Bifidobacterium animalis subsp. lactis, BPL1TM HT), and twice as much arachidonic acid as the STD formula contained. The second group received the STD formula, while the third group was exclusively BF for exploratory purposes. In the course of the study, visits were conducted at 6 months and 12 months of age. Compared to the BF and STD groups, the Bacillota phylum levels in the INN group were significantly reduced after 6 months. At the end of 6 months, the alpha diversity indices of the BF and INN groups differed significantly from those of the STD group. At 12 months, the Verrucomicrobiota phylum levels in the STD group were significantly lower than those in the BF and INN groups. Based on the comparison between 6 and 12 months, the Bacteroidota phylum levels in the BF group were significantly higher than those in the INN and STD groups. When comparing the INN group with the BF and STD groups, Clostridium sensu stricto 1 was significantly higher in the INN group. The STD group had higher levels of calprotectin than the INN and BF groups at 6 months. The immunoglobulin A levels in the STD group were significantly lower than those in the INN and BF groups after 6 months. Both formulas had significantly higher levels of propionic acid than the BF group at 6 months. At 6 months, the STD group showed a higher quantification of all metabolic pathways than the BF group. The INN formula group exhibited similar behavior to the BF group, except for the superpathway of phospholipid biosynthesis (E. coli). We hypothesize that the novel INN formula may promote an intestinal microbiota that is more similar to the microbiota of an infant who consumes only human milk before the weaning period.The World Health Organization recommends exclusive breastfeeding on demand until at least the sixth month of life. Breast milk or infant formula is the infant’s primary food source until the age of one year, followed by the gradual introduction of other foods. During weaning, the intestinal microbiota evolves to a profile close to that of the adult, and its disruption can result in an increased incidence of acute infectious diseases. We aimed to determine whether a novel starting formula (INN) provides gut microbiota compositions more similar to those of breastfed (BF) infants from 6 to 12 months of age compared to a standard formula (STD). This study included 210 infants (70 per group) who completed the intervention until they reached the age of 12 months. In the intervention period, infants were divided into three groups. Group 1 received an INN formula with a lower protein content, a casein to whey protein ratio of approximately 70/30, twice as much docosahexaenoic acid as the STD formula, a thermally inactivated postbiotic ( For infants, human milk is the preferred form of nutrition, and exclusive breastfeeding is strongly recommended for the first six months of life . In bothThe gut microbiota is assembled in a child’s first year of life during a maturation process. This is done by changing the positive and negative interactions between microbial taxa . The afoDespite the well-known benefits of breastfeeding, there are times, especially while weaning, when the mother might find it difficult or even impossible to breastfeed, which might result in the infant losing weight. In this context, infant formula can be used as a food source for adequate infant nutrition together with complementary foods. Within this context, the incorporation of novel food ingredients into infant formulas may contribute to their optimal growth and development ,10. The Infancy weight gain and rapid growth are associated with obesity risk in adulthood . The proBifidobacterium animalis subsp. lactis BPL1TM can reduce fat accumulation in visceral adipose tissue in obese individuals [TM HT) modulates the gut microbiota composition [Additionally, in recent years, research has been conducted on the use of prebiotics, probiotics, synbiotics, and postbiotics in infant formulas. Several studies demonstrated that the probiotic strain ividuals ,19,20 anposition . Moreoveposition ,23. It iOur previous article reported the results of a multicenter, randomized, blinded, controlled clinical trial examining the effects of a novel starting formula on weight gain and body composition in infants up to 6 and 12 months as well as its safety and tolerability compared to infants fed a standard formula (STD) and a reference breastfed (BF) infant group (INNOVA 2020 Study) . The des® Natal or STD), the novel formula (Nutribén® Innova 1 or INN) contains less protein, a lower casein-to-whey protein ratio, and twice as much DHA/ARA. In addition, INN contains postbiotic BPL1TM HT. Based on WHO guidelines, the INN formula is considered safe since weight gain and body composition were within normal limits. At 6 and 12 months, both formula groups gained more weight than a reference BF group, whereas no differences were found between the STD and INN groups. However, infants who received the INN formula experienced significantly fewer general disorders and disturbances than infants who received the STD formula. The STD formula group was significantly more likely to cause bronchiolitis, atopic dermatitis, and bronchiolitis [Compared to the STD  levels at 21 days, 2 months, and 6 months. Further, we found that the major metabolic pathways of bacteria were more similar between the INN formula and BF groups than between the STD formula and BF groups [In a previous report, we examined the impact of INN on the fecal microbiota composition of infants up to 6 months of age. In terms of the richness and diversity of the gut microbiota, the INN formula was more comparable to BF infants in terms of several genera, including F groups .In the present work, we studied the fecal microbiota changes and associated metabolic pathways in the infants of the INNOVA 2020 Study between 6 and 12 months of life. Infants received either INN, STD, or exclusive BF together with complementary foods from 6 months