chongqing from December 2005 to January 2012. A lesion that was believed to be the source of the bleeding  was considered to be a positive finding. We analyzed the diagnostic yield of CE and SBE and the etiologies of OGIB. Result. CE and SBE have similar diagnostic yields, at 71.9% (196/231) and 71.8% (251/304), respectively. The most common etiology was erosions/ulceration (27.1%) followed by mass lesion (19.4%) and angiodysplastic/vascular lesions (13.9%). By stratified analysis, we found that erosions/ulceration (27.1%) was the most common etiology for the 21–40-year age group. Mass lesion was the most common etiology in the 41–60-year age group. However, in the >60 years age group, angiodysplastic/vascular lesions were significantly increased compared with the other groups, even though erosions/ulceration was most common. Conclusion. In this study, we found that CE and SBE have similar diagnostic yields and erosions/ulceration was the most common reason for OGIB, followed by mass lesion and angiodysplasias. Obscure gastrointestinal bleeding (OGIB) is defined as recurrent or persistent bleeding or iron deficiency anemia after a negative initial evaluation by gastric and colonic endoscopy . It has In the past, the conventional diagnostic strategies for small intestine disease including small intestine radiography, abdominal computed tomography (CT), angiography, and red blood cell scanning have had a low diagnostic rate because of the length and unique anatomical structure of the small bowel –6. RecenIn previous studies, the main etiology for OGIB was considered to be angiodysplastic lesions , 10. HowOGIB was defined as overt bleeding  or occult bleeding  in a patient with no pathologic causes that could be identified on conventional endoscopies. The exclusion criteria were as follows: serious physical condition, suspected perforation of the GI tract, bleeding tendency, and a lack of informed consent. Between December 2005 and January 2012, 545 consecutive patients who underwent CE and/or DBE for the indication of OGIB at the Department of Gastroenterology  were evaluated for inclusion and 532 patients that underwent CE or DBE were finally included. The studies had got the informed consent of all the patients included. Choosing CE or DBE for the examining was determined by the patients with the suggesting of doctors.CE studies (OMOM Jinshan Science and Technology (Group) Co., Ltd., Chongqing, China) were performed according to the standard protocol. Patients were asked to fast overnight after ingestion of 2 L polyethylene glycol-electrolyte solution before ingesting the capsule. Two hours after capsule ingestion, patients were allowed to drink and after 4 hours they were allowed to eat. Sensor array and recorder techniques were performed periodically to check the position of the capsule, and 8 h after ingestion the sensor array and recorder were disconnected. Data were then downloaded. All videos were reviewed by two experienced endoscopists who had each performed more than 100 capsule examinations.DBE was performed using a DBE system . This technique consisted of a video endoscope with an inner-diameter biopsy channel of 2.2 mm (EN-450P5) or 2.8 mm (EN-450T5), a flexible overtube, and a balloon controller. The DBE was performed through the mouth or colon according to the suspected site of the lesions. When the location was not clear, it was always performed through the mouth. The preoperative preparation, sedation, and analgesia were performed as described by Ohmiya et al. . DBE wasχ2 test and Fisher's exact test were used together with the calculation of the odds ratio and its 95% CI. The diagnostic yields and total CE and SBE rate were examined by χ-squared test. P values of less than 0.05 were considered to be statistically significant. All statistical analyses were performed using the Statistical Software Package version 11.0 .Values are presented as medians, means ± SD, or percentages. For comparison of percentages, the Overall, 545 patients were considered for OGIB and underwent CE or DBE. Among them, 235 patients underwent CE but 4 patients did not complete the procedure. Nine of the 310 patients undergoing SBE were excluded because they did not complete the procedure. Finally, 532 patients were included in the analysis. Two hundred thirty-one patients underwent CE and 301 patients underwent DBE. The basic characteristics of the patients are shown in As shown in Positive/suspicious lesions in patients with obscure gastrointestinal bleeding were as follows: mass lesion, bleeding, erosions/ulceration, angiodysplastic/vascular lesions, parasitic diseases, inflammation, polyps, and others (diverticulum and lymphangiectasis). As shown in By stratified analysis, it was found that in different age groups the etiologies were not the same. In the youngest age group (<20 years) the percentages of mass lesions, erosions/ulceration, inflammation, and polyps leading to bleeding were almost the same. In addition, 12% of the patients in this group were seen to be bleeding in the enteroscopy but the reason was not found, which is significantly higher than in the other groups. In the young age group (21–40 years), the most likely reason for bleeding was erosions/ulceration. Mass lesions and inflammation were also more common than other reasons. In the middle age group (41–60 years), the most significant reason was mass lesion, which was even a little higher than erosions/ulceration. In addition, angiodysplastic/vascular lesions and inflammation were also relatively common reasons for bleeding. In the old group (>60 years), erosions/ulceration (26.7%) was the greatest reason. But the occurrences of angiodysplastic/vascular lesions were significantly increased compared with the other groups. In summary, in this subgroup analysis, we found that, in the youngest group, the reason for bleeding was diverse, since the frequencies of the etiologies were similar. In the young age group, erosions/ulceration was the most common reason for bleeding. In the middle age group, mass lesion was the most common reason for bleeding. In the old age group, both erosions/ulceration and angiodysplastic/vascular lesions occurred more frequently.In another stratified analysis, as shown in P < 0.01) [CE and DBE have gained widespread clinical acceptance in the OGIB diagnostic process , 14, 15. < 0.01) . The mai < 0.01) .Previous studies have reported that angiodysplastic/vascular lesions were the most common cause of OGIB in western populations. Heine et al. reported that, in 168 patients with suspected small bowel bleeding, 123 (73%) had positive findings and the majority of cases involved angiodysplasia (52%) . May et P < 0.05). In the middle group, mass lesions were the main cause. This is consistent with a previous study, which reported that, in patients between 40 and 60 years, tumors accounted for the largest proportion of OGIB [In the stratified analysis, we found that the causes of OGIB in the youngest group were diverse and the percentages of erosions/ulceration, mass lesions, inflammation, and polyps were similar. However, in the young group, the occurrence of erosions/ulceration was significantly increased . Furthermore, we also found that, in both female and male groups, more than half of the patients were 60 or older; this indicated that we should pay more attention for the angiodysplasias in old patients. Overall, in the present study, we found that the etiologies were not similar between females and males or young and old patients.In addition, we also found that the percentages of mass lesion, erosions/ulceration, and inflammation had no significant difference between females and males. But the percentage of angiodysplasias in females was much higher than in males (19.0% versus 9.7%, The large sample number was one strength of the present study, but it was not without limitations. Firstly, the endoscopists reported mucosal erosions of the small bowel, but further definitive categorization of such lesions was not clear. Secondly, the follow-up results for the patients with positive findings were unknown.In conclusion, we found that erosions/ulceration was the most common reason for OGIB, followed by mass lesion and angiodysplasias. The etiology for OGIB in different age groups was not similar. In the 21–40-year age group, erosions/ulceration was thought to be the main reason; in the 41–60-year age group, the percentage of mass lesions increased. In >60 years age group, angiodysplasias were not the primary reason but had significantly increased over the others. In females, angiodysplasias also had a high frequency of occurrence compared with males.


