Methamphetamine (MA) remains one of the most commonly used amphetamine-type stimulants, accounting for the second most widely-used substance after marijuana. Due to increased use of MA, a wide variety of research has focused on the patterns of MA use initiation among adolescents. Nevertheless, there are few data available for people who use MA. The present study set out to assess the sequential patterns of substance use initiation in patients with MA use disorders in Iran.This cross-sectional study described substance initiation patterns for 302 patients who used MA admitted to hospitals and psychiatric centers of Shiraz University of Medical Sciences. The study was conducted between April 2015 and June 2016. After obtaining informed consents, participants were interviewed by trained interviewers using face-to-face, semi-structured interviews. The collecting data were analyzed using the chi square tests and one-way analysis of variance (ANOVA) tests to compare the relationship between qualitative and quantitative variables, respectively.Out of 302 participants enrolled in the study, 16 (5.3%) and 286 (94.7%) were female and male, respectively. The mean age of participants in the study was 37.29 years. The mean age of onset of MA use was found to be 15.9 years. 46.1% of the patients started MA use before 15 years. 77.2% of the patients who used MA had family members with a history of substance use. 93.71% of the patients who used MA started substance use with tobacco, alcohol, or opium, as the most frequent substances. Tobacco, as the first substance or starting substance, exhibited the most widely-used substance (69.53% of the cases). Tobacco-alcohol-cannabis-opium-heroin-MA sequencing was significantly related to the early onset of the substance use. Early-onset substance use was significantly higher in those with lower income, primary education, and family history of substance use. No significant relationship was found between employment status with the age of onset of substance use, and different substance use with marital status.Tobacco, alcohol and opium can be considered as the main sequencing substances for initiation to MA use. Standardized measures to decrease and control access to main starting and sequencing substances, including tobacco, alcohol, and opium, can greatly help decrease the early onset of the MA use, develop suitable prevention, and establish early intervention strategies. Amphetamines, as sympathomimetics and psychostimulants, are the most commonly-used drugs after cannabis in the UK, Australia, and several Western European countries. Methamphetamine (MA), a potent form of amphetamine first made in 1893 by Japanese researcher Nagai Nagayoshi 6 years after the discovery of amphetamine, has been one of the most commonly used amphetamine-like drugs in recent years , 3. GeneMA is used through a variety of routes, including inhalation, smoking, intravenous injection, and oral intake . This whMA is a heavily-abused substance with an estimated 24 million users worldwide, indicating a serious and growing public health issue in a variety of countries . AlthougConsidering the increased prevalence of the stimulant use such as MA in Iran, there is an urgent need to study the sequence and profile of substance use before MA use in Iran. Therefore, the present study was tailored to evaluate the sequential patterns of substance use initiation in patients with MA use disorders in Iran.This study was carried out in accordance with the recommendations of ethical guidelines, IR.SUMS.REC.1394.S1206. The research protocol was approved by Shiraz University of Medical Sciences. All subjects were given written informed consent in accordance with the Declaration of Helsinki.This cross-sectional study was conducted between April 2015 and June 2016 to investigate the substance use in the patients who used MA and to find the sequential patterns of MA use. Our sample consisted of all patients who used MA admitted to hospitals and psychiatric hospitals affiliated to Shiraz University of Medical Sciences, including Ibn-e-Sina Psychiatric Educational Hospital, Hafez Educational Hospital, and Recovery Center during the study period.In the centers that the samples were collected, all the people used substances and almost all the patients used MA. Interviews were conducted by a psychologist or assistant psychologist. The participants were evaluated at one-time point by face-to-face, semi-structured interviews for approximately 20–30 min. Those patients who met DSM5 diagnostic criteria for MA use disorders were included in the study. Only a small number of the patients who did not meet these criteria were excluded from the study (such as those who did not sign the consent form or lacked a good memory). In total, 302 patients  were participated in this study. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines  to strenAge between 18 and 65 years oldMA use over the past year based on DSM5 criteriaDSM5 criteria for MA use disordersPotential participants were eligible for the study if they met the following inclusion criteria:People with cognitive impairment, severe aggression, and psychosis who were unable to cooperate in the interview and whose information was not sufficiently reliable at the time of the interviewDiscontent to participate in the studyPatients were excluded from the study if they met one of the following exclusion criteria:Demographic information including age, sex, marital status, occupation, income, and educationThe history of different types of substance use in the past yearThe age of the first substance useThe first substance usedSequential use of substances from beginning up to now The history of substance uses in the family, the number of family members with substance use, and the type of substances usedPrevious history of admission to Psychiatric HospitalAfter obtaining written informed consent, qualified patients were interviewed and the required information was collected on the basis of a pre-prepared checklist. In-person interview checklist included:The tobacco group: including hookah and cigarettesThe alcohol group: only including alcoholThe cannabis group: including marijuana and cannabisThe opium group: including opium and opium sapThe heroin group: including heroin and crackThe cocaine group: only including cocaineThe Ritalin group: only including RitalinThe MA group: only including MASubstances used were classified according to substance use and drug classification as follows:The sequential patterns for MA use were determined based on the order of substance use in patients who used MA. In the questionnaire, we asked participants specifically about the order of the substances that they used before MA use.P values < 0.05 were considered to be statistically significant.The data were evaluated by SPSS software version 20. The results were analyzed by descriptive statistics, including mean ± standard deviation for quantitative variables and frequency tables for qualitative variables. In addition, chi-square and one-way analysis of variance (ANOVA) tests were used to compare the relationship between qualitative and quantitative variables, respectively. If the result of the ANOVA test was significant, a least significant difference test was applied to locate which of the means differed. A total of 302 participants were enrolled in the study. Table Based on the demographic characteristics, participants were divided into several groups, including the education level ; the monthly income ; the age of onset of substance use ; the substance use in the family ; type of substances used in the family members ; the substance type in the last year ).p ≤ 0.0001). After tobacco, 13.6 and 10.6% of the patients who used MA started substance use with alcohol and opium, respectively, showing statistically significant differences (p ≤ 0.0001). Other substances used included cannabis (3.3%), heroin (1.7%), and MA (1%), respectively. Only one case (0.3%) mentioned Ritalin as the first substance and no one (0%) started substance use with cocaine; in total, 93.71% of the patients who used MA started substance use with tobacco, alcohol, or opium.As shown in Fig. The comparison between heroin and MA use showed that 41 of the patients who used MA started with MA earlier than heroin . In contrast, 190 of the patients who used MA started with heroin earlier than MA .The comparison between cannabis and opium use demonstrated that 92 of the patients who used MA started with cannabis earlier than opium . In contrast, 70 of the patients who used MA started with opium earlier than cannabis .The comparison between cannabis and tobacco use revealed that 167 of the patients who used MA started with tobacco earlier than cannabis . In contrast, 12 of the patients who used MA started with cannabis earlier than tobacco .The comparison between alcohol and tobacco use indicated that 154 of the patients who used MA started with tobacco earlier than alcohol . In contrast, 38 of the patients who used MA started with alcohol earlier than tobacco .The comparison between alcohol and opium use showed that 136 of the patients who used MA started with alcohol earlier than opium . In contrast, 48 of the patients who used MA started with opium earlier than alcohol .The comparison between alcohol and cannabis use showed that 100 of the patients who used MA started with alcohol earlier than cannabis . In contrast, 37 of the patients who used MA started with cannabis earlier than alcohol .A variety of sequencing patterns was obtained in this study, the most common of which included:n = 24).Sequencing D: tobacco-opium-heroin-MA (n = 20).Sequencing F: tobacco-alcohol-cannabis-opium-heroin-MA (n = 19).Sequencing C: tobacco-opium-MA (n = 17).Sequencing E: tobacco-alcohol-opium-heroin-MA (n = 3).Sequencing A: MA (n = 2).Sequencing B: tobacco-MA  (Table The comparison between the age of onset of substance use and current monthly income showed the number of patients who used MA with early onset of substance use was significantly higher in the low-income group (6) Table .Table 3P-value = 0.04).The comparison between the age of onset of substance use and education level showed that the number of patients who used MA with high education was lower in the early-onset group, while the number of patients who used MA with primary education was higher in the early-onset group. These findings were statistically significant (The comparison between the age of onset of substance use and the starting substance type showed no significant relationship. Table The comparison between substance use in the family and different sequences of substance use showed a higher rate of odds ratio (OR) for sequencing C, as a result of which early onset of substance use was correlated with family member uses. In other words, patients who used MA with family history of substance use started MA use earlier than others.P value = 0.03)  Table . The famThe relationship between the use of stimulants in the family, including cocaine, MA, and Ritalin, showed no significant difference between sequences and use of stimulants in the family. No significant relationship was found between employment status and the age of onset of substance use as well as between different substance use and marital status.A number of studies have investigated the sequence of substance use initiation –23, suggOur findings showed early onset of MA use in Iran. This early-onset MA use was significantly higher in those with lower income, primary education, no history of hospitalization, and family history of substance use. Tobacco followed by alcohol and opium, as starting