onwards.Actinobacteria, Bacteroidetes, Cyanobacteria, Firmicutes, Fusobacteria, Proteobacteria, Patescibacteria, Synergistetes, and Verrucomicrobia are referred to as Actinobacteriota, Bacteroidota, Cyanobacteriota, Bacillota, Fusobacteriota, Pseudomonadota, Candidatus Patescibacteria, Synergistetes, and Verrucomicrobiota, respectively [ectively . Bacillota levels were significantly lower in the INN group than in the BF and STD groups after 6 months. The BF and INN groups had significantly different alpha diversity profiles than the STD group based on the alpha diversity indices measured at 6 months. Compared to both the BF and INN groups at 12 months, the Verrucomicrobiota levels were significantly lower in the STD group. When comparing 12 months to 6 months, significant differences were observed. The Bacteroidota levels were significantly higher in the BF group. In addition, there was a significant increase in the Bacillota levels in both the STD and INN groups. The Pseudomonadota levels were significantly decreased in all study groups. The study groups showed significant increases in all alpha diversity indices.The Bifidobacterium was the main genus in all of the studied infants at 6 months of age. The STD group had significantly lower levels than both the BF and INN groups. There was a significant increase in Clostridium sensu stricto 1 in the INN group compared to both the BF and STD groups.Ruminococcus gnavus group, Clostridioides, Flavonifractor, and Lachnoclostridium genera were found in the STD group than in the BF or INN groups. The Rothia and Escherichia-Shigella genera were found at higher levels in the INN group than in either the BF or STD group. A significantly higher number of the Veillonella at 12 months. We observed a significant decline in the Bifidobacterium, Veillonella, Enterococcus, and Escherichia-Shigella genera from 6 to 12 months. In contrast, there was a significant increase in the Blautia, Faecalibacterium, Lachnoclostridium, Anaerostipes, Ruminococcus, Subdoligranulum, Eubacterium hallii group, and Roseburia genera. Both the BF and INN groups showed significant increases in Collinsella levels. The Ruminococcus gnavus group and Flavonifractor genera increased significantly in the INN group, while Rothia decreased significantly. It was found that Clostridioides decreased significantly in the STD group, while Streptococcus increased significantly. In addition, Bacteroides increased significantly in the BF group.In comparison with the INN group, the BF and STD groups had significantly lower levels of Bacillota and Actinobacteriota phyla as well as the Eggerthella and Streptococcus genera were most closely associated with the BF group when compared to the INN formula group , and L-Tryptophan biosynthesis. Compared to the BF group, only D-glucarate degradation was significantly higher in the INN group. At 12 months, no significant differences were observed.The STD group showed several differences according to the metabolic pathways at 6 months compared to the BF group A–J. TherE. coli). Between 12 months and 6 months, no significant differences were observed in the STD group.A comparison between 12 months and 6 months showed that the BF group had an increased abundance of all metabolic pathways A–J. The According to Pearson’s correlations, there were some associations between the bacterial diversity indices, bacterial variables, SCFA levels, metabolic traits, and clinical outcomes in the BF, STD, and INN groups .Bifidobacterium negatively correlated with the diversity indices (Shannon and Pielou’s evenness) and D-galacturonate degradation I, glycolysis, the superpathway of phospholipid biosynthesis (E. coli), and L-tryptophan biosynthesis. Rothia, Eggerthella, and Veillonella exhibited similar characteristics to Bifidobacterium, with negative associations with the major metabolic pathways. There was a negative association between Actinobacteriota and bronchiolitis  and was only inversely correlated with L-tryptophan biosynthesis in the STD formula group. The biosynthesis of L-tryptophan was positively associated with Clostridium sensu stricto 1 and Akkermansia. The presence of Collinsella was negatively associated with cases of bronchiolitis  and negatively associated with D-galacturonate degradation I and L-tryptophan biosynthesis. There was a positive correlation between Collinsella and glycolysis. L-tryptophan biosynthesis positively correlated with Eggerthella and Akkermansia. There was a negative association between Veillonella and glycolysis , the INN formula group exhibited similar behavior to the BF group. The STD group did not show any significant differences between 12 months and 6 months.The purpose of this study was to assess the differential effects on the intestinal microbiota of feeding infants with a novel INN compared to STD and breastfeeding at 6 months and 12 months of age, while the infants were weaning. A significant reduction in An adequate diet in infancy and early childhood is essential to the development, growth, and health of children . As a reIn our study, the main comparison was made using the BF group. A detailed description of the effects of the different groups on weight gain, body composition, safety, and tolerability has been provided elsewhere .It is critical to emphasize that breastfeeding should continue until the child reaches the age of two years. This is in addition to the introduction of complementary foods after 6 months ,32.Actinobacteriota (mainly Bifidobacterium) and Bacillota (with diverse representation from numerous genera) [Bifidobacterium plays a critical role in maintaining host homeostasis during early life, as one of the most abundant genera within the infant intestinal microbiota [Bifidobacterium is typically the dominant microbial taxon [Actinobacteriota and Bacillota phyla representing more than 90% of the relative abundance afterward. In our study, the main genus present in all of the infants studied at 6 months of age was Bifidobacterium, which decreased significantly at 12 months in all groups. Even though another study evaluating the fecal