In recent decades we have observed a remarkable increase in the rate of caesarean section (CS) in both developed and developing countries, especially in China. However, the real reasons for this phenomenon are uncertain. Notably, the number of women requesting elective CS without accepted valid medical indication has also increased, generating a nationwide debate because several studies have shown that this may be the underlying cause of the increase in CS rates observed recently. Therefore, we carried out a multicentre, large-sample, cross-sectional study to describe the CS rate and indications for CS in mainland China during 2011.This was a multicentre, large-sample, cross-sectional study of women who delivered infants in 39 hospitals in 14 provinces in China during 2011. We selected 111, 315 deliveries that occurred during 2011, excluding miscarriages or termination of pregnancy before 28 gestational weeks.The overall rate of CS in mainland China was 54.90%. The most common indication for CS was caesarean delivery on maternal request , followed by cephalo-pelvic disproportion (14.08%), fetal distress (12.46%), previous CS (10.25%), malpresentation and breech presentation (6.56%), macrosomia (6.10%) and other indications (22.12%). CDMR accounted for 15.53% of all the deliveries and 28.43% of all CS deliveries in mainland China.CDMR appears to be a considerable driver behind the increasing CS rate in mainland China. The relaxation of China’s “one-child policy” may translate into a greater number of CS because of previous CS delivery. To decrease the CS rate, we should first decrease the rate of CS on maternal request. Appropriate policies and guidelines should be considered to accomplish the goal.The online version of this article (doi:10.1186/s12884-014-0410-2) contains supplementary material, which is available to authorized users. There has been a remarkable increase in the rate of caesarean section (CS) in both developed and developing countries in the past decades, increasing from about 5% in developed countries in the early 1970s to more than 50% in some regions of the world in the late 1990s . Based oThe indications for CS also vary by regions and patient ethnicity . To dateThis study was approved by the human ethics committees of the Beijing Obstetrics and Gynecology Hospital and the Capital Medical University. The names of the institutional review boards that approved the study in the other 38 hospitals were listed in the additional file 2 *P*(1-P) /d2, where deff is the design effect; N, the sample capacity; u, 1.96 when confidence coefficient is 95%; P, the probability value. According to the formula, the sample size in each layer should be 2,400. The study randomly selected 39 different hospitals of different levels of care in 14 provinces and 7 territories in mainland China. For our analysis, we selected 111,315 deliveries that occurred during the year 2011, excluding incomplete data and miscarriages or termination of pregnancy before 28 weeks of gestation because of fatal malformations, intrauterine death, or other reasons. Figure This was a multicentre, large-sample, cross-sectional study. To reflect the population of China, we chose hospitals in seven territories of mainland China (except Hong Kong and Macau), based on stratified random sampling: north, south, east, west, northeast, northwest, and central China. The study population comprised women who gave birth in 39 hospitals in 14 provinces in China, from 1 January 2011 to 31 December 2011. The data were obtained from 14 provinces, municipalities, and autonomous regions within China , covering 39 hospitals of different levels. The hospitals comprised 8 secondary care and 12 tertiary care general hospitals and 12 secondary care and 7 tertiary care specialty hospitals . The sample size was calculated using the following formula: N = deff uQuestionnaire: The questionnaire included maternal characteristics; gestational, intrapartum, delivery, postpartum and neonatal care, and laboratory tests. Abstracted data included demographic data; gravidity; parity; maternal medical history; specific information on maternal or fetal pregnancy-related complications; gestational age at delivery; method of delivery; all primary indications for CS; the newborn’s sex, birth weight, birth length and Apgar score; and the maternal and perinatal outcomes. The primary indications for CS were divided into three categories: maternal indications, fetal indications, maternal request with no obstetric reasons. Maternal indications include previous caesarean delivery, elderly primigravida, cephalo-pelvic disproportion, prolonged labor (dystocia), maternal infection, complications of pregnancy such as preeclampsia, oligohydramnios, placenta praevia, placental abruption, presence of cardiac disease, or other maternal pathologies. Fetal indications included precious infant, malpresentation, fetal distress, macrosomia and multiple fetuses. The questionnaire was designed by obstetric and statistical experts and finalized after many discussions regarding its feasibility.Training of investigators: The head of each sub-center in each province, municipality, or autonomous region accompanied 2–3 investigators while attending face-to-face training on the questionnaire entry and completion. Instructions for completing the questionnaire were also sent out to the investigators.Data entry: Investigators from each province, municipality, and autonomous region were responsible for training their personnel for data entry. Data were collected and recorded by specially trained medical staff . Data were first entered in a hardcopy format and then entered into computer network databases.Data collection: Data were collected and entered into a computer network database. Case collection and hardcopy data entry were carried out from January to April 2012. Then, data were entered into network database from May to June 2012, and data quality control was carried out during the same period. Each participating hospital was responsible for its own case collection and data entry, and all personnel that participated in data entry received training beforehand. Data included birth outcomes of each hospital throughout 2011.Quality control: In each sub-center one or two specialized personnel were trained in data quality control, and they were responsible for their entire region. After the data were sent to the survey headquarters, specialized personnel at the headquarters were responsible for the second round of quality control assessment.P-value of <0.05 was considered significant.All data were input into SPSS software  for statistical analysis. Continuous variables were expressed as the mean ± SD or the median (and interquartile range), as appropriate. Differences in the baseline characteristics between two groups were tested using the Student’s t-tests for variables with normal distribution and the Mann–Whitney U tests for variables with skewed distributions. Categorical data were expressed as frequency (percentage) and the differences in frequency between the two groups were examined using the chi-squared test. A two-tailed In total, 111,317 deliveries at ≥28 weeks of gestation were included in the present study. Based on this sample, the overall rate of CS in mainland China was 54.90%.We selected only the deliveries occurring at ≥37 weeks of gestation n = 102,424) for the analysis of the indications for CS. As shown in Figure ,424 for χ2 = 166.59, P < 0.001). To some extent the distribution of the indications for CS was different between the two types of hospitals . The rate of CS for high-risk pregnancy was higher in the tertiary care hospitals than that in the secondary care hospitals, and the indications included previous CS delivery , malpresentation and breech presentation , oligohydramnios  and preeclampsia . In contrast, the rate of CS as a result of cephalo-pelvic disproportion was higher in secondary care than that in tertiary care hospitals , which might have been due to a lower standard of medical technology in the secondary care setting compared with the tertiary care setting. Therefore, many cephalo-pelvic disproportion cases cannot be actively managed through the stages of labor in secondary care hospitals. When we compared the rate of CS for high-risk pregnancy between the two types of hospitals, we found that the rate of high-risk pregnancies between the two types of hospitals was different. As shown in Table Table P < 0.001). However, the rate of CDMR decreased with increasing maternal age. This suggests that as maternal age increased, the medical indications for CS also increased, and thus the rate of CDMR was lower (P < 0.001). It should be noted that there was also a key difference in the rate of previous CS delivery in different age groups  (Table P < 0.001). Male infants were also associated with a higher rate of operative intervention in vaginal deliveries than female infants  . There was no correlation between the sex of infant and the rate of CDMR, but male infants had a higher rate of delivery by CS with indications compared with female infants .Based on the pre-labor BMI of gestating women, we found that obese women had a higher rate of CS and CDMR. The rate of spontaneous vaginal delivery decreased with increasing pre-labor BMI. Additionally, nulliparous women had higher rates of CS and CDMR than parous women (1) Table . Male inOur study showed that the overall rate of CS in mainland China was 54.90% and the most common indication for CS was maternal request (28.43%). CDMR accounted for 15.53% of all deliveries and 28.43% of the CS deliveries in mainland China in our study.The overall rate of CS in tertiary care hospitals was slightly higher than that in secondary care hospitals, probably because women with high-risk pregnancies were more likely to be admitted to tertiary care than to secondary care hospitals. This presumption is supported by the higher rate of high-risk pregnancy in the tertiary care hospitals compared with the secondary hospitals, as shown in Table Our study results also indicated that male infants were more likely than female infants to be delivered by CS. Male infants also had a higher rate of operative intervention in vaginal deliveries  than female infants. Although there was no correlation between the sex of infants and rate of CDMR, male infants had a higher rate of delivery by CS with indications compared with female infants. This might be because male infants have higher risks of adverse perinatal complications, such as gestational diabetes mellitus in the mother, preterm delivery, fetal distress and macrosomia, failure to progress during the first and second stages of labor, cord prolapse, nuchal cord, true umbilical cord knots, placental abruption, and placenta praevia -17.In the past few decades, we have witnessed a steady rise in global CS rates. In addition to an increase in the numbers of CS deliveries performed worldwide, there has also been a change in the indications for CS; a reflection of changing times . Based oIn our study, we found that the main indication for CS was maternal request. With increasing living standards, more women are likely to choose CS as their preferred method of delivery to avoid the issues associated with vaginal delivery, such as the fear of pain during childbirth, subsequent pelvic floor collapse, and incontinence. China’s “one-child policy” was implemented at the end of the 1970s, but was more effective in urban than in rural areas. However, in recent years, there has been some relaxation in the application of the policy all over the country, especially for families in rural areas . AdditioWhat are the reasons for the increased CDMR rates among the mainland Chinese population? First, tocophobia (fear of childbirth) may be the most common reason for the increasing rate of CDMR . A surveSecond, a common belief in Chinese society, and one reinforced in the media, is that CS delivery is a safer and more convenient way to give birth than vaginal delivery . The perFinally, changes in obstetric management and the increasing autonomy of patients in deciding the mode of delivery may contribute to the increasing rate of CDMR . HoweverHowever, several surveys have shown that CS has an adverse effect on long-term reproductive health , and theTherefore, to reduce the rate of CS, we should try to reduce the rate of CDMR. This means that the perception of women and their families that CS is the safest and most convenient way for childbirth needs to be changed. First, appropriate treatment for fear of childbirth is very important. A study showed positive effects of psychoeducational group therapy in nulliparous women with severe fear of childbirth in terms of fewer CS deliveries and more satisfactory delivery experiences relative to control women with a similar severe fear of childbirth . SecondlAs a multicenter clinical epidemiological study, we assessed the largest number of deliveries  from 39 hospitals in 14 provinces and regions over mainland China, while the majority of similar studies assessed a smaller number of deliveries from one hospital or from a local area. This was the major strength of our study.The lack of information on ethnicity  and the differences in specialty level of the different hospitals (tertiary vs. secondary vs. primary) are the main limitations. Different results might be obtained for other ethnic groups. Furthermore, the high CS rate issue affects not only China but the whole world. Further analysis about indications for caesarean section in the world should be performed. As a retrospective study, part of the clinical data was not completed and undetected deviations may exist. However, it is important to bear in mind that selection bias and undetected deviations may not have influenced the results. Another limitation of the study was that it was only a descriptive analysis and we did not perform any multivariable analysis.Our study results show that CS on maternal request was a considerable driver of the increasing CS rate in mainland China. With the easing of China’s one-child policy, there are likely to be more CS deliveries in the future, because of previous CS delivery. Therefore, to decrease the rate of CS, we should first decrease the rate of CDMR. Appropriate policies and guidelines should be considered to reach this goal.