substances, was found to be an important risk factor for MA use disorders. Sequencing D (tobacco-opium-heroin-MA) was the most common sequencing pattern in patients who used MA. Sequencing F  was significantly related to the early onset of MA use.The abuse of substances, including MA, is associated with substantial costs and limited treatment options. Researches on the patterns and sequences of substance initiation provide a far more comprehensive portrait to develop suitable prevention and early intervention strategies.Yen et al. in Taiwan, cigarette was found to be the most commonly used substance, and most adolescents had used cigarette, alcohol, areca quid, and glue before MA use [Brecht et al. in California, tobacco, alcohol, and marijuana were found as a sequencing pattern for MA use in 95% cases [Brecht et al. in California [In the present study, tobacco, followed by alcohol and opium, was found to be the first substance or starting substance used in patients with MA use, serving as a starting substance for initiation to MA use. Tobacco, alcohol and opium accounted for 93.71% of the first substances used by patients who used MA participated in this study. In a study carried out by e MA use . No diffThe tobacco group, including hookah and cigarettes: 96% of the patients who used MAThe heroin group, including heroin and crack: 71.6% of the patients who used MAThe opium group, including opium and opium sap: 49.7% of the patients who used MAThe cannabis group, including marijuana and cannabis: 39.3% of the patients who used MAThe alcohol group, only including alcohol: 32.1% of the patients who used MAThe cocaine group, only including cocaine: 5.3% of the patients who used MAThe Ritalin group, only including Ritalin (methylphenidate): 1% of the patients who used MAPrevalence of substance use in the last year was as follows:Darke et al.in 2012 [The prevalence of substance use in the past year was similar to that found in the study carried out by .in 2012 .Yen et al. in Taiwan was carried out in 2005 while our study was performed in 2016, and the age of onset of substance use decreases over time. In a study conducted by Darke et al.in Australia [In this study, 46.1% of the people who used MA started before 15 years, while 53.9% of them started MA use after 15 years; the mean age of onset of the first substance use was 15.9 years. In the study carried out in Taiwan, 71% of the patients who used MA used substances after 15 years of age ; the reaustralia , the mean = 24), F , C , E , A , and B , respectively. Common sequencing patterns obtained in the study carried out by Yen et al. in Taiwan [n = 12), cigarette-MA (n = 86), cigarette-areca quid-MA (n = 41), cigarette-alcohol-MA (n = 39), alcohol-cigarette-MA (n = 12), cigarette-areca quid-alcohol-MA (n = 39), cigarette-alcohol-areca quid-MA (n = 39), and alcohol-cigarette-areca quid-MA (n = 9). The difference between the sequence patterns can be attributed to the high prevalence of opioid use in Iran and the high prevalence of other substances such as Areca quid in Taiwan. However, the first 4 sequencing patterns showing high prevalence started with cigarettes both in the present study and in the study conducted in Taiwan [Commonly-used sequencing patterns obtained in this study included D , but in the study carried out in Taiwan , none ofDarke et al. in Australia [Brecht et al. in California [The comparison between the sequencing patterns of tobacco and cannabis use indicated that most patients who used MA 93.29%) used tobacco earlier than cannabis, which was consistent with the study conducted by ustralia . Inconsi3.29% uselifornia .The comparison between the sequencing patterns and the age of onset of substance use showed that sequencing F  was significantly related to early onset of substance use. This means that patients who used MA with lower age of onset used more substances before starting MA use. This finding was consistent with the studies carried out in Taiwan  and AustRussell et al., a significant relationship was found between MA use and lower education, showing that patients who used MA generally had a lower education level [In this study, there was a significant relationship between early onset of substance use and education; early onset of substance use was found in the patients who used MA with low educational levels while late onset of substance use was found in those with higher educational levels. In a study performed by on level . The higon level , in whicRussell et al. [Svingen et al. in Nebraska [In the present study, early onset of MA use was associated with a family history of substance use; in other words, patients who used MA with a family history of MA use started MA use earlier than other substances. In addition, sequencing F was also significantly associated with the greater number of family members with a history of substance use. In the studies carried out by l et al.  and SvinNebraska , a signiNebraska ; the resDarke et al. in Australia [The early age of onset of substance use was significantly associated with low monthly income. In most similar studies, the role of income levels was not investigated because those studies have chosen their samples from adolescents and only one study was presented descriptive income sources. In the study carried out by ustralia , 88, 21,To the best of our knowledge, this is the first study to examine the sequencing patterns of MA use, which can be the basis for future studies. However, the present study had some potential limitations, including the use of self-reporting, social desirability, selection bias and the low number of participants, especially female gender; the latter limitation led to no gender comparisons for variables. Therefore, the results may limit the generalizability of the results to some extent.The present study is the first study to examine the sequential patterns of substance use for MA disorders in Iran. In this study, the early-onset MA use was significantly higher in patients who had lower income, primary education, no history of hospitalization, and family history of substance use. Tobacco, alcohol and opium were found to be as a sequential pattern for initiation to MA use.Tobacco-alcohol-cannabis-opium-heroin-MA sequencing was significantly related to the early onset of the MA use.Findings from this study may support targeted prevention efforts and development of more effective interventions. Standardized measures to decrease and control access to main starting and sequencing substances, including tobacco, alcohol, and opium, can not only greatly help decrease the early onset of the MA use, but also lead to development of suitable prevention and early intervention strategies. In addition, programs focusing on increasing knowledge and changing the attitudes of adolescents toward drug abuse can assist to prevent MA use through decreased use of these substances in the society. However, because of gender limitations, it is recommended to include more women users in future studies in order to make gender comparisons possible.


Sulindac has been used for treating colorectal polyps widely. However, the efficacy and safety of sulindac for colorectal polyps are unclear. This study aims to evaluate the efficacy and safety of sulindac for colorectal polyps.Randomized controlled trials of sulindac in the treatment of colorectal polyps will be searched in PubMed, EMbase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), WanFang, the Chongqing VIP Chinese Science, and Technology Periodical Database, and China biomedical literature database (CBM) from inception to August, 2020. And Baidu Scholar, Google Scholar, International Clinical Trials Registry Platform, and Chinese Clinical Trials Registry will be searched to obtain more relevant studies comprehensively. Two researchers will perform data extraction and risk of bias assessment independently. Statistical analysis will be conducted in RevMan 5.3.This study will summarize the present evidence by exploring the efficacy and safety of sulindac in the treatment of colorectal polyps.The findings of the study will provide helpful evidence for the efficacy and safety of sulindac in the treatment of colorectal polyps, facilitating clinical practice and further scientific studies.The private information from individuals will not publish. This systematic review also will not involve endangering participant rights. Ethical approval is not required. The results may be published in a peer-reviewed journal or disseminated in relevant conferences.DOI 10.17605/OSF.IO/N5GDH It may be associated with a high-fat, high-protein diet and lack of physical activity. A number of studies have also shown that metabolic syndrome-related indicators such as blood lipid, blood glucose, and body mass index are correlated with colorectal polyps.,4The colorectal polyp is a mass protruded from the surface of the colorectal. It may be an adenoma or a hypertrophy of the intestinal mucosa, collectively known as a polyp until its pathological nature is determined. Polyps are solitary or multiple, and hereditary or nonhereditary. Depending on the severity of symptoms, polyps can be treated with Chinese and Western medicine, colonoscopy, laser, freezing, ligation, and transabdominal or transanal methods. A number of current epidemiological and laboratory studies have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit or even reverse precancerous lesions in colorectal cancer, and some prospective studies have shown that sulindac reduces the number and size of colorectal polyps in patients with colorectal cancer, especially familial adenomatous polyposis (FAP).,8 However, there is no systematic review and meta-analysis regarding the efficacy and safety of sulindac for colorectal polyps. Thus, this study will assess the efficacy and safety of sulindac for colorectal polyps.The formation mechanism of colorectal polyps is complex and affected by a variety of factors. Over a long period of time, various pathogenic factors may act independently or synergistically at different stages, eventually causing cell canceration. Some polyps can develop into colorectal cancer, and colorectal cancer is the third most common cancer worldwide and the second leading cause of cancer-related deaths. Early detection and treatment are the key to improve prognosis. Resection or chemotherapy of colorectal polyps is particularly important.22.1This protocol of systematic review and meta-analysis has been drafted under the guidance of the preferred reporting items for systematic reviews and meta-analyses protocols (PRISMA-P). Moreover, it has been registered on open science framework (OSF) on August 26, 2020. (Registration number: DOI 10.17605/OSF.IO/N5GDH)2.2Ethical approval is not required as there is no patient recruitment and personal information collection, and the data included in our study are from published literature.2.32.3.1Randomized controlled trials (RCTs) including sulindac for colorectal polyps will be included. The language will be limited to Chinese and English.2.3.2 regardless of nationality, race, age, sex, and source of cases.All the included cases conform to the “guidelines for management of colorectal polyps,”2.3.3The control group was treated with placebo or no medication; the treatment group was treated with sulindac. The duration of treatment in both groups was not limited.2.3.4The main outcome measures were clinical efficacy and polyp disappearance rate. Invalid: the patient's condition was not improved or even aggravated. Effective: the clinical symptoms and signs such as diarrhea or increased frequency of defecation, abdominal