microbiota of Australian newborns showed a significant increase in the Bifidobacteraceae family and several strains of Bifidobacterium after the consumption of infant formula [In previous work, other authors reported that the gut microbiota of 24 Canadian term infants at 4 months of age was dominated by  genera) ,34. The crobiota . During al taxon . Howeveral taxon , with th formula , most pu formula ,42,43,44Bifidobacterium, followed by Enterobacteriaceae and Bacteroides, regardless of whether the infant was breastfed or formula-fed. Infants who were formula-fed were only associated with the Lactobacillus group [Although different technologies have been used to compare the microbiota of breastfed and formula-fed infants ,46,47, 1us group .At 6 months, the INN formula group had similar alpha diversity indices as the BF group. At 12 months, all groups showed a significant increase in alpha diversity. This is similar to other studies that compare the fecal microbiota of infants from 6 months to 12 months  and fromVerrucomicrobiota spp. and Clostridiales spp., members of the intestinal microbiota, are associated with increased expression levels of il10 and tgfb as well as the Treg transcription factor FOXP3 in an animal model, and the potential induction of regulatory immunity in the host was speculated [Verrucomicrobiota levels were significantly lower in the STD group than in the BF and INN groups.eculated . In addiThe Rivera-Pinto algorithm is used to identify microbial signatures ; based oEscherichia coli, Clostridium, and Bacteroides [A growing body of research indicates that gut colonization after birth has a long-term “programming” effect on health. In light of this, it has been hypothesized that gut microbiota plays a significant role in modulating the immune system, and, as a consequence, it has a critical role in preventing infections in infants. Several factors influence this colonization process, including feeding habits . In geneteroides .Calprotectin is a calcium-binding protein of the S-100 protein family that is predominantly found in neutrophils and throughout the human body. Calprotectin is present in feces as a result of neutrophil migration into the gastrointestinal tract as a result of inflammation. As a biomarker for gastrointestinal disorders, fecal calprotectin concentrations are well correlated with intestinal inflammation . There wE. coli is capable of using both galactarate and D-glucarate as carbon sources for growth. By interacting with coenzyme A through the pyruvate dehydrogenase complex, pyruvic acid produces carbon dioxide, NADH, and acetyl CoA. In phosphoenolpyruvate synthetase, pyruvic acid interacts with water and ATP, resulting in the release of hydrogen ions, phosphates, AMPs, and phosphoenolpyruvic acids [E. coli) is involved in the synthesis of lipopolysaccharides. In humans and other animals, this elicits a strong immune response (and contributes to Gram-negative septic shock), which is detected at picomolar levels by the toll-like receptor-4 receptor found in the innate immune system [During 6 to 12 months of intervention, the BF group demonstrated increased levels of the various metabolic pathways. Degradation, the formation of different metabolites, and lipid and protein synthesis are among the different processes. The process of glycolysis involves the conversion of a six-carbon glucose molecule into two three-carbon keto acids (pyruvate) . D-glucaic acids ,59. The e system . A variee system .In comparison with the BF group, only the INN formula group showed a similar metabolic pattern. The metabolic pathways were all increased at 12 months, following the inclusion of complementary foods and the development of metabolic processes and the immune system. In contrast, the STD formula group showed upregulation of that process in the 6 months after the intervention, without statistical changes at the end.In this study, the primary strength is its design, which is a randomized, multicenter, double-blind, parallel, comparative clinical trial comparing two starting infant formulas for infants based on very strict eligibility, inclusion, and exclusion criteria. The hypotheses were that the weight gain among infants fed the INN formula would be similar to that observed among children fed the STD formula. For exploratory analysis, a third group of unblinded BF infants was also used.The study does, however, have several limitations. First of all, the fecal microbiota diversity and bacterial groups were not initially calculated based on the number of infants per group. Rather, they were calculated in order to assess differences in growth rates. In order to obtain significant differences in certain underrepresented bacterial groups, the number of infants examined in the present study would need to be higher. There is another limitation associated with the microbiota methodology. It is important to note that, in our study, we used a methodology that involves the amplification of specific segments of the 16S ribosomal RNA of bacteria; however, sequencing the whole gene would allow for more accurate identification of the microbial species beyond families and genera. As well, the variation in the fecal microbiota cannot be attributed to a specific component of the experimental formula, since it differs from standard milk formulas in several respects. We recommend that new longitudinal studies be conducted between birth and weaning using sufficient numbers of infants fed formulas that differ from standard formulas by a single ingredient. Nutrients, probiotics, or postbiotics that have a significant impact on intestinal microbiota should be considered in these studies. Recent research indicates that dietary patterns are consistently correlated with bacterial groups that play a similar role in both health and disease . MoreoveThroughout this clinical trial, the ethical–legal principles established in the latest revision of the Declaration of Helsinki, the recommendations of the International Conference on Harmonization Tripartite, and the current