Epidemiological studies have investigated the association between parity and the risk of stroke, but the results have been inconsistent. The objective of this study was to assess the association among middle-aged and older Chinese women. We used data from the Dongfeng-Tongji Cohort Study. In total, 14,277 women were included in the analysis. Participants were classified into four groups according to parity. Stroke cases were self-reported during face-to-face interviews. Multivariable logistic regression models were used to investigate the association between parity and the risk of stroke while controlling for potential confounders. The prevalence of stroke among the study subjects was 2.7% . In the fully adjusted model, women who had experienced two, three, or four or more live births had 1.24 times , 1.97 times  and 1.86 times , higher risk of stroke, respectively, compared with women who had experienced one live birth. High parity was associated with an increasing risk of stroke in the present study. Further longitudinal studies are needed to confirm the association and to explore the unclear mechanism underlying the link between parity and stroke risk. Stroke is a global health problem; it is the second most common cause of death and a leading cause of adult disability worldwide2An epidemiological study has shown that stroke has a greater effect on women than on men because women experience more events and are less likely to recoverParity has been reported as a long-term risk factor for coronary heart disease (CHD)67810With regard to the controversy, the association between parity and risk of stroke remains to be clarified. Therefore, in this study we aimed to examine the association between parity and risk of stroke in middle-aged and older Chinese women based on the data from the Dongfeng-Tongji Cohort Study.P for trend < 0.001). The subjects with higher parity tended to have higher BMIs (P for trend <0.001). The incidence of stroke was positively related to parity, at 1.2%, 2.2%, 4.4%, and 5.2% for women who had experienced one, two, three, or four or more live births, respectively. Interestingly, family members of women with higher parity were less likely to suffer from stroke (P for trend < 0.001). Compared with women who had experienced one live birth, women with higher parity  were more likely to report physician-diagnosed hypertension and diabetes. Women with higher parity tended to have a lower passive smoking rate and lower educational level (P for trend < 0.001). However, they had a higher smoking rate themselves than did those with a lower parity (P for trend < 0.001). In addition, higher parity women had a lower rate of adopting contraceptive methods or hormone replacement therapy (P for trend < 0.001). All differences for the listed variables except physical activity were statistically significant among different parity groups (P < 0.05).121314151612The age-adjusted and fully adjusted prevalence of stroke is presented by parity in In this large, population-based study, we found that higher parity was associated with a significantly elevated risk of stroke among middle-aged and older Chinese women. After controlling for potential confounders, the association attenuated but remained statistically significant for women who had experienced three or more live births and those who had experienced one live birth, suggesting that higher parity is a risk factor for stroke in this population of Chinese women.In the current study, women who had experienced one live birth were taken as the reference group. Nulliparity may reflect an inability to conceive or complete a pregnancy because of health factors such as polycystic ovary disease among Chinese women21et al., in an earlier British study of middle-aged and elderly women, demonstrated a higher mortality rate from cerebrovascular disease in parous women than in nulliparous women251011et al.The findings of our study are consistent with those of previous studies concerning the association between greater number of pregnancies and greater risk of stroke in women beyond typical childbearing ageThe biologic mechanism underlying the link between parity and stroke has not been well understood. Pregnancy itself is a risk factor for hemorrhagic stroke2933Pregnancy is a very important period for women, and may result in obesity and postpartum weight retention, which are of crucial importance to a woman’s health in later life5512et al.6The above-mentioned adverse changes induced by high parity provide biological plausibility for the increased risk of stroke associated with increasing parity in women. While a study conducted by Zhang Our study has several strengths. A large sample size, structured questionnaires, standardized medical examinations, laboratory measures and accurate measures of potential confounders were used in the study, and information regarding demographics, reproductive health factors, lifestyle behaviors, history of disease, and medical examination results were available and valid in our study. Additionally, our interviewers were blind to the objectives of the research, and all were well trained before conducting the study. Therefore, to our knowledge, ascertainment bias was unlikely in our study.This study has several limitations that need to be acknowledged. First, our data were cross-sectional. Although we demonstrated that higher parity was associated with risk of stroke in the present study, causal and temporal associations could not be ideally inferred. However, it is reported that the mean onset age of stroke was 64.9 ± 7.0 years old in Chinese women4734In conclusion, parity is associated with the risk of stroke independent of possible confounders. Our findings have significant implications for further longitudinal studies, in which pregnancy complications, more socioeconomic information, and changes in physiology and lifestyle during pregnancy and the postpartum period can be prospectively measured to confirm the effects between parity and stroke. Further studies are also very much needed to explore the unclear mechanism underlying the link between parity and stroke.Data for the analysis was derived from the base-line survey of Dongfeng-Tongji Cohort Study, which is a collaborative study between Tongji Medical College, Huazhong University of Science and Technology, and Dongfeng Motor Corporation. The rational, design, fundamentals, and methods of the Dongfeng-Tongji Cohort Study have been described in detail previouslyAmong the 27,009 eligible participants, 14,957 were women. For current analysis, we excluded women who never had a live birth (n = 205). The participants who had missing data on parity or on self-reporting stroke were also excluded. All together, 680 participants were excluded from our study. The final sample size for the study was 14,277 women.Written informed consent was obtained from all the participants. The study was approved by the Medical Ethics Committee of the School of Public Health, Tongji Medical College, Huazhong University of Science and Technology and Dongfeng General Hospital. All the methods in the present study were carried out in accordance with the approved guidelines.Individuals with stroke in this study were the survivors from nonfatal stroke. The occurrence of stroke was ascertained by asking the following question: “have you suffered a stroke that was confirmed by a physician?” Every positive response was written down clearly. The patients who suffer aphasia or vascular dementia after stroke may be disabled to describe their medical history. In this situation, their family member was asked to help them to answer the questionnaire in our current study. In the current study, we did not distinguish between ischemic stroke and hemorrhagic stroke.Parity was defined as the self-reported total number of live births. In this study, parity was classified into four categories: one live birth, two live births, three live births, and four or more live births.The questionnaire collected demographic information on sex, age, education and marital status . Lifestyle information on smoking status (smoke more than 1 cigarette per day in the previous 6 months), passive smoking , alcohol drinking status (drink more than once per week in the previous 6 months), and physical activity was also obtained. Physical activity was defined as those who practiced walking, biking, tai chi, jogging, swimming, dancing, climbing stairs, playing ball sports more than 20 minutes per day and more than three times per week over the past 6 months. A positive family history of stroke was defined as the self-reported of at least one first-degree family member  being diagnosed by physician as having stroke. The reproduction related information including history of delivery, abortions, menopausal status , age at menopause, history of contraceptive use, and history of hormone replacement therapy (HRT) were also collected. The anthropometric data included weight, height, waist circumference and systolic and diastolic blood pressures. Results of laboratory tests were obtained by medical examination. The BMI (body mass index) was calculated as the ratio of the weight in kilograms divided by height squared in meters.P values were two-sided, and P < 0.05 was considered to be statistically significant. The association between parity and prevalent stroke was assessed graphically according to age-adjusted model and fully adjusted model, separately, in the current study.The analysis of variance (ANOVA) was used to test differences in means among four categories of parity for the numerical variables, and chi-square tests were used for categorical variables. Categorical data were summarized as proportion (%) and numerical variables were described as mean ± SD. We regarded stroke as a dependent variable and a series of multivariable logistic regression models were used to calculate the odds ratios (ORs) and 95% confidence intervals (95% CIs) across parity categories. Women with one live birth were regarded as the reference category. Model 1 examined the relationship between parity and stroke without adjustment for any covariates. Model 2 included education, marital status, smoking status, passive smoking status, alcohol drinking status, physical activity, family history of stroke, diabetes, hypertension, and factors related to reproductive health including menopausal status, age at menopause, use of contraceptives, and hormone replacement therapy (HRT). Model 3 included the covariates in Model2 plus abortion. Model 4 included the covariates in Model 3 plus age. At last, Model 5, the fully adjusted model, included all the above mentioned potential confounders in Model 4 plus BMI. The Cochran-Armitage trend tests were conducted using SAS statistical software (version 9.4) and other statistical analyses were performed by using SPSS software (version 17.0). All reported How to cite this article: Zhang, Y. et al. Parity and Risk of Stroke among Chinese Women: Cross-sectional Evidence from the Dongfeng-Tongji Cohort Study. Sci. Rep.5, 16992; doi: 10.1038/srep16992 (2015).