tenderness, and other clinical symptoms and signs were alleviated, and the scores of clinical indicators were improved by 50% ∼ 79%; Significant effect: the clinical symptoms and signs such as diarrhea or defecation frequency increased, abdominal tenderness and other clinical symptoms and signs were significantly reduced, and the scores of clinical indicators were improved by >80%. Total effective = significant effective + effective.Secondary outcome measures were adenoma diameter change and adverse reactions. ① Polyp characteristics: the pathological type of polyps, the number and size of colorectal polyps, the degree of atypical hyperplasia of colorectal polyps. According to the World Health Organization (WHO) classification, the degree of atypical hyperplasia is divided into mild and severe. The adverse pathological features were defined as intraepithelial neoplasia with a diameter of >1 cm or a high degree of atypia. ② Drug safety and adverse reactions: the adverse drug reactions of sulindac in the study group were monitored by outpatient review and emergency telephone emergency system every 6 months.2.4The treatment group used other drugs, such as aspirin, ibuprofen, naproxen, and so on;The outcome indicators of the original study did not meet the requirements;As for duplicate published literature, select the literature with the most complete data;Literature with incorrect or incomplete research data that cannot be obtained after contacting the author.2.5PubMed, EMbase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), WanFang, the Chongqing VIP Chinese Science and Technology Periodical Database, and China biomedical literature database (CBM) were searched by computer to collect RCTs of sulindac for colorectal polyps, and the retrieval time was from the establishment of each database to August 2020. At the same time, search Baidu, Google Scholar, International Clinical Trials Registry Platform (ICTRP), and Chinese Clinical Trials Registry (ChiCTR) to get more comprehensive data. Keywords were “intestinal polyps,” “colorectal polyps,” “familial adenomatous polyposis,” “sporadic colorectal polyps,” “sulindac,” and so on. PubMed retrieval strategies are shown in Table 2.6Endnote X7 was used for literature management. Two researchers independently screened the literature, extracted the data, and cross-checked them. In case of disagreement, the third researcher was consulted to assist in judgment, and the lack of data was contacted with the author as much as possible to supplement. In the process of literature screening, first read the title and abstract, and then read the full text after excluding the obviously unrelated literature to determine whether it is included. Excel 2019 was used to set up a data extraction table to extract data.The extraction contents were as follows: ① included basic research information ; ② information about intervention measures ; ③ risk evaluation items of bias in RCTs; ④ Related outcome indicators. The literature screening process is shown in Figure 2.7Two researchers independently evaluated the risk of bias in RCTs in accordance with the Cochrane Handbook of Systematic Reviewers, including the following items: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other bias. The quality of studies was classified as being at of high, unclear, or low risk of bias. In case of disagreement, a third researcher decided.2.82.8.1Q test was used to qualitatively determine inter-study heterogeneity. If P ≥ .1, there was no inter-study heterogeneity, If P < .1, it indicated inter-study heterogeneity. At the same time, I2 value was used to quantitatively evaluate the inter-study heterogeneity. If I2 ≤50%, the heterogeneity was considered to be good, and the fixed-effect model was adopted. If I2 > 50%, it was considered to have significant heterogeneity, the source of heterogeneity would be explored through subgroup analysis or sensitivity analysis. If there was no obvious clinical or methodological heterogeneity, it would be considered as statistical heterogeneity, and the random-effect model would be used for analysis. Descriptive analysis was used if there was significant clinical heterogeneity between the 2 groups and subgroup analysis was not available.The RevMan 5.3 software provided by the Cochrane Collaboration was used for statistical analysis. ① For dichotomous variables, relative risk (RR) was used for statistics. For continuous variables, weighted mean difference was selected when the tools and units of measurement indicators are the same, and standardized mean difference was selected with different tools or units of measurement, and all the above were represented by effect value and 95% confidence interval. ② Heterogeneity test: 2.8.2If data are missing or incomplete, we will contact the relevant authors to obtain the data. If not, this study will be removed.2.8.3To reduce the clinical heterogeneity between studies, subgroup analysis was conducted according to the age, which was divided into minors, adults, and the elderly. Subgroup analysis was carried out for the included studies according to the types of colorectal polyps.2.8.4To test the stability of meta-analysis results of indicators, a one-by-one elimination method will be adopted for sensitivity analysis.2.8.5For the major outcome indicators, if the included study was ≥10, funnel plot was used to qualitatively detect publication bias. Egger and Begg test are used to quantitatively assess potential publication bias.2.8.6 And the quality of evidence will be rated as high, moderate, low, and very low.The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) will be used to assess the quality of evidence. It contains 5 domains .3Colorectal polyp is a common disease of digestive tract, which can be divided into non-neoplastic and neoplastic. Non-neoplastic polyps mainly include inflammatory polyps, proliferative polyps, and juvenile polyps. The etiology of colorectal polyp mostly comes from gene mutation, gene suppression, and family inheritance. For example, familial adenomatous polyposis and Gardner syndrome are caused by gene mutation; the pathogenic gene of Peutz-Jeghers syndrome may be a tumor suppressor gene; Turcot syndrome and juvenile polyp are familial genetic diseases. Neoplastic polyps mainly refer to adenomatous polyps, with a high probability of canceration, which is the most important precancerous disease of colorectal cancer and has a rising trend in recent years.,13 Studies have confirmed that NSAIDs have a very significant protective effect on intestinal polyps, colon cancer, and rectal cancer, which can reduce the risk of intestinal polyps by 78%, colon cancer by 87%, and rectal cancer by 85%. However, smoking and drinking are also risk factors, whereas eating bean products and vegetables are protective factors. Therefore, when using such drugs to prevent the above diseases, we should pay attention to personal life and behavior habits. If we can cooperate with abstinence, quit smoking, and eat bean products and vegetables properly, we should also pay attention to the protection factors. In vitro studies also showed that NSAIDs and cyclooxygenase-2 (COX-2) inhibitors could inhibit the formation of colorectal tumors by inhibiting cell proliferation, inducing apoptosis, inducing cell cycle arrest, and interfering with tumor angiogenesis through cox-dependent and nondependent mechanisms.,15Clinical studies have shown that long-term use of natural or synthetic drugs, such as NSAIDs, may prevent polyps from developing in the colon, this effect known as chemoprophylaxis. reported that sulindac had a regression effect on FAP patients. Researchers have found that the effect of sulindac in FAP patients act after 3 months. Polyps were significantly subsided in all patients after taking sulindac for 12 months, regardless of whether they had undergone surgery. Long-term maintenance therapy with sulindac can reduce the number of residual colorectal adenomas, the degree of heteromorphism and the proportion of villous tubular adenoma in patients, which may delay or prevent the occurrence of colon cancer. Piazza found that sulindac derivatives did not promote the differentiation of adenoma cells during cell culture, and induction of apoptosis was one of the main mechanisms. It was further speculated that sulindac may reduce the degree of adenoma atypia by inducing apoptosis of adenoma cells. So far, although sulindac is not enough to replace surgery, patients still need to regularly review colonoscopy, but it can be used as a beneficial supplement to surgical treatment.Sulindac is a precursor drug with minimal activity, which can be metabolized into active sulfide after entering the human body. It can inhibit cyclooxygenase and reduce the synthesis of prostaglandins, thus has analgesic, anti-inflammatory, and antipyretic effects. As early as 1983, Waddell and LoughryHowever, there is no systematic review and meta-analysis assessing the efficacy and safety of sulindac for colorectal polyps. This is the first protocol for systematic review and meta-analysis evaluating the efficacy and safety of sulindac for colorectal polyps. This systematic evaluation and meta-analysis can provide evidence-based evidence for clinicians to use sulindac in the treatment of colorectal polyps. However, the study has some limitations. Due to different dose and course of sulindac for colorectal polyps, the results were affected and the bias was caused. In addition, we only search for articles in Chinese and English, which may cause certain publication bias.Data collection: Qing Long and Liang Ao.Data curation: Qing Long, Liang Ao.Formal analysis: Qing Long.Funding acquisition: Yan Li.Funding support: Yan Li.Literature retrieval: Liang Ao and Kuo Li.Resources: Liang Ao, Kuo Li.Software: Liang Ao.Supervision: Yan Li.Writing – original draft: Qing Long and Liang Ao.Writing – review & editing: Qing Long and Yan Li.