A metric that predicts the presence of cancer-related liver disease would allow early implementation of treatment. We compared the demographic and clinical characteristics of patients with no evidence of liver disease, with a cancer-associated liver disease, and with a liver disease not associated with cancer.Retrospective, hospital-based, cross-sectional study which reviewed the medical records of subjects who underwent health examinations at a Taiwanese hospital from 2000 to 2004 and who had normal levels of amino transaminases. Demographic and clinical data were analyzed by univariate and multivariate statistics.A total of 2344 subjects had no evidence of liver disease (non-LD), and 1918 subjects had at least one liver disease (LD). The LD group was further divided into those with a cancer-associated liver disease  and those with a liver disease not associated with cancer . Age, BMI, percentage of males, globulin:albumin ratio (G/A), percentage of patients with gallstones, AST, and ALT were significantly higher in the LD group. Univariate analysis showed that the G/A was significantly higher in the LD-2 group than the LD-1 group; multivariate analysis indicated that the G/A was not independently associated with liver disease, but that subjects who were older and had higher BMI were significantly more likely to have a cancer-associated liver disease. Conclusions: For patients with liver disease, a multivariate model can be used to distinguish those with a cancer-associated liver disease from those with a liver disease not associated with cancer. Liver disease includes many diverse conditions, diseases, and infections that affect the morphology and function of the liver . AlteratTraditionally, definitive diagnosis of a liver disease requires analysis of biopsy specimens and/or imaging data provided by ultrasonography, laparoscopy, or computed tomography. Liver biopsy is the gold standard for diagnosis of most liver diseases, but this must be performed by an expert pathologist, is costly, and is associated with potentially serious adverse effects, such as intraperitoneal hemorrhage . Thus, bSeveral reports have suggested that cirrhosis may be present if the aspartate transaminase: alanine transaminase ratio (AST/ALT) is greater than 1.0 , 4. A prIn this retrospective study, we compared numerous demographic and clinical factors of patients with a cancer-associated liver disease and patients with liver diseases that are not associated with cancer.This was a retrospective, hospital-based, cross-sectional study in which the medical records of 5,585 subjects who underwent health examinations at the China Medical University Hospital  from 2000 to 2004 were screened Figure . All 4,2Subjects who never drank alcohol were classified as “non-drinkers”; those who reported drinking alcohol often were classified as “habitual drinkers”. Fatty liver disease, cirrhosis, gallstones, and splenomegaly were all diagnosed by abdominal sonography. Fatty lAll venous blood samples were obtained in the morning after a 12 h overnight fast. Globulin, albumin, and other serum parameters were analyzed by a biochemical autoanalyser  at the Department of Clinical Laboratory within 4 h of collection. Hepatitis B surface antigen was detected by an ELISA test from Enzygnost, Dade Behring GmbH  and the antibody to hepatitis C virus was detected by an ELISA test from Abbott .Chi-square test, a one-way ANOVA, or a two sample t-test. A simple linear regression model was used to identify the correlation of the G/A with specific patient characteristics. Then, a multivariate logistic regression model was used to predict the probability of a subject being diagnosed with liver disease relative to the G/A and the significant characteristics identified by univariate analysis. For all statistical tests, a P value < 0.05 was considered significant. All data were analyzed using SAS 9.0 .Data are expressed as means and standard deviations for age, body mass index (BMI), AST, and ALT, and as number and percentage for other characteristics. All subjects were classified as having no evidence of liver disease (non-LD), a liver disease that was associated with cancer , or a liver disease not associated with cancer  based on symptoms and ultrasonography. Inter-group comparisons were performed with Pearson’s Figure Table Chi-square test. The results indicate significant differences in these three groups for age, BMI, sex, alcohol usage, G/A ratio, AST, ALT, and heptatis C virus (HCV).Table P = 0.008). Thus, we performed a simple linear regression model of G/A ratio and patient characteristics for all 4262 subjects .Several previous studies have proposed the use of specific serum markers to predict advanced liver disease. For example, hypoalbuminemia and hypergammaglobulinemia are accepted biochemical features of liver cirrhosis , 11. PatP = 0.108). Instead, our multivariate analysis indicated advanced age and elevated BMI were significantly and independently associated with the presence of cancer-associated liver disease. The difference with the previous study [The limitations and complications of liver biopsy and the prospect that certain demographic characteristics and serum markers might be able to discriminate patients with cancerassociated liver diseases from those with liver diseases not associated with cancer motivated the present study. We found that age, BMI, percentage of males, G/A ratio, percentage of patients with gallstones, AST, and ALT were significantly higher in patients with liver disease (LD) relative to patients with no evidence of liver disease (non-LD). In agreement with a previous study of hepatitis C patients , our unius study  may be bWe used our univariate and multivariate models to construct ROC curves for G/A ratio by considering variables that were significantly associated with liver disease. The ROC curve for the univariate model, which only considered G/A as an indicator of liver disease, was very poor in predicting the presence of cancerassociated liver disease (LD-1) from liver disease not associated with cancer. In other words, the G/A ratio alone has poor sensitivity and poor specificity in the prediction of cancer-associated liver disease Figure . In contOur study is limited in that the number of subjects was not large enough to develop separate algorithms for each specific type of liver disease; our algorithm Figure  only disDespite these limitations, our study indicates that subjects with normal AST and ALT, who were older, male, had higher BMI, lower AST, and higher ALT had significantly higher ORs for liver disease and that age and elevated BMI are significantlyo associated with the presence of cancer-associated liver disease. We can suggest several avenues for future studies. A study with a larger sample size would allow the development of an algorithm that could be used to predict specific liver diseases, much as the fibrotest is used to predict liver fibrosis . We sugg


Hypoxia is a characteristic of many solid tumors and an adverse prognostic factor for treatment outcome. Hypoxia increases the expression of carbonic anhydrase IX (CAIX), an enzyme that is predominantly found on tumor cells and is involved in maintaining the cellular pH balance. Many clinical studies investigated the prognostic value of CAIX expression, but most have been inconclusive, partly due to small numbers of patients included. The present meta-analysis was therefore performed utilizing the results of all clinical studies to determine the prognostic value of CAIX expression in solid tumors. Renal cell carcinoma was excluded from this meta-analysis due to an alternative mechanism of upregulation. 958 papers were identified from a literature search performed in PubMed and Embase. These papers were independently evaluated by two reviewers and 147 studies were included in the analysis. The meta-analysis revealed strong significant associations between CAIX expression and all endpoints: overall survival , disease-free survival , locoregional control , disease-specific survival , metastasis-free survival , and progression-free survival . Subgroup analyses revealed similar associations in the majority of tumor sites and types. In conclusion, these results show that patients having tumors with high CAIX expression have higher risk of locoregional failure, disease progression, and higher risk to develop metastases, independent of tumor type or site. The results of this meta-analysis further support the development of a clinical test to determine patient prognosis based on CAIX expression and may have important implications for the development of new treatment strategies. Hypoxia is a characteristic of many different types of solid tumors and is caused by an inadequate vascular supply. Hypoxic areas are characterized by low oxygen concentrations, limited nutrient supply, and an acidic extracellular environment. Hypoxia is an independent prognostic factor of poor outcome in patients  and decrTumor cells have adopted several mechanisms to survive the hostile conditions during hypoxia, of which one is the hypoxia-inducible factor (HIF) pathway , 10. UpoMany clinical studies investigated the prognostic value of CAIX, and a recent meta-analysis of renal cell carcinoma (RCC) concluded that high CAIX expression was associated with a better overall survival (OS) . By contThe research question of this meta-analysis was defined as follows: “what is the prognostic value of tumoral CAIX expression in patients with solid tumors?” From this research question, three distinctive keywords were identified, i.e., prognosis, CAIX, and tumor. Different formulations and truncations of the keywords were tested as free text searches to see if appropriate papers could be identified. The search algorithm was applied as a free text search and consisted of the combined mention of all three keywords, in any of the formulations or truncations . The search for literature was performed on the 31st of August 2015 in both the PubMed and Embase databases. A total of 958 papers were identified from both databases  screened the remaining papers independently. The first round of screening was based on the title and abstract, whereas the second round consisted of a detailed evaluation of the full-text. Papers were evaluated based on the predetermined inclusion criteria. First, only solid primary tumors of various types were included, thereby automatically excluding hematological cancer. Second, only immunohistochemical detection of CAIX was included, because mRNA upregulation of CA9 does not fully correlate with an increase in functional protein expression, possibly due to posttranscriptional processing and/or differences in stability –19. ThirSeveral different parameters, if reported, were extracted from each paper, i.e., the number and origin of patients, number of events, treatment modalities, tumor site, tumor stage, tumor type, group dichotomization, antibody supplier, expression pattern, cellular localization, and endpoints. The univariate hazard ratio (HR) was extracted to assess prognostic value of CAIX expression. When the univariate HR with corresponding 95% confidence interval (95%CI) was not reported, the method from Tierney et al. was used to estimate the HR . Multivahttp://www.ohri.ca/programs/clinical_epidemiology/oxford.asp)  to better suit the study design of the included papers . The method of scoring based on awarding stars in different categories remained, however, identical. The NOS was commended in the 2011 version of the Cochrane Collaboration handbook and is an easy method to evaluate the methodological quality of cohort studies (available at ord.asp) .p-Values <0.05 were considered as statistically significant.Distribution and frequencies of the extracted data parameters were analyzed using SPSS version 22). Meta-analysis was performed using R statistical software with the Metafor Library (version 1.9-8) . Meta-an. The assThis meta-analysis encompassed a total number of 24,523 patients across 147 independent studies. Many studies included only a small number of patients  with a median follow-up time between 12.6 months and 13.9 years and are often inconclusive, which underlines the need for a meta-analysis. All papers were published between 2001 and 2015 of which approximately 50% were published after 2010. The majority of the included studies treated patients with surgery alone (36.7%) or in combination with either chemotherapy (8.8%) or standard radiotherapy (8.8%), or the combination of all three modalities (23.1%). Single radiotherapy treatment or combined with chemotherapy was reported in 5.4 and 6.1% of the papers, respectively. In 4.8% of the studies, a form of experimental treatment was administered, including experimental radiotherapy , hormonaImmunohistochemical staining of CAIX was predominantly performed using the M75 antibody (46.3%) targeting the proteoglycan domain of CAIX , 32. OthOverall, patients suffering from tumors with high CAIX expression had a worse treatment outcome Figure . This asp < 0.0001, Figure Effect of pretreatment expression of CAIX on OS could be evaluated in 104 studies. The complete data to estimate the HR could not be retrieved from 11 papers and were therefore not included in the analysis [Table 1 in Supplementary Material –43]. Ovep < 0.001) . The negative association between high CAIX expression in tumors and worse LC remained significant in head and neck  and liver tumors    Figure . Subgroup = 0.0002) [Figure Metastasis-free survival was reported in 12 of the 147 included studies. Based on 11 of these studies, high CAIX expression was significantly associated with a shorter MFS   Figure . Subgroun = 50), DFS , DSS , and PFS . For both LC  and MFS , the association with CAIX expression became even stronger when only high-quality studies were included.This meta-analysis used an adjusted version of the NOS to evaluate the quality of a study. The scores of this quality assessment ranged between 1 and 7 stars, i.e., the maximum, awarded per study. Approximately half of the studies (52.4%) were considered as high-quality studies, i.e., with a number of stars greater or equal to the median (5 stars). Meta-analysis of only the high-quality studies revealed significant prognostic values of CAIX expression for OS (HR = 1.81, 95%CI 1.57–2.09, Many clinical studies investigated the prognostic association of CAIX expression with treatment outcome. Most of these studies, however, include only limited numbers of patients and remain inconclusive. This current meta-analysis is the first complete overview of all reported clinical studies investigating the impact of pretreatment CAIX expression in solid tumors on prognosis. Overall, these results clearly show that high CAIX expression is an adverse prognostic marker in solid tumors, irrespectively of the endpoint evaluated, as summarized in Figure ca9 in the end of 2000 (via PI3K (The papers included in the current meta-analysis were all published between 2001 and 2015, which is likely attributed to the identification of the hypoxic responsive element in the promotor region of  of 2000 . This st of 2000 . Neverthvia PI3K  or the uvia PI3K , 172, tuvia PI3K , 12. Thivia PI3K . This cavia PI3K –176. In via PI3K , 177. Thvia PI3K –180. TheA meta-analysis usually overestimates its results because of selective reporting and publication bias . This meThe different staining and scoring methods used in the included papers to quantify CAIX expression might be an additional source of bias. Visual quantification was used in the majority of the reports and could either be based on staining intensity, the number of stained cells, or a combination of both. In addition, different thresholds have been used to dichotomize patients based on their CAIX expression. This discrepancy in methods is one of the reasons of significant heterogeneity between studies, which therefore requires the use of a random-effect model in the meta-analysis , 182. AdTo identify possible bias in a selected study, an adjusted version of the NOS was used, which is a quick and easy method to assess the quality of studies that has been commended in the Cochrane handbook . HoweverIt remains impossible to eliminate every source of bias in a meta-analysis. Nevertheless, the high statistical significance of the results presented here clearly show that CAIX expression is associated with worse prognosis in a global patient population and in the majority of tumor sites. These findings are similar to the results of the meta-analysis in head and neck cancer , but difStudy was conceived and designed by SK, AY, RN, PL, and LD. Screening of papers and data extraction was performed by SK and AY. Statistical analyses were performed by RH. Writing of the first draft of the manuscript was performed by SK. AY, RH, RN, PL, and LD contributed to the writing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Broussonetia papyrifera (L.) L'Hér. ex Vent) is a dioecious tree native to East Asia and mainland Southeast-Asia, introduced prehistorically to Polynesia as a source of bark fiber by Austronesian-speaking voyagers. In Oceania, trees are coppiced and harvested for production of bark-cloth, so flowering is generally unknown. A survey of botanical records of paper mulberry revealed a distributional disjunction: the tree is apparently absent in Borneo and the Philippines. A subsequent study of chloroplast haplotypes linked paper mulberry of Remote Oceania directly to a population in southern Taiwan, distinct from known populations in mainland Southeast-Asia.Paper mulberry  in order to relate results to a previous survey of ITS diversity.In Near and Remote Oceania, contemporary paper mulberry plants are all female with the exception of Hawaii, where plants of both sexes are found. In its natural range in Asia, male and female plants are found, as expected. Male plants in Hawaii display an East Asian ITS genotype, consistent with modern introduction, while females in Remote Oceania share a distinctive variant.Most paper mulberry plants now present in the Pacific appear to be descended from female clones introduced prehistorically. In Hawaii, the presence of male and female plants is thought to reflect a dual origin, one a prehistoric female introduction and the other a modern male introduction by Japanese/Chinese immigrants. If only female clones were dispersed from a source-region in Taiwan, this may explain the absence of botanical records and breeding populations in the Philippines and Borneo, and Remote Oceania. Prehistoric settlement of the Pacific involved the intentional transport of many plant and animal species of economic value , 3, 4, 5B. kazinoki, is the main source of fiber for handmade paper in Japan, where B. papyrifera is known as an introduced species [n = 26), and dioecious . The male inflorescence is a dense, many-flowered, pendulous catkin of 4–8 cm; the female inflorescence is a dense, many-flowered, globose head of about 2 cm, and the fruit is a collection of a small fleshy orange to red druplets [The plant family to which paper mulberry belongs, the Moraceae, includes figs and many other plants that provide food and fiber , 12. A n species . Paper mdruplets . The swedruplets  mapped tB. papyrifera samples from Polynesia, Southeast Asia and East Asia, we analysed non-coding internal transcribed spacer (ITS) sequences of nuclear ribosomal DNA, and inter-simple sequence repeat (ISSR) sequences in total DNA extracts. Diversity was found in Asia and not in Polynesia [In a survey of olynesia , with tholynesia . The datolynesia . A subseolynesia  indicatePiper methystichum) a well-studied dioecious domesticate that was introduced from Vanuatu into Polynesia [Dioscorea alata) [In Oceania, most traditional crops, except for coconuts and a few others, are propagated asexually , 18, 19.olynesia , and thea alata) . Sexual a alata) . In the a alata) . As a rea alata) .A relict population of paper mulberry has long been known to exist in a crater on Rapanui , 23, andMatthews  noted thB. papyrifera plants produce large quantities of pollen, as attested in India and Pakistan [Broussonetia species difficult. The absence of verified paper mulberry pollen in palaeoecological contexts does not disprove the past presence of male plants, or prove the presence of only female plants in an area where the tree is present today.Male Pakistan ; 28, 29 Pakistan . No largPakistan ). PollenWe are interested in the sex distribution of paper