Depression is a common disease which occurs after stroke, affecting approximately one third of stroke survivors at any 1 time after stroke (compared with 5%–13% of adults without stroke), with a cumulative incidence of 55%. Acupuncture, which has a long history in China, is the generic name of different kinds of acupuncture therapies, including manual acupuncture (MA), electroacupuncture (EA), fire needle (FN), dry needling (DN), and so on. Clinical studies have shown that acupuncture has a good therapeutic effect on post stroke depression (PSD), but the evidence-based medicine of it is insufficient. The purpose of this study is to systematically evaluate the efficacy of different kinds of acupuncture therapies in the treatment of PSD, and to provide evidence-based basis for the clinical application of acupuncture in the treatment of PSD.A systematic search will be performed on English databases  and Chinese databases , WanFang Data, VIP and Chinese biomedical databases). The retrieval time limit will be from the establishment of the database to August 2020. Two researchers will independently screen the literatures, extract data, and evaluate the quality of the included studies. Bayesian network analysis will be conducted by using STATA V.14.0 and ADDIS V.1.16.7.In this study, the efficacy of different kinds of acupuncture therapies in the treatment of PSD will be evaluated by the degree of reduction in depression, total numbers of adverse events, quality of life indices, improvement of social and life functions and the expression of nerve cell factors.This study will provide reliable evidence-based evidence for the clinical application of acupuncture in PSD. Although antidepressant drugs may benefit people with persistent depressive symptoms after stroke, it should be used with caution, as little is known about the side effects. A large Cochrane systematic review including 63 trials with 9168 ischemic or hemorrhagic stroke survivors showed that there was not enough reliable evidence to support using SSRIs as the routine drugs to promote recovery after stroke, although it could reduce the average depression score. What is more, no clear consensus has been reached regarding to the timing of antidepressants or the discontinuation of adjunctive psychotropics in the treatment of depression. In the future, greater efforts are required to improve the diagnosis and management for PSD.Few guidelines exist regarding the assessment, treatment, and prevention of post stroke depression (PSD).1.2 suggested that there were clear dose-response relationships between menstrual pain outcomes and acupuncture “dose”, including type of acupuncture therapy, needle location, number of needles used, and frequency of treatment. However, little research has been conducted to directly examine effects on clinical outcomes when these parameters of acupuncture are changed.Acupuncture, which has a long history in China, is the generic name of different kinds of acupuncture therapies, including manual acupuncture (MA), electroacupuncture (EA), fire needle (FN), dry needling (DN), and so on. MA is most used as research object to study the therapeutic effect of acupuncture. Different kinds of acupuncture therapies may differ in their effectiveness, a narrative review which included 63 trials with 7060 participants examined the effectiveness of acupuncture for depression, and found that severity of depression was significantly reduced during treatment for acupuncture compared with no treatment/wait list/treatment as usual. However, the possible benefit of acupuncture provided alone or in conjunction with pharmaceutical medication such as SSRIs compared with pharmaceutical monotherapy is unclear, mostly due to the very low quality of available evidence. In the other hand, there were less reviews focused on the effectiveness of acupuncture in treating PSD. An overview of meta-analysis result of acupuncture in the treatment of PSD showed that acupuncture was potentially effective and safe monotherapy for post stroke depression, however, there were insufficient researches in this area. What is more, most of the meta-analysis did not attach importance to the comparison of different acupuncture therapies.,18In recent years, improving depressive symptoms by acupuncture therapies have received more and more attention. A Cochrane review1.3Objectives of this systematic review and network meta-analysis are to:1.compare and rank all acupuncture therapies in terms of efficacy in the treatment of PSD; and2.explore the relationship between acupuncture “dose” and the depression improving outcome.2Because it is a network meta-analysis, there is no need for ethics.2.1This network meta-analysis has been registered on INPLASY network (Registration number: INPLASY2020100104).2.22.2.1Randomized controlled trials (RCTs) in English or Chinese will be included. There are no restrictions on publication date. Animal studies or studies with incomplete data will be excluded.2.2.2 the Diagnosis and Statistical Manual of Mental Disorders (DSM), Chinese Classification of Mental Disorders (CCMD), or the 17-item Hamilton Rating Scale for Depression (HAMD-17).We will include RCTs that involved patients who suffered post stroke depression. The diagnosis of stroke should base on computer tomography (CT), magnetic resonance imaging (MRI), or clinical criteria. Meanwhile, depression were diagnosed according to the International Classification of Diseases, Tenth Edition (ICD-10),2.2.3The RCTs with experiment group(EG) and control group(CG) meeting one of the following conditions will be included:1.the intervention of EG is the therapy based on acupuncture, the intervention of CG is SSRIs;2.using acupuncture plus placebo as the intervention of EG, and SSRIs plus sham acupuncture as the or the intervention of CG3.using different kinds of acupuncture therapies as the intervention of CG and EG respectively. as the common comparison object, in order to achieve the comparison between different kinds of acupuncture therapies.Our selection of acupuncture therapy for analysis will include MA, EA, FN, DN, laser needle(LN), or the combination of different kinds of acupuncture therapies, regardless of acupoint selection or acupuncture manipulation. According to our preliminary search result in the database, we found that there were few trials focused on the comparison between different kinds of acupuncture therapies, whereas more trials were focused on the comparison between acupuncture and western medicine. Therefore, we chose the SSRIs which had become the first-line antidepressant medication class over the last quarter of a century2.2.4Primary outcomes1.Degree of reduction in depression, measured by self-rating scales such as Beck Depression Inventory (BDI) or clinician-rated rating scale such as Hamilton Depression Rating Scale (HAMD);2.Total numbers of adverse events.Secondary outcomes1.Quality of life indices such as the World Health Organization Quality of Life (WHOQOL);2.Improvement of social and life functions such as Activity of Daily Living Scale (ADL);3.The expression of nerve cell factors, such as serotonin (5-HT), IL-23.There are several scales used for assessment of depression, for example HAMA, MADRS, SDS, BDI, if 2 or more scales are used in a research, we apply the following hierarchy:1.HAMD,2.MADRS;3.CGI-S;4.BDI;5.PHQ and6.All other depression scales.If researchers used more than 1 quality of life measure, we apply the following hierarchy of scales:1.World Health Organization Quality of Life,2.WHO Quality of Life-BREF (WHOQOL-BREF),3.Short Form Health Survey and4.Any other quality of life measures used.2.2.5The following databases will be searched from inception to July 2020: PubMed, The Cochrane Library, Medline, Embase, China National Knowledge Infrastructure (CNKI), WanFang Data, VIP and Chinese Biomedical Databases. The combination of free words and medical subject headings, including “depression, depressive disorder, acupuncture therapy, acupuncture, electroacupuncture, dry needle, stroke, etc”, will be used as the retrieval mode. The search strategy for PubMed is shown in Table 2.2.6NoteExpress V.3.2 will be used to manage studies. First, duplicate literature will be removed through electronic/manual-based steps in NE. Second, 2 reviewers will independently screen the study article titles and abstracts and select the studies which meet the eligibility criteria. If there are disagreements, the third reviewer should be consulted. Two reviewers independently extracted the general information of the included studies. Extracted data include authors, year of publication, sample size, source of diagnosis, the observation period, interventions and test results of all groups. If there is any necessary data missing, corresponding authors will be contacted and asked to provide relevant details. Some studies will be excluded if the full text or data are unable to get access and the reasons for exclusion will be reported in detail in these cases.http://www.prismastatement.org). The literature screening process is shown in Figure The entire process will be presented by the PRISMA flow chart (2.2.7https://training.cochrane.org/handbook/current/chapter-08), the methodological quality and the risk of bias of the included studies by means of the risk of bias 2.0(ROB 2.0) tool. One researcher assessed the risk of bias of included studies by using ROB 2.0 and the other researcher confirmed the judgment. Any differences will be resolved through discussions with the third researcher. The following items were categorized as having high, low or unclear risk of bias: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other biases which focusing on baseline imbalance.According to Cochrane Handbook for Systematic Reviews of Interventions version 6 or standardized mean differences (SMDs), meanwhile, binary outcomes will be calculated as odds ratios (ORs).Bayesian network analysis will be conducted to compare the effects of different acupuncture therapies. STATA V.14.0 and ADDIS V.1.16.7 will be used to perform the network meta-analysis. We will use the  The simulation iteration number will be set to 50,000 and the tuning iteration number will be initially set to be 20,000. Meanwhile, the Bayesian approach will also be used to estimate the rank probabilities. A rank probability plot will be given to show the priority of different acupuncture therapies.The results of node splitting will be used to evaluate the inconsistency between direct and indirect evidence. If there is no relevant inconsistency in the evidence, a consistency model can be used to draw conclusions about the relative effect of the included treatments. Convergence is assessed using the Brooks-Gelman-Rubin method, which could compare the within-chain and between-chain variance to calculate the Potential Scale Reduction Factor (PSRF).Evidence supporting the relationships of the included studies will be determined by analysis of a network plot, and resultant figures and network meta-analysis graphs will be presented.2.2.9https://gradepro.org/). GRADE approach provides guidance for rating quality of evidence and grading strength of recommendations in health care. It has important implications for those summarizing evidence for systematic reviews. It assessed a body of evidence by referring to the concepts of the GRADE system, and determined and recorded the quality of a body of evidence for each clinical question, there are 4 quality levels: high, moderate, low, and very low.The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach will be used to assess the quality of evidence for main outcomes. Two reviewers will do this independently through GRADEpro GDT (3,27 suggest that the severity of disability after stroke correlates with the degree of depression. Clinical studies have shown that at the similar stroke level, PSD patients showed a significant decline in activity of daily living and a more severe degree of handicap than non-PSD patients. PSD may also aggravate cognitive impairment in stroke patients.PSD affects the prognosis of patients. Some evidences On the one hand, acupuncture can assist in eliminating bad emotions by significantly improving the functional communication and language function, cognitive and limb movement function of stroke patients. On the other hand, acupuncture can modulate glutamate receptor and EAAT expression, down-regulated the levels of NF-κB protein, iNOS and NO, so as to achieve the purpose of relieving PSD.In China, acupuncture, an important part of TCM, is commonly used in hospitals as an important role in clinical treatment.As far as we know, NMA has not been used to compare the effectiveness of different acupuncture therapies for PSD in recent years. Furthermore, we will use the GRADE approach to assess the quality of evidence for main outcomes. But the limitation of language will lead to some bias. Besides, the lack of literature on acupuncture treatment of PSD which are large sample size and high quality may affect the authenticity of this study.Data curation: Chang Rao, Wei Liu.Funding acquisition: Yuzheng Du.Investigation: Jipeng Yang.Resources: Zefang Li, Xi Nan.Software: Zefang Li, Xi Nan, Chunsheng Yin.Supervision: Yuzheng Du.Writing – original draft: Chang Rao, Wei Liu.Writing – review & editing: Chang Rao, Wei Liu.


Brucella DNA in investigated samples. Anti-Brucella antibodies were detected in 37 (21.02%) bovine milk samples using MRT and in 66 (16.4%) and 71 (17.7%) bovine sera using RBPT and i-ELISA, respectively. Real-time PCR detected Brucella DNA in 31 (7.71%) from a total of 402 bovine sera and identified as Brucella abortus. Seroprevalence and molecular identification of bovine brucellosis varied in some regions in Pakistan. With the use of machine learning, the association of test results with risk factors including age, animal species/type, herd size, history of abortion, pregnancy status, lactation status, and geographical location was analyzed. Machine learning confirmed a real observation that lactation status was found to be the highest significant factor, while abortion, age, and pregnancy came second in terms of significance. To the authors' best knowledge, this is the first time to use machine learning to assess brucellosis in Pakistan; this is a model that can be applied for other developing countries in the future. The development of control strategies for bovine brucellosis through the implementation of uninterrupted surveillance and interactive extension programs in Pakistan is highly recommended.Bovine brucellosis is a global zoonosis of public health importance. It is an endemic disease in many developing countries including Pakistan. This study aimed to estimate the seroprevalence and molecular detection of bovine brucellosis and to assess the association of potential risk factors with test results. A total of 176 milk and 402 serum samples were collected from cattle and buffaloes in three districts of upper Punjab, Pakistan. Milk samples were investigated using milk ring test (MRT), while sera were tested by Rose–Bengal plate agglutination test (RBPT) and indirect enzyme-linked immunosorbent assay (i-ELISA). Real-time PCR was used for detection of  Brucella , Pakistan . These tGujranwala  is located north of the nearby provincial capital of Lahore. The city is Pakistan's fifth most populous metropolitan area. According to the 9211 Virtual Governance System, the livestock of this district include cattle , buffaloes , sheep , goats , equines , and camels (78 only).Gujrat  is situated at the shore of the river Chenab along the nearby cities of Sialkot and Gujranwala and forms part of the so-called “Golden Triangle” of industrial cities with export-oriented economies. According to the 9211 Virtual Governance System, the livestock of this district includes cattle , buffaloes , sheep , goats , equines , and camels (62 only).https://irrigation.punjab.gov.pk/).Important livestock breeds of these districts are Sahiwal and cross-bred cattle, Nili Ravi buffaloes, Teddy and Beetal goats, and Lohi and Kajli sheep. The prevalent diseases of these regions related to livestock are milk fever, mastitis, Degnala disease (aspergillosis), bovine ephemeral fever, contagious caprine pleuropneumonia (CCPP), peste des petits ruminants (PPR), hemorrhagic septicemia (HS), and foot and mouth disease (FMD). Vaccination to these diseases  is applied . The lanThis study was approved by the ethical committee of the College of Veterinary & Animal Sciences, Jhang University of Veterinary & Animal Sciences, Lahore, Pakistan via approval number CS/481. Oral and written consent was also taken from each farmer before blood and milk sample collection.Bos taurus, n = 208) and domestic water buffaloes  located in the districts of Narowal, Gujranwala, and Gujrat in the period March to October 2015. Approximately 4–5 ml of blood were collected aseptically from the jugular vein of each animal in a blood vacutainer containing gel with clot-activating factors  that were placed at room temperature for more than 0.5 h and stored immediately at 4°C in an icebox and were transported to the Epidemiology and Public Health Laboratory, College of Veterinary and Animal Sciences, Jhang, Pakistan. All tubes were centrifuged  at 5,000 rpm for 5 min for serum separation. After centrifugation, the supernatants were collected in sterile Eppendorf tubes (1.5 ml) by pipettes and stored at −20°C for further analysis.In this study, 402 blood samples were collected from cattle  and descriptive epidemiological data related to risk factors  were collected using a pre-structured questionnaire .Milk samples were investigated by milk ring test (MRT). The MRT antigen was procured from the Veterinary Research Institute Lahore, Pakistan. As per the manufacturer's recommendations, the MRT antigen was kept at room temperature 1 h before use. The MRT antigen was standardized against the OIE International Standard Serum (OIEISS) to give a positive result at an OIEISS dilution of 1:500 and a negative reaction at 1:1,000. One milliliter of milk sample was added to a test tube, and then 30 μl of antigen was added, mixed, and incubated at 37°C for 1 h. A sample having a change in color at the top of milk was considered positive .Brucella antibodies by Rose–Bengal agglutination test (RBPT)  and i-ELISA  according to the manufacturer's recommendations. The RBPT antigen was standardized against the OIEISS to give a positive reaction at a dilution of 1:45 and a negative reaction at a dilution of 1:55. The i-ELISA was calibrated according to the OIE specifications to correctly detect the OIE ELISA strong positive standard serum (OIEELISAspSS)  according to the instructions of the manufacturer.Brucella and species-specific (Brucella abortus and Brucella melitensis) real-time PCRs were used for the detection of Brucella DNA (Genus ella DNA . PCR wasB. abortus and B. melitensis) (B. abortus S-99 (ATCC 23448), B. melitensis 16M (ATCC 23456) and Brucella suis biovar 1 (ATCC 23444) were used as positive controls. Reference strains of Escherichia coli (ATCC 25922), Staphylococcus aureus (ATCC 25923), and Ochrobactrum intermedium (DSM 17986) were used as negative controls.The PCR protocol was modified (volume and temperature) than previously published to obtain the most optimal results where DNA used in this study as template was extracted from serum not from bacterial colonies. Briefly, PCR reaction was performed in 15 μl of multiplex PCR mixture with 2× TaqMan™ environmental master mix , 0.2 μM of each primer, 0.1 μM of each probe, and 5 μl of template DNA. Amplification and real-time fluorescence detection were carried out on a StepOnePlus™ Real-Time PCR System . The reaction conditions were as follows: decontamination at 50°C for 2 min, initial denaturation at 95°C for 10 min followed by 50 cycles of denaturing at 95°C for 25 s, and annealing/elongation at 57°C (itensis)  for 1 miBrucella DNA was analyzed using Pearson's chi-squared test (χ2). The estimation of χ2 was done using RStudio Version 1.1.463.Correlation of potential risk factors  with molecular detection of Machine learning has been used widely in prediction, clustering, and classification based on features. One of the powerful machine learning techniques is decision tree , which iDecision tree technique is not only a classifier but also a model that can be visually seen and easily understood, which is important to the inferences beyond the model. It also explains the rules used for dividing data using inferred rules for this division. The aim was to predict a value of certain variables based on a created model. It uses training samples consisting of features (attributes). The data were divided into subsets, where data in lower subsets were purer than data in upper subsets. The attribute chosen to be represented in a node was the attribute with the highest information gain (Gini) of all attributes. The resulted model was represented in a tree-like shape, where internal node was a test conducted on an attribute, branches were the results of the test, and leaf nodes represented the decision taken. A pipeline was proposed by Fountain-Jones et al.  for usinAll features are categorical so they need to be encoded or converted to numeric values. This conversion is shown in The data were divided into a training set of 281 cases (70%) and a test set of 121 cases (30%). Three different runs have been conducted on the features, and the results of three serum tests RBPT, i-ELISA, and real-time PCR were used as the independent variable. Three different trees resulted from the experiment and are shown in Performance of the machine learning model was evaluated to find out if it actually worked and if it gave trustworthy predictions on new data other than the data it was trained on. The performance metrics precision or positive predicted value (PPV), recall or negative predicted value (NPV), accuracy, and area under the receiver operating characteristic curve (AUC ROC) were calculated from prediction scores for the serum tests RBPT, i-ELISA, and real-time PCR.Brucella antibodies were detected in 19 (17.7%) and 18 (26.08%) of 107 from cattle and 69 from buffaloes milk samples, respectively  were positive. Anti-ectively . Moreoveectively . A higheectively .Twenty eight animals were positive to all the three tests . The reaA total of 176 lactating animals were additionally tested by MRT. The test detected one animal exclusively and another animal that was only positive on the real-time PCR . On the Brucella DNA was detected in serum samples positive by RBPT or i-ELISA. Brucella abortus DNA was identified in 31 (7.7%) bovine sera (Brucella DNA was not amplified from seronegative serum samples. A higher number of Brucella DNA positive samples were detected in 18 (9.27%) buffaloes than in 13 (6.25%) cattle. Brucella DNA was amplified from 8.21, 7.46, and 7.46% of bovine sera from Narowal, Gujranwala, and Gujrat districts, respectively.ine sera . BrucellThe risk factors geographical location, animal species, age, herd size, and reproductive disease/problem revealed no statistical significance by Pearson's chi-squared test with diagnostic test results  as shown in The evaluation parameters of machine learning model revealed that the three tests recorded performance metrics very close to each other . The PPVComparing the results of the three models of diagnostic tests –4 revealBrucella spp. in various farm animals and wildlife species highlights their role in disease spread  highly cross-react. Isolation and identification of the etiological agent from biological specimens remain the “gold standard” for epidemiological investigation and determination of antimicrobial resistance, but these methods are time-consuming and hazardous. The detection of Brucella DNA by PCR in clinical samples is a preferred tool for conclusive diagnosis of brucellosis  higher in buffaloes than in cattle  and serum samples (17.7% by i-ELISA) found in this study are slightly higher than in previous reports on bovine brucellosis (0–15%) in Pakistan , 21, 40..02% and n cattle . Cattle n cattle , 41, 42.n cattle . The pheBrucella is an environmental contaminant, as illegal disposal of infected materials contributes to the spread of disease as known for the River Nile and its canals in Egypt  are used to rear animals in small and medium herds. These areas are irrigated by canals and the rivers of Ravi and Chenab to support the economical production of livestock. This study found a lower disease frequency in regions with a dry environment than in those regions that have access to rivers/irrigation water. This points to the fact that in Egypt . Insteadin Egypt .Statistical association of risk factors with brucellosis test results  was studied using chi-squared test. There was no significant relationship recorded . The autAfter building the machine learning model based on decision tree, it was then necessary to assess its performance before its application on the data . Each ofBrucella antibodies were detected in lactating and pregnant animals. These findings are in agreement with reports from India, Zimbabwe, and Sudan, where the risk of brucellosis increased in pluriparous cows , respectively. These are the cardinal symptoms of Ethiopia , 56, 57.Ethiopia , 51, 52.Brucella-positive animals must be prohibited, and a compensation policy must be brought into force to get acceptance of farmers for these measurements. Additionally, biosafety and biosecurity practices must be set in force to decrease the incidence of brucellosis (The determination of brucellosis prevalence and associated risk factors is an important determinant to predict the epidemiological status of the disease. Eradication of brucellosis is only possible when positive animals are culled. Consequently, the trade or movement of cellosis .Not only surveillance and vaccination still remain uncoordinated, but they also constitute a financial limitation in developing countries. Therefore, brucellosis control should take good advantage of the rapid progress in the field of artificial intelligence including machine learning for computational analysis of big epidemiological data aiming for more effective disease management. Machine learning, as one of the necessary components for digitalization of animal health, is expected to open up many possibilities that boost precision livestock industry, health, and well-being, offering new opportunities for future farms.Brucella abortus was identified as a causative agent of bovine brucellosis in upper Punjab, Pakistan. Animals without any sign of illness may remain carriers shedding brucellae into the environment. Machine learning results revealed that the lactation status was the root node in all tests supporting the real findings, while age, abortion, and pregnancy were located in a lower level of significance. To the authors' best knowledge, this is the first time to use machine learning to assess brucellosis risk factors in Pakistan, a model that can be applied for other developing countries in the future. Elimination of positive shedders, development of control strategies, and interactive extension programs for brucellosis are urgently needed in developing countries like Pakistan.Brucellosis remains a lingering infection jeopardizing dairy herds in Pakistan. The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This study was approved by the ethical committee of the College of Veterinary & Animal Sciences, Jhang- University of Veterinary & Animal Sciences, Lahore, Pakistan via approval number CS/481. Oral and written consent was also taken from each farmer before blood and milk sample collection.Data curation was carried out by AK. Formal analysis was performed by AK, AS, and AH. Investigation was done by AK, IK, SE-u-H, UW, MF, SA, and HE-A. Methodology was provided by AK, FM, HN, and HE-A. Supervision was carried out by FM, IK, ME, HN, and HE-A. Writing – original draft was done by AK and HE-A. Writing – review and editing were performed by AK, FM, AH, AS, IK, ME, SE-u-H, UW, MF, SA, HN, and HE-A. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The present study aimed to analyze the dynamic and nonlinear association between screen time, executive function (EF), and fundamental motor skills (FMS) in preschoolers, considering sex and body mass index (BMI) from a network perspective. Forty-two preschoolers  provided screen time, EF, FMS, and BMI data. EF was measured using the Go/No Go task, and accuracy of Go (sustain attention), reaction time of Go, and accuracy of No Go (inhibitory control) were considered. Relationships between screen time, EF, FMS, sex, and BMI were explored using a network analysis. The emerged network highlights that screen time is intensely associated with the other variables in the network, while the accuracy of Go has the greater connectivity with other nodes in the network (2.27), being the most sensitive to potential intervention changes. Moreover, sex (1.74), screen time (0.93), and accuracy of Go (0.71) showed the greatest closeness. This study showed that in the emerged network, independent of sex, screen exposure affects the accuracy on Go task, and these components affect the variables in the network, as motor abilities and tasks involved in inhibitory control.  Executive function (EF) is a general term referring to complex cognitive processes needed for performing challenging goal-directed tasks, especially those that escape routine, and is composed of three core elements: inhibitory control (IC), working memory (WM), and cognitive flexibility (CF) ,2,3. ThePrevious studies have widely assessed the IC as a measure of EF in this population, considering the preschool period has been identified as the key in its emergence . Thus, EIn the last few years, studies have given greater attention to the relationship between EF and children’s motor development, due to the close connection between brain development and motor abilities . Indeed,Recent studies have shown that a considerable number of preschoolers worldwide are not compliant with screen time , and areAlthough often examined separately, the relationship between screen exposure, FMS, and EF in preschoolers could be better understood through the science of networks. EF is derived from complex neural connections ,29, and This cross-sectional study used baseline data from the “Movement’s Cool” project, aiming to analyze the association between physical activity (PA) and health outcomes in preschoolers. All the ethical aspects were followed. The evaluation methods and procedures were approved by the Research Ethics Committee of Health Science Center , and by the Education Board of the João Pessoa, Brazil city.Preschool children, aged 3–5 years old, of both sexes, and registered in Early Education Childhood Centers (EECC) of João Pessoa/Brazil were eligible. The preschool public education zone is organized in nine districts, where the 55 EECC 3–5 years old registered students are located. Ten institutions, located in deprived areas of six different districts, agreed to participate in the study. For this study, three EECC, situated in three different districts, were randomly selected. The three preschools were located in deprived areas, with low socioeconomic status (SES): 50.5% of the mothers or fathers were unemployed, and over 71.8% of the mothers had not finished high school. The Human Development Index of the EECC areas ranges from 0.4 to 0.5. A total of 42 children completed the entire assessment protocols and composed the final sample.Measurements were performed over four months (August to October 2019 and March 2020). All the schools and parents were informed about the project’s protocols and procedures in meetings with the project coordinator, and agreed to participate. All children authorized by their parents were evaluated.A prior meeting with the school’s manager was conducted during the first day at school. On the second day, the sociodemographic data and screen time were provided by parents, and the Test of Gross Motor Development—Second Edition (TGMD-2) was applied. On the third day, EF data was collected.2).Height (cm) and weight (kg) were determined using a Holtain stadiometer and digitized weighing scales (Seca 708), respectively, while the participant was lightly dressed and barefoot. BMI was calculated by dividing body weight with the squared height in meters . For screen time the questions were: “How many hours during a week day does your child usually watch TV, use computer, smartphones, or electronics games?” and “How many hours during a weekend day does your child usually watch TV, use computer, smartphones, or electronics game?”. Then, the same procedure used for sleep hours was applied. Children were then classified as compliant/noncompliant with screen time when spending: (i) ≤1 h of sedentary screen time per day, for the 3 and 4 years-old children; (ii) ≤2 h of sedentary screen time per day for the 5 years-old children .FMS were measured using the TGMD-2 . The TGMThe TGMD-2 was administered at each preschool, according to the recommended guidelines . Before Using the media player classic software, the videos were analyzed to evaluate skills’ criteria. Two Professors in the motor behavior field, with experience in assessing the TGMD-2, carried out a training process on the protocol’s criteria with a master student who did not participate in data assessment. The training process was carried out over 2 weeks and 10% of the videos were randomly analyzed twice by the evaluator, with an interval of 10 days between each evaluation, to determine the intraclass correlation coefficient (ICC). A high agreement for the locomotion score: ICC = 0.93 (95% CI: 0.69–0.98), for the object control score: ICC = 0.98 (95% CI: 0.93–0.99) and for total motor score (MS): ICC: 0.96; (95% CI: 0.82–0.99) were observed. The locomotion and object control scores were based on the presence (one) or absence (zero) of each of the performance criteria. For each subtest, the sum of the raw scores varied from 0 to 48 points.EF was assessed using Early Years Toolbox—EYT. The “EYT” is a battery of computerized tasks that was developed to assess the EF of children aged 3–5 years-old . The batp < 0.05, and all data were analyzed using SPSS Windows v 20.0 .Variables were checked for normality using Kolmogorov–Smirnov tests, and described as categorical or continuous or variables. Chi-squared test was used to calculate the association between proportion of screen time guideline adherence and sex, and Cohen’s d was used to assess effect size among continuous variables , definedA network analysis was used to assess the association between adherence to screen time guidelines, FMS, and EF trials, considering children’s age, sex, and BMI. The betweenness, closeness, and strength centrality indicators were reported. Variables with higher betweenness values are more sensitive to changes and may act as a hub, connecting other pairs of variables in the network. A variable with a high closeness value will be quickly affected by changes in any part of the network and may also affect other parts. The strength indicator is essential to understand which variables present the most robust connections in the current network pattern.The “Fruchterman–Reingold” algorithm was applied. Data were shown in the relative space in which variables with stronger permanent association remain together and with less strongly applied variations repelled one another . To impr2 = 1.87; p = 0.172). The boys showed better performance in locomotion, object control, accuracy on Go trial, and reaction time and the girls performed better on accuracy No Go. The effect size was large for all comparisons (Cohen’s d > 0.50), except for BMI , and sex (0.659) presented the highest values of betweenness and the variables Ac-Go (0.714), sex (1.740), and screen time (0.928) have a higher closeness value .This study aimed to assess the associations between compliance with screen time recommendation, EF, and FMS in preschoolers. Although these association have been commonly examined separately, cognition and motor aspects share the same brain basis ,45 and aThe current results showed low compliance with screen time recommendation (less than 10%). This is lower than the percentage observed for preschoolers from Canada (24.4%), Australia (17.3%), Belgium (61%), and Portugal 20.3%), while no differences between sexes has been seen ,20,21,46.3%, whilSeveral computational measures have been proposed to assess the EF in childhood, based mainly on general accuracy scores. General accuracy of Go/No Go task represents the proportion of correct responses in frequent stimulus and less frequent stimulus . In the The results of the current study also highlighted that girls were more accurate than boys on No-Go trials, reflecting their better inhibition response. Gender differences in emotion expressions, and sensitivity to feedback contribute to differences in inhibitory capacity between sexes ,55,56. FIt was also observed that boys performed better in both locomotor and object control skills than girls. This is not surprising as several studies reported that boys better performed total FMS scores, especially on object control skills ,58. NoneThe current study also showed that the accuracy of Go, which represents the ability to sustain attention, showed the highest betweenness in the network. This centrality measure indicates that accuracy of Go has the greater connectivity with other nodes in the network, being the most sensitive to potential intervention changes. Indeed, children with greater skills for sustained attention exhibited greater IC, showing a close relationship between the development of attention capacity and improvements in EF during childhood ,59,60. GMoreover, sex, compliance with screen time recommendations, and accuracy of Go showed the greatest closeness. These variables are responsible for spreading the effect of interventions more quickly on all other variables present in the network. Improving FMS, maintaining or improving BMI, and improving RT in children initially depends on improving screen time (namely compliance with guidelines recommendation), and accuracy of Go. As no difference in compliance with screen time has been seen between boys and girls, the strength of this variable in the network is related to similar opportunities for boys and girls. It is also important to mention that environmental factors, such as screen time, could negatively influence both the performance in FMS and in EF tasks in early childhood ,61,62. TAccuracy of Go, sex, and compliance with screen time recommendations showed greater closeness in the network. Evidence suggests that, regardless of gender, few preschoolers meet the recommendations of screen time ,46. HoweIn addition, recent findings demonstrate that children with lower screen time demonstrated better EF, and children who engaged in more PA demonstrated better gross motor skills . In thisThe strengths of this study include the computerized Go/No Go assessment task that improves the standardization and sensitivity of EF performance; as far as we know, this is the first study to report the relationship between compliance with screen time recommendations, EF, and FMS in preschoolers through a network perspective. However, some limitations should be highlighted. The lack of information regarding the type of screen time (passive or active), the content of the screen offered to the children , as well as the parent-reported screen time are notable limitations. However, it is also worth mentioning that there is no objective validated method of assessing screen time in preschool-aged children. Moreover, the assessed children spend 10 h per day in preschool settings, where electronic devices are forbidden, and screen time is restricted to home time, likely under parent supervision. Further, the present study comprises a specific low-income sample. It is known that children from low-income families, and living in socially vulnerable environments ,76, are Thus, the present study shows that in the emerged network, independent of sex, the compliance with screen time recommendation affects the accuracy on the Go task, in preschoolers. The relationship between these components affects other variables present in the network, such as motor abilities and tasks involved in inhibitory control. Future studies should focus on interventions that reduce screen exposure in younger children.