mulberry in Oceania because the question of sex has direct bearing on whether or not the plant can naturalize, form breeding populations, and survive without human assistance.B. papyrifera. A comparison of gene sequences for Eucommia ulmoides Oliv. [Trichosanthes dioica [Carica papaya [Pistacia vera [In dioecious plants sex determination genes and pathways are not universal. No master sex determination gene has been identified, and many genes that affect sex determination have been found . In somees Oliv. , Trichoss dioica , Carica a papaya , Pistacicia vera  and papecia vera  does notIn the present paper, we have identified the sex of paper mulberry in Near and Remote Oceania in order to determine if one or both sexes are present, and to reconsider the possible mechanisms of dispersal and survival of the tree in the light of this information.B. papyrifera. To distinguish the sex of these plants more effectively, we developed a duplex PCR protocol based on the male-specific sequence recorded in GenBank (HQ202152.1) [In work aimed at helping plant breeders create new cultivars, Wang et al.  identifi02152.1) . We thenThe Corporación Nacional Forestal (CONAF) from Chile issued a research permit for collecting inside the National Park on Easter Island. The Département de la Récherche, French Polynesia issued permits for collecting in the Marquesas, Tahiti and Austral Islands; the Province Museum of Central Sulawesi aided in sampling in Sulawesi, Indonesia. The Herbarium Pacificum , the Auckland Herbarium  and the US National Herbarium  issued permits for herbarium sampling.Plant specimens were examined directly or online at the following locations: (1) B.P. Bishop Museum, Honolulu, USA; (2) Herbarium Bogoriense, Bogor, Indonesia; (3) National Museum of Natural History, Santiago, Chile; (4) Auckland Herbarium, Auckland Institute and War Memorial Museum, New Zealand, (5) Landcare NZ, Lincoln, New Zealand, (6) National Herbarium, Smithsonian Institution, Washington D.C., USA., and (7) National Museum of Natural History, Paris, France.Young leaves were collected in New Caledonia, Western Polynesia  and Eastern Polynesia  between 2008 and 2014. Leaf samples collected in 2008 in Fiji, Samoa, Tonga, Marquesas, Tahiti, Pitcairn, Raiatea and Rapanui were preserved at -20°C in the laboratory . Leaf saThe origin of all 340 contemporary and the 12 herbarium samples are shown in Four samples collected in Taiwan were used as sex controls, and came from two male plants  and two female plants . The sex of these plants was determined in the field by visual observation of male and female inflorescences during the flowering season.™ PicoGreen® dsDNA Assay Kit (#P7589) as indicated by the supplier. Extracted DNA was stored in double distilled sterile water at -20°C until analysis.Genomic DNA was extracted following a CTAB extraction protocol described by Lodhi et al.  and modi5´- GGA AGG AGA AGT CGT AAC AAG G -3`) and ITS-C (5´- GCA ATT CAC ACC AAG TAT CGC -3`) primers as described by Blattner [The ITS-1 region was amplified using ITS-A  and two reverse primers, MMRS18 (5´- GCC ATG TCA ACG TCA TCA -3`) and MMRL (5´- CTG GAC AAG ACC AAC TTT GAA TCC G -3`). One of the reverse primers targets the male-specific sequence identified by Wang et al. [2, 0.625 mM of dNTPs, 5.5 pmol of the forward MMF primer, 4 pmol of the reverse MMRS18 primer and 1.5 pmol of the second reverse MMRL primer, 1 U of GoTaq™ Flexi DNA Polymerase and 1x PCR buffer  in a final volume of 20 μl.We designed three primers based on the male-specific sequence of the g et al. , depositg et al. , while tg et al.  are showThe amplification program used an initial denaturation at 94°C for five min, and 30 cycles with a denaturation step at 94°C for one min, an annealing stage at 55°C for one min, and an elongation step at 72°C for 45 sec, followed by a final extension at 72°C for seven min. For each PCR assay, positive sex-control samples  and a negative control (water) were included. All PCR reactions were set up in a UV-treated PCR cabinet.™ and visualized under UV light. A 1 kb plus DNA ladder (Thermo Scientific GeneRuler # SM1331) was included in every gel. Bands were photographed with a UV transilluminator and gel images were analyzed by visual inspection. All samples were analyzed in duplicate. Male individuals were identified by the presence of both the 273 and 420 bp bands. Female individuals displayed a single 420 bp band  according to the manufacturer’s instructions and sequenced by Macrogen Inc. . For comparison, sequences were aligned using the MUSCLE algorithm implemented in MEGA6 .Of the seven herbaria examined (234 accessions) only 26 exhibited reproductive organs, and one had the sex indicated as part of the label . Most paThe ITS-1 sequences displayed a G/T transversion at nucleotide position 203, as noted previously . The G vThe duplex PCR method reported here facilitated visual scoring of PCR products and unambiguous identification of male and female paper mulberry plants. The differential amplification of DNA from male and female plants with the MMF-MMRS18 primer pair is due to a six bp polymorphic region between the relative positions 277 to 294 within the HQ202152.1 sequence . The priAnalysis of 33 samples from the native range  indicated the presence of both male and female plants. The sex ratio was approximately even for all sampled locations, consistent with the known presence of breeding populations in eastern Asia [B. papyrifera found in the Pacific according to our results is depicted in These results answer the long-standing question regarding the presence of a single sex of paper mulberry plants in Remote Oceania, revealing that the overwhelming majority of specimens are female plants. The geographical sex distribution of Because paper mulberry is dioecious, the spatial distribution of male and female plants is critical for sexual reproduction of the plant, and has implications for the formation of breeding populations, and for genetic diversity present in the introduced range of this species. Although today there is a growing tendency to use improvements in sequencing technologies and massive genetic analysis , this woIn a former study, using chloroplast DNA sequences, we demonstrated a tight genealogical link between paper mulberry populations in South Taiwan and Remote Oceania by way of Sulawesi and New Guinea, presenting the first study, to our knowledge, of a commensal plant species transported to Polynesia whose phylogeographic structure concurs with expectations of the “out of Taiwan” hypothesis of Austronesian expansion . NonetheOn a wide geographical scale, the co-occurrence of male and female plants is an indication of where breeding populations might exist and provides a rough outline of the likely natural range . Our resB. papyrifera, most samples from the Pacific do not bear fruits or flowers. To our knowledge, the first collectors in the Pacific were P. Commerson, the naturalist from L.A. de Bougainville’s expedition to the Pacific in 1768, and J. Banks and D. Solander, the botanists from J. Cook’s first expedition into the Pacific in 1769. These early collections testify to the plants present at a time before modern translocations and plant introductions to these islands [B. papyrifera, labeled as coming from the Friendly Islands. As discussed previously [The results of the archival research showed that the vast majority of plant materials kept in museum herbaria did not have reproductive organs that are usually included for taxonomic use. In the case of  islands . Within eviously  these arOn almost all islands of Near and Remote Oceania represented in our sample set, we found only female individuals among extant plants. Apart from the exception discussed below, the predominance of female individuals in this region is consistent with one of the scenarios suggested by Matthews , namely In the case of the Solomon Islands, both the contemporary and herbarium samples that are all less than 50 years old were collected near Honiara, on Guadalcanal Island. As demonstrated in Chang et al.  all thesth and 20th centuries [The presence of both female and male plants in Hawaii is probably the result of at least two introductions made during different historical periods, before and after modern colonization of the islands by immigrants from across Eurasia. The ITS-1 sequence displayed by all female plants in our Hawaiian sample set exhibits the same “T” polymorphism found in all other female plants in Remote Oceania. Strikingly, the male plants from Hawaii all display the “G” polymorphism found in Asian paper mulberry plants , 15. Indenturies .Why were male and female clones introduced to Hawaii, at different times by different people? One possibility is that there was a cultural or practical bias in the choice of paper mulberry plants taken to Remote Oceania by Austronesian voyagers and in the choice by Chinese or Japanese immigrants in historic times. In principle, male and female clones of paper mulberry may have certain agronomic or use traits preferred by different people at different times and places. The qualities required as a source of medicine and/or papermaking in East Asia, for example, may be unlike those required for bark-cloth manufacture. However, there is no relevant information on such differences and preferences in the regions of Southeast and East Asia where paper mulberry is still economically important. The past selection of female or male clones for propagation, in the source regions, could also have been incidental and unrelated to the sex of the plants. The periodical harvesting of clones in the introduced range, and concomitant absence of sexually mature plants, could have led to the unintentional loss of male plants, particularly if they were only rarely introduced. In the absence of breeding, outside the natural range of the species, new male and female offspring could not be generated and no further sex selection could be made.Carica sp.), a molecular sex marker has been used to select female plants and avoid unnecessary cultivation of males [In Hawaii today, the possibility now exists to test and compare male and female trees for the purposes of bark-cloth or paper production, and to conduct breeding experiments, although the genetic diversity present in Hawaii is limited compared to that present in Asia. Sexual dimorphism in some dioecious plants is linked to economically important traits such as disease resistance, leaf quality , or fruiof males . The sexof males .Our results are consistent with the observation of only female-inflorescences of paper mulberry in herbarium collections from Rapanui, Pitcairn and Tahiti, and the presence of females and putative male plants from Hawaii. The earliest female specimens  were colHistorical accounts from the first contact expeditions include descriptions of clothing or plantations, starting as early as 1606, and mention either the presence of bark-cloth or of paper mulberry trees on islands as far apart as Pitcairn, Tahiti, Rapanui, the Austral Islands, New Zealand and many more . In the In a previous paper  we discuth century, before European settlement, most likely because of an early cultural shift by Maori to the use of native flax (Phormium tenax), a naturally abundant fiber plant used for woven and plaited textiles.We can now discuss the previous reports of a general absence of paper mulberry in Borneo and the Philippines , 43, 44.Antiaris toxicaria [B. papyrifera can be found in the Philippines or Borneo, they may also point to locations or areas where archaeological evidence for early bark-cloth production can be found. Of course, it is to be expected that the tree, if introduced to a particular location at an early date, through migration or exchange, would continue to be moved to other locations over various distances, and across cultural boundaries (e.g. between Austronesian-speaking and Non-Austronesian speaking peoples). There is not necessarily a direct physical correspondence between the locations of living clonal stands and locations of early Austronesian settlement. The approach suggested here is just one of many ways that can be used, in principle, to narrow the search area for archaeological evidence of early Austronesian activities (including bark-cloth production) in Southeast Asia [In the Philippines and Borneo, ethnographic records of bark-cloth production could be used to guide a search for surviving clones of paper mulberry. If these can be found in contexts that are not obvious locations for modern introduction, we predict that they will be female with the ITS-1 variant G and the chloroplast haplotype cp-17 . Althougoxicaria ), ethnogast Asia , 47, 48.B. papyrifera into Polynesia. Orliac [B. papyrifera made up 32% of the total identified oven charcoal  based on charcoal identification [B. papyrifera pollen collected from a sedimentary lake core deposit on Rapanui, although palynological identification of B. papyrifera is problematic, because of the morphological similarity with pollen from other species of the Moraceae and also the Urticaceae and a range of other introduced plants of economic importance [Streblus spp.) [Ficus prolixa) [At present, there is some direct archaeological evidence for the early introduction of . Orliac , 50 idenfication . Flenleyfication  also ideportance . Horrockportance  identifius spp.) . On Huahprolixa) . Kahn etprolixa)  identifiThe present observation of only female plants in all extant populations in Remote Oceania does not necessarily correspond to the initial expansion of Austronesian speakers into this region, but it does indicate a genetic bottleneck and a close cultural link to the early bark-cloth traditions of island Southeast Asia (through Sulawesi) and Taiwan. In the absence of breeding populations, the spread (i.e. movement) of paper mulberry depends entirely on a continuous human cultural tradition of preserving, propagating and transporting the plant. If self-maintained living female clones of ancient origin cannot be found in the Philippines and Borneo, or at any location along any other possible route of introduction into the Pacific, then it would appear that long-term survival of paper mulberry at any given location is also dependent on human care.Populus tremuloides [Under cultivation, clones of paper mulberry may be thousands of years old, and one possible direction for future genetic research is the development of a molecular clock based on the accumulation of mutations in different branches (ramets) of a single clonal lineage (genet). This approach has been used to estimate an age of 12,000 years for a naturally occurring genet of whispering aspen, muloides . To deveS1 FigBold and italics: primers designed for this study; underlined: primers designed by Wang et al. (30).(TIF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


Background and Objective. Most patients with fibromyalgia benefit from different forms of physical exercise. Studies show that exercise can help restore the body's neurochemical balance and that it triggers a positive emotional state. So, regular exercise can help reduce anxiety, stress, and depression. The aim of this study was to analyze the benefits of moderate aerobic exercise when walking in two types of forests, young and mature, and to assess anxiety, sleep, pain, and well-being in patients with fibromyalgia. Secondary objectives included assessing (i) whether there were differences in temperature, sound, and moisture, (ii) whether there was an improvement in emotional control, and (iii) whether there was an improvement in health (reduction in pain) and in physical and mental relaxation. Patients and Methods. A study involving walking through two types of forests (mature and young) was performed. A total of 30 patients were randomly assigned to two groups, mature and young forests. The participants were administered the following tests: the Spanish version of the Revised Fibromyalgia Impact Questionnaire (FIQR) at baseline and the end-point of the study, the State-Trait Anxiety Inventory (STAI) after each walk, and a series of questions regarding symptomatic evolution. Several physiological parameters were registered. Results. FIQR baseline and end-point scores indicated a significant decrease in the symptomatic subscale of the FIQ . The within-group analysis revealed that differences were significant with respect to days of intense pain, insomnia, and days of well-being only in the group assigned to the mature forest, not in the group assigned to the young forest. No differences were found with respect to anxiety. Conclusions. Although the main aim of this research was not achieved, as the results revealed no differences between the groups in the two forest types, authors could confirm that an aerobic exercise program consisting of walking through a mature forest can provide the subjective perception of having less days of pain and insomnia and more days of wellness, in patients with fibromyalgia. In recent years, in Japan, the practice of recreational and relaxation activities conducted in forested environments and extensive green spaces for therapeutic purposes has increased considerably. This approach is called forest therapy or “shinrin-yoku”  and represents a popular form of natural therapy for the many people looking to reduce stress . PreventFibromyalgia (FM) is a rheumatic syndrome of unknown etiology characterized by chronic, diffuse musculoskeletal pain, fatigue, sleep disorders, and morning stiffness and is associated with psychological disorders, mainly anxiety and depression. This condition also exhibits hypersensitivity along with verifiable pain in specific anatomical points  and affeThe main objective of the study was to assess the short-term effects of walking through the woods in natural conditions on fibromyalgia symptoms and to demonstrate that people with FM performing moderate exercise in therapeutic forests exhibit a significant improvement in their clinical symptoms when compared with the same type of exercise in younger forests. Secondary objectives included assessing (i) whether there are significant differences in temperature, sound, and moisture between mature and young therapeutic forests; (ii) whether people who exercise in therapeutic forests significantly improve emotional control, have a sense of improved health, and observed a reduction in pain; (iii) and whether the therapeutic forest provides patients with greater physical and mental relaxation. Institut d'Assistència Sanitària in Girona. All participants signed informed consent.A randomized single-blind clinical trial of two groups, with individuals 20 to 70 years old who were diagnosed with FM, was designed. People with FM, belonging to the Garrotxa Association of Chronic Fatigue and Fibromyalgia, were invited to participate. People with Chronic Fatigue Syndrome were excluded. Information study documents about the project were sent by mail to the association and potential participants were contacted by telephone to enroll and schedule a meeting prior to starting the study. All patients met the diagnostic criteria of the American College of Rheumatology , 20, 21.Participants were assigned to each group using a list of random numbers. Each group took 1.25-kilometer walks in the evenings between 5 and 6 pm during six days. During the walks, participants were accompanied by two nurses trained in interviewing. These nurses were blinded to the type of forest and ensured that the walks were performed in a homogeneous manner. Additionally, the nurses were responsible for managing the data collection notebooks. Spanish version of the Revised Fibromyalgia Impact Questionnaire (FIQR) [panish version of State-Trait Anxiety Inventory (STAI) [Each participant's information regarding age and approximate date of fibromyalgia diagnosis was gathered and self-referential comorbidity was recorded before beginning the study using a standardized questionnaire. Participants' weights and heights were measured on the first and last day of intervention. Blood pressure, heart rate, oxygen saturation, and temperature of the participants were determined at the beginning and end of each walk. In conjunction with thee (FIQR)  and the y (STAI)  that werA young forest is one that presents only first age classes species. Usually, it is a forest with a homogeneous dense or very dense structure and impenetrable undergrowth –26.A mature forest, regardless of its location, urban