Milk fatty acid (FA) is a main nutritional component that markedly effects human health. Intentional modification of the FA profile has the potential to improve milk quality. This study aimed at the factors affecting elevated FA levels and the estimation of the genetic parameters for milk FAs in the Korean Holstein population.Total 885,249 repeated test-day milk records including, milk yield, saturated fatty acids (SFA), polyunsaturated fatty acids (PUFA), monounsaturated fatty acids (MUFA), total unsaturated fatty acids (TUFA), fat and protein percentages were analyzed using CombiFoss FT+ system . Genetic parameters were estimated by the restricted maximum likelihood procedure based on the repeatability model using the Wombat program.The FA profile varies along with the lactation and the energy balance (EB). With the negative EB in early lactation, mobilization of body fat reserves elevates the desirable FA levels. As a result of that, milk quality is increased by means of nutritionally and usability aspects during the early lactation. Moreover, heritability estimates for SFA, MUFA, PUFA, TUFA were 0.33, 0.42, 0.37, 0.41 respectively. According to the parity wise heritability analysis, first parity cows had relatively lower heritability for SFAs (0.19) than later parities (0.28).Genetic parameters indicated that FAs were under stronger genetic control. Therefore, we suggest implementing animal breeding programs towards improving the milk FA profile. The objective of this study was to evaluate the phenotypic and genetic variability of fatty acid (FA) groups and identify the factors that influence changes in the FA profile of the Korean Holstein population. The milk fatty acids are derived from four major pathways. Directly from the diet, de novo synthesis in the mammary gland, formation in the rumen by biohydrogenation or bacterial degradation, and release from body fat stores ,2.Practical efforts to improve the milk FA profile to increase the benefits to the consumers are driven by two reasons based on nutritional and usability aspects. A concern for dairy consumers is that the nutritional approach leads to a lower proportion of unsaturated fatty acids (UFAs) and a higher proportion of saturated fatty acids (SFAs). Consequently, there can be various deleterious effects on human health like cardiovascular disease risk, elevated blood pressure, insulin resistance, and hyperlipidemia, particularly of low-density lipoprotein cholesterol ,4.From a usability point of view, textural properties of milk and butter are known to be affected by FA composition. Higher proportions of UFA are desired due to more spreadable and softer butter, with less adhesive consistency of milk and butter. However, there are some issues related to high UFA content in milk fat, including its lower stability and the accompanying phenomena such as oxidation and possible sensory changes .Making Intentional modifications to the FA profile requires a thorough knowledge of the different factors that effect on milk fat composition and the extent to which these relevant factors are involved in influencing the FA profile. According to the previous literature, factors affecting the FA profile of milk are breed, cow’s individuality, milk yield, lactation (parity and stage), feed composition, management and metabolic factors . But theThe focus of this study was to evaluate the effect of parity, lactation stage, and energy balance on the contents of fatty acids and estimate their genetic parameters according to the parity and collectively. Selection for improved FA profiles would be feasible only if there is sufficient genetic variation in FA composition.Test-day records of milk composition were collected from 2012 to 2018 by the Korea Animal Improvement Association (KAIA). The test day milk records included milk yield, FA composition,  fat and protein percentages of cows that were 1 to 305 days in milk at sampling. The cows were milked twice daily at morning (05:00 h) and afternoon (16:00 h). Milk composition was analyzed weekly based on samples collected from 2 consecutive milkings. Test-day milk samples were analyzed by FTIR spectroscopy using the CombiFossFT+ system .The season of calving was defined as summer (May to October) and winter (November to April). The age at first calving ranged from ≤23 months, 24 to 25 months, 26 to 28 months and ≥29 respectively. The original data set consisted of 885,249 test-day records.SAS 9.2 package  was used to analyze descriptive statistics of all parameters. Genetic parameters, including genetic (co)variance components, were estimated by the restricted maximum likelihood procedure based on a repeatability model using the Wombat program.The linear model for all parities and individual parities were illustrated as follows :ijklm is the SFA, MUFA, PUFA, TUFA observation; μ is the overall mean; DIM is the covariate describing the effect of days in milk; Agei is the fixed effect of calving age I; Seasonj is the fixed effect of calving season j; ampmk is the fixed effect of milk collecting time k; parityl is the fixed effect of parity l; am is the additive genetic effect of cow m; pm is the permanent environmental effect of cow m; e is the random residual effect associated with each record.Where, YHeritability was calculated using this equation:h2 is heritability, Where This EB equation was based on parity, lactation week, and milk composition volume as follows ,15.EquationWhere; wk2, wk3 . . . to wk12 = lactation wk2 to 12; par1 – par4 = parity categories 1 to 4; milk = milk yield (kg/d); prot = % milk protein; FP = ratio of % fat to % protein in milk.A total of 885,249 milk samples was evaluated for SFA, MUFA, PUFA, TUFA at KAIA. Mean SFA content was 2.43 g/dL of milk with the range of 0.05 g/dL of milk to 14.2 g/dL of milk while the mean TUFA content was 1.29 g/dL of milk with the range of 0.01 g/dL of milk to 8.03 g/dL of milk. The average milk yield was 17.34 kg/d while mean fat and protein percentages were 3.83 and 3.24 respectively .In this study stage of lactation was considered as a class variable with 3 levels early lactation (1 to 100 d), mid-lactation (101 to 200 d), and late lactation (200 to 305 d). SFA increased over lacation. SFA content at early lactation was 2.29 g/dL of milk, 2.32 g/dL of milk at mid-lactation and 2.45 g/dL of milk at late lactation. The patterns for MUFA, and TUFA were similar to one another and showed a minimum at mid-lactation, PUFA content was not observed a significant change over lactation .Lactation stage, along with energy balance of dairy cows, has an impact on the FA profile of cow’s milk. Changes in milk FA composition during lactation, predominantly at the beginning of lactation, originate from alterations in the pathways of FA derivation, the diet, de novo synthesis in mammary glands, ruminal biohydrogenation and body fat mobilization.During lactation, the cycles of lipolysis and lipogenesis in body stores are altering to meet her energy requirements for milk secretion. The increased energy demands of fetal development and milk secretion are mainly evident in the transition period of lactation. Therefore, cows, like other lactating animals, often enter a NEB at the start of lactation .Early lactation is the most challenging period in terms of energy status and herd management. High utilization of energy reserves during this period is reflected in milk fat content mainly in the FA composition and mutual ratios between individual FA groups. The general pattern can be described as high uptake of long-chain FAs by the mammary gland affecting the de novo synthesis of FAs. Therefore, SFAs are at their lowest proportion in the second week, with increasing amounts until 12 weeks as the energy balance improves . These fEstimates of genetic parameters for fatty acids proportions in milk fat are required to make genetic selection decisions. In this study, heritability estimates for SFA, MUFA, PUFA, TUFA were 0.33, 0.42, 0.37, 0.41 respectively . High heStoop et al  reportedThere is conflicting evidence in the literature about the effect of parity on the fatty acid composition of bovine milk. According to the parity wise heritability analysis, first parity cows showed a lower heritability in SFA than higher parities (0.19). There was no significant difference between heritabilities in other parities . In the Mentioned findings and relationships confirm the impor tance of maintaining the fatty acid composition in Korean Holstein cows in relation to the economic effectiveness of dairy milk with high quality. Our study showed that the lactation stage, energy balance and parity significantly contribute to variation in milk fat composition. So, this can be used in future breeding programs to improve the FA profile of milk fat by increasing UFA concentrations and decreasing SFA concentrations.According to our findings, the milk FA profile in early lactation is healthier for the consumer. The FA composition of milk depends on the parity, stage of lactation, and energy balance. Overall high heritability estimates of FAs suggested that milk fat composition can be changed by genetic selection. The test day records from commercial herds are an effective tool for genetic selection directed towards improving milk quality. Moreover, we conclude that milk and other dairy products can be labeled by parity and the stage of lactation at the market level.