areas or natural, is one in which the absence of timber exploitation during at least the last 4 or 5 decades has allowed reaching a more advanced and complex structure, with a wider range of age groups, including old trees with a large diameter . The closure of the crowns of the trees causes little undergrowth. This composition allows a wide biodiversity and an ecosystem that includes many more types of lichens, fungi, mosses, invertebrates, and their predators, that is, all the flora and fauna in the natural evolution of a forest –26.We refer to a therapeutic forest when the structure of the forest has relatively mature trees, or at least components of maturity (trees), and it is accessible to be visited.Quercus robur), typical of the valley bottoms and quaternary plains that were successively filled by volcanic materials and lacustrine deposits. These forests grow in a middle-European sub-Atlantic climate, in the biogeographic mountain region, specifically the submontane area, and are very rare in the south of the Pyrenees. The walks were performed through flat areas in these woods.The two forests are located in the Garrotxa Volcanic Zone Natural Park, specifically between Olot and the beech forest in Jordà . The topography of this area is characterized by rolling hills and small mountains, corresponding to volcanoes of reduced dimensions that emerged approximately 17,000 years ago from lava flow. The forests are mainly composed of wet oak groves of sessile oak (The “Can Serra” mature forest (mature forest group) has many centenarian trees with large and irregular shaped trunk and big roots above the ground. The dominant species is sessile oak, with a harmoniously irregular high mountain structure and a considerable density of old trees with sizable treetops. This area presents rare and very penetrable undergrowth, with sufficient space to accommodate a group of people on a therapeutic walk through the existing trails .Rubus ulmifolius), hawthorn (Crataegus monogyna), or broom (Cytisus scoparius). The vegetation is homogeneous, compact, closed, and less penetrable (The young forest “Les Llongaines” (young forest group) consists of a more regular and dense woodland with an age range of 5–35 years, without any tree exceeding 50 years. The dominant species is sessile oak, although there is a small sector with beech trees. This is a large open area inhabited by species such as bramble  and dispersion (standard deviation) measures for quantitative variables. Descriptive data was calculated for the overall sample and stratified according the type of forest (mature and young). In order to assess the effect of forest type in the FIQR scores and in the secondary outcomes we conducted an inferential analysis using a between-group comparison of the differences between baseline and the end of the study scores with the nonparametric Mann-Whitney  U Z = −2.55; p = 0.009), and oxygen saturation, which was higher in participants assigned to the mature forest .Initially, 34 participants who were randomized in two groups enrolled in the study. Nonetheless, only 30 of them took part in the research because four dropped out by choice, alleging time incompatibility before the start of the study. All participants were women, and 14 and 16 participants were assigned to the mature forest and to the young forest, respectively. The average age of all participants was 62.3 years (SD = 7.7) with an average weight of 70.7 kg (SD = 14.1) and height of 158.3 cm (SD = 28.2). At baseline systolic blood pressure was of 131.4 mm Hg (SD = 20.4), diastolic blood pressure of 77.2 mm Hg (SD = 9.1), heart rate of 74.4 bpm (SD = 9.2), oxygen saturation of 96.2% (SD = 2.1), and body temperature of 35.4°C (SD = 0.4). p = 0.083), atmospheric pressure (p = 0.673), sound (p = 0.656), temperature (p = 0.371), and moisture (p = 0.816)) ) .At baseline, the mean score of all participants in the FIQR scale was 58.7 points (SD = 20.5). The breakdown of the FIQR score on its three subscales was 16.6 points (SD = 6.7) for the functional disability subscale, 10.1 points (SD = 6.6) for the overall impact of the disease subscale, and 32.0 (10.7) points for the subscale of clinical symptoms, without exhibiting statistically significant differences between participants assigned to either group.Z = −2.04; p = 0.41). Z = −2.86; p = 0.004) and tenderness , was observed.In the total sample, the within-group analysis (pre-post) revealed a difference score of 3.8 points (SD = 22.9) for the total FIQR, 1.3 points (SD = 8.0) for the subscale of functional disability, −0.9 points (SD = 7.9) for general impact subscale, and −4.2 points (SD = 11.0) for the clinical symptoms subscale, which was statistically significant , 0.5 points (SD = 9.0) in the subscale of functional disability, −2.6 points (SD = 6.7) in general impact, and −4.1 points (SD = 11.8) in the clinical symptoms. In the group assigned to the young forest, the difference in the total FIQR was −1.7 points (SD = 24.6), 2.2 points (SD = 7.2) for the subscale of functional disability, 0.6 (SD = 8.6) points for overall impact, and −4.3 points (SD = 11.8) for clinical symptoms.  trait anxiety scale of the STAI was 4.9 points (SD = 8.3) and 34.9 points for the STAI-state subscale (SD = 9.5). At baseline, no significant differences were observed in any of the STAI subscales among the participants in both groups. State and trait anxiety STAI subscales did not show statistically significant differences between the baseline and the end of the study scores among the groups . Similarly, no differences were found in any of the recorded physiological parameters  between the start and end of the study.With respect to anxiety, the mean score for the overall sample ofWith respect to subjective assessments on the number of days of perceived well-being/discomfort between baseline and end-point, a decrease in the number of days with symptoms was observed. However this difference was not statistically significant, either for the entire sample or between groups. The within-group analysis revealed that only the mature forest group and not the young forest group exhibited significant differences in the days of intense pain, insomnia, and sense of well-being .The main aim of this research, which was to demonstrate that the clinical benefit of moderate exercise would be superior in mature forests than in younger forests, was not achieved, as the results revealed no differences in the FIQ score between groups. However, participants who walked in the mature forest, unlike those who did so in the young forest, reported significant differences between baseline and final scores with respect to the number of days of intense pain, days of insomnia, and days of well-being. Other controlled studies with FM patients that used different types of activity  reported improvements with respect to pain, functional status, and life quality as well , 28. OurThere is a benefit associated with the intervention because the scores in the FIQR subscale for symptoms revealed a global decrease in intensity, specifically pointing to significant differences in anxiety and pain items. Other studies showed similar findings of patient improvement after conducting different types of physical exercises –32. HoweAlthough anxiety is one symptom that typically improves in most studies on exercise and FM, no significant differences in anxiety were found between groups in our study. The lack of response could be attributed to the short duration of the study, which only lasted two weeks. Studies of longer duration, usually more than eight weeks, have obtained better results , 34.Phytoncides are antimicrobial allelochemic volatile organic compounds derived from plants. Some plants give off very active substances which prevent them from rotting or being eaten by some insects and animals or degraded by bacteria and fungi . Due to When comparing both groups (young/mature forest), the group that walked through the mature forest reported feeling more relaxed than usual, in a statistically significant manner, compared with those who performed the exercise in the young forest. This subjective perception may be related to the alleged benefits of walks through mature woodland. Walking through the forests implies contacting phytoncides produced by trees, as well as enjoying the fresh air, pleasant scenery, and mild climate.Moreover, the health benefits of activities undertaken in forests can be explained by a better mental and breath control, which involves the recovery of homeostasis . “NaturaThese physiological responses to the environment might interact with each other, leading to positive health outcomes. These mechanisms could be explained with respect to the results observed in other epidemiological studies that have reported positive relationships between the environment and health parameters. At present, there is little evidence on the direct benefits of walking through the woods in reducing chronic pain and fatigue in patients with FM .The study has several limitations. First, due to its exploratory nature, it was underpowered to detect minor differences in the primary efficacy variable, which is the FIQR score. Another limitation, as previously stated, was the short duration of the study length. Perhaps greater differences could have been found if the forest had had therapeutic features closer to those of older forest with more evolved natural dynamics. However, such types of forest are very scarce and valuable and are generally located at a considerable distance from urban areas, which would have prevented the study. Finally, phytoncides were not measured in this study which prevents demonstrating their contribution in the alleviation of symptoms in the FM.Nonetheless, the results are encouraging and are consistent with those observed in studies of healthy individuals. As previously mentioned, walking in the woods among phytoncide emanations in a pure environment surrounded by landscapes of scenic quality is part of most forest therapy programs. Further research with programs of longer duration, conducted in more mature forests, would clarify the potential benefit of forests in people with FM. Perhaps these exercises could be a complement to existing therapies.