Objective: To identify the potential risk factors for acute mastitis during lactation comprehensively. Subsequently, to evaluate logistic regression model in predicting the risk of lactational mastitis in Chinese women by applying receiver operating characteristic (ROC) curve.Methods: A case–control study among Chinese women enrolled 652 patients with mastitis and 581 healthy women with breastfeeding experience as control. The retrospective information was obtained by questionnaires that included medical history of pregnancy, delivery, puerperium and breastfeeding behaviors. Univariate analysis and multivariate logistic regression model were performed to investigate the relationship between these factors and the occurrence of lactational mastitis. Using ROC curve to evaluate the prognostic value of these selected indicators in the risk of acute mastitis.Results: The multivariate logistic regression analysis showed that the primiparity (P < 0.001), mastitis in previous breastfeeding (P < 0.001), nipple’s heteroplasia (P < 0.001), cracked nipple (P < 0.001), breast trauma by external force (P = 0.002), lateral position (P = 0.007), breast pump (P = 0.039), nipple sucking (P = 0.007), sleep with sucking (P = 0.007), and tongue-tie (P = 0.013) were risk variables independently and significantly related with mastitis. While vaginal delivery (P = 0.015), clean nipple before breastfeeding (P = 0.015), first contact with child within 1 h (P = 0.027) were protective factors. The ROC analysis demonstrated that the area under the curve of model 2 was 0.8122 (95%CI = 0.7885–0.8360), which stated that the model presented a high sensitivity and specificity.Conclusion: By means of collecting and summarizing the risk factors associated with the occurrence of breast mastitis in Chinese women, we established risk discriminant model to identify and warn the individuals susceptible to acute mastitis early, which will allow practitioners to provide appropriate management advice and effective individual care. Breastfeeding is a natural infant feeding method highly recommended by the World Health Organization (WHO)  and the Lactational mastitis is an acute inflammatory process of affected mammary duct and peripheral connective tissue by pathogenic bacteria, which is clinically characterized by a red, hot, swollen and wedge-shaped area of the breast with influenza-like symptoms, such as fever and malaise . It can In summary, lactational mastitis is the focus of renewed attention with high economic, social and public health impact. The aim of this research is to investigate and clarify the risk factors associated with the occurrence of breast mastitis in Chinese women, and to establish risk assessment model to identify and warn the individuals susceptible to lactational mastitis early. Furthermore, our aim is also to standardize propaganda and education and to formulate preventive measures, which will allow practitioners to provide appropriate management advice, scientific treatment strategies and effectively individual care.9/l and NEUT > 7.0 × 109/l, (4) axillary lymph node enlargement. Symptoms must be present for a minimum duration of 24 h. Controls enrolled in the present study were female who attended post-partum follow up clinics at Health Management Center of Qilu hospital and must meet the following criteria: (1) age ranging from 20 to 40, (2) breastfeeding experience without acute mastitis during lactation, (3) stopped breastfeeding within 2 years.The patients who participated in this case–control study were recruited at breast surgery department of Shandong Cancer Hospital and Qilu Hospital of Shandong University between June 2016 and December 2017. The diagnosis was made according to the Academy of Breastfeeding Medicine (ABM) diagnostic criteria for lactational mastitis , which wThe sample size of the case–control study was estimated with PASS 11 software. According to previous literature, the average proportion of multiple exposures in control group was approximately 20% ,15. MeanBased on the previous studies and a review of the literatures ,16, a quIn addition to considering the logic, the items listed in the questionnaire also should be arranged in order and preset as three dimensions of delivery and postpartum characteristics, breastfeeding behaviors and characteristics, infants practices and characteristics. The reliability and validity of the scale were measured by Cronbach’s α coefficient and exploratory factor analysis respectively. As far as possible, we selected simple and understandable questions for respondents to simplify the contents and ensure the accuracy of the results. Furthermore, minimized personal information related topics, and reduced the incidence of such cases that were loss of compliance due to fear of privacy leakage, so as to ensure the authenticity of the questionnaire.The procedures of research were divided into design phase, implementation phase and data analysis phase . (1) DesStrict quality control was essential to avoid measurement bias from investigators and respondents. Uniform training was provided to all investigators on the survey requirements, the definition of the contents and the methods of the investigation. In the field study, direct inquire after was adopted to make the inquiry method and time the same for each participant. Both parties established good communication to ensure that the questions in the questionnaire were fully understand by the subjects, so as to obtain objective and accurate data.The ethical approval of the survey was obtained from the Human Ethics Committee of Shandong Cancer Hospital. Every subject signed a written consent. The original questionnaires and data were involved special person in charge, special closet for storage, special computer for registration and encryption.P < 0.05 was considered as statistically significance.Participants’ baseline characteristics according to mastitis status were presented using proportions for categorical variables. Comparisons of categorical variables in both mastitis and control groups were done using chi-square test (χ2). To analyze the association between mastitis and the potential risk factors, a multivariate logistic regression model was constructed and odds ratio (OR) with 95% confidence interval (CI) were calculated. To assess abilities of combined variables with significant differences in multivariate logistic regression to predict incidence of mastitis, ROC curves, which correlated true- and false-positive rates (sensitivity and 1-specificity), were constructed. In addition, ROC curves established by risk factors from American ABM guidelines for treatment of mastitis was used as reference. Both AUCs (area under the curve) were calculated and the statistical significance of differences between the two AUCs also was determined. All statistical analyses were performed with SAS 9.3 and a two-sided The sample size of case group and control group calculated by PASS 11 software is 230. Taking into account the 10% rate of lost follow-up and the 10% rate of unqualified questionnaires, at least 289 samples are required for each group. Based on the steps and procedures mentioned in the method, we approached 833 eligible patients who had acute lactational mastitis. Among them, 768 patients agreed to participate and only 691 patients completed the questionnaires, the other 77 cases were unfinished due to poor communication and cooperation during the investigation and no response/lost follow-up. Finally, 652 cases were qualified, the remaining 39 cases were excluded owing to incomplete information collection/multiple selection or mission of the options in the questionnaire. Similar to the above processes, 846 healthy women with breastfeeding experience were recruited into our study as controls and 581 females completed the investigation in the end . There wBefore the questionnaire was officially issued, we invited 32 patients with mastitis and normal women with previous breastfeeding experience to conduct a small-scale test. The researchers adjusted the content and structure of the questionnaire according to the feedback and calculated the reliability and validity of the questionnaire.P < 0.001, and Kaiser–Meyer–Olkin (KMO) = 0.858, that represented good structural validity.The reliability of the scale measured by Cronbach’s α coefficient was 0.932. By the score with expert review, the content validity index of the scale was 0.897, and with the Bartlett test, the χ2 = 6684.148, The study enrolled 652 patients with lactational mastitis and 581 healthy women after completing all the questionnaires designed to collect retrospective information about different factors related to mastitis. In descriptive analyses, the average age was 29.89 ± 3.37 for cases and 30.26 ± 3.78 for controls. Many essential relations were also established between the age range at last delivery, residence, occupation, education, delivery number and mode, mastitis in previous breastfeeding, maternal body mass index (BMI), smoking, drinking and acute infectious mastitis.P = 0.010), primiparity (P = 0.018), caesarean section (P = 0.011), history of mastitis (P < 0.001) comparing with the control. Meanwhile, there were no significant differences between case and control subjects with regard to age at last delivery (P = 0.318), residence (P = 0.087), occupation (P = 0.163), maternal BMI (P = 0.272), smoking (P = 0.076) and drinking (P = 0.889). Information about the main sociodemographic characteristics of the samples is shown in Concerning sociodemographic characteristics, women in the case group were more likely to have Bachelor or below  and applanation nipple . The more important concern is that cracked nipple  would prominently lead to acute mastit is in lactating women. In contrast, cleaning nipple before breastfeeding regularly  may effectively avoid the occurrence of infectious mastitis. Considering the breastfeeding behaviors and practices, use of breast pump  and breast trauma by external force  were mastitis risk factors. Nevertheless, there was no statistically difference between cases and controls related to the non-medical staff massage.At the same time, some associations deserving attention are variables of infants practices and characteristics. For instance, sucking manners  and sleep with sucking  were significantly associated with infectious mastitis. Compared with the way of areola sucking, nipple sucking  were more administrated to children in the case group than in the control group. A higher risk of mastitis was noted when the infant suffered from tongue-tie . In addition, connecting difficulty between mother and baby did not yield a significant difference in the case–control study.As to the maternal physical condition and psychological mood, the factors of anemia and throat infection were illustrated without significant variation. Similarly, uses of unauthorized oral antibiotics and negative emotion were not associated with mastitis that was opposite to the views reported in other literatures ,17. Cont2 = 33.2405, P < 0.0001), which stated that the model 2 presented a good fit and a terrific adjustment . That is to say, if separation from the maternity and newborn after birth prolonged due to hypoxia, hospitalization or any other reasons may increase the risk of mastitis in lactation. The initial 1–2 h after birth is the best time for sucking action and foraging reflex . It is aThis finding is consistent with previous evidence ,30 that For the last 20 years, a few research have reported the relationship between the delivery mode and acute lactational mastitis ,15,16. FSignificantly, a previous history of lactational mastitis is also a strong mastitis predictor in our study, and this factor is associated with a nearly 5-fold risk of mastitis in the multivariate analysis . In the past, scholars used to think that lactation mastitis was a simple infectious disease, and now this view is facing a challenge. Its pathogenesis has changed from a simple infectious disease to inflammatory reaction , and theNipple is located in the posterior part of the baby’s oral cavity while sucking, which can effectively stimulate the sensory nerve on the nipple, thus promoting lactation reflex and avoiding nipple injury. As a result, the WHO, the UNICEF and Maternal and Child health Department of National Health Commission of the People’s Republic of China have successively promulgated the breastfeeding handbook, which promote and guide breast feeding with nipple and areola, so as to better discharge milk and avoid nipple pain and breakage . To concIn the present study, the demonstrated improvement was likely a result of correlation between breast pump , breast trauma by external force , sleeping lateral position  and infectious mastitis. Because mammary gland ducts are filled with milk, the tube wall is thin, and the subcutaneous tissue of the mammary gland is rich in lymphatic vessels and capillaries, it is prone to cause local breast tissue damage and edema in the effect of external force compression, collision, inappropriate massage and infant kicking. When sleeping on the side, the milk remains in the breast tube near the side of bed due to gravity, and the breast is compressed leading to galactostasis. Meanwhile, the frequent and improper use of breast pumps was a relevant mastitis risk factor , which mThere are intimate links between bacterial invasion with occurrence and development of acute mastitis during lactation. First of all, the bacteria on the skin surface can intrude through the cracked nipple and areola, and retrograde to interlobular mammary gland. Second, the microorganisms in the baby’s mouth enter the mammary duct and stay in it . FinallyPrevious studies  have conAlthough unauthorized oral antibiotics was not an independent risk factor for mastitis in this analysis. Theoretically, use of large amount of antibiotics without indication can reduce maternal resistance and lead to microbial imbalance of breast bacteria, and the potential pathogens have overgrown as losing the inhibition of other bacteria . AntibioThe results of our study demonstrated that relevant factors related to an increased risk of infectious mastitis in Chinese breastfeeding women, which will allow practitioners to provide appropriate management advice and professional health care. It is important to investigate preventive measures in order to maintain and increase breastfeeding exclusivity and duration, especially for high-risk individuals. There are still many questions to answer about lactational mastitis, but work is in progress to broaden our knowledge in this relevant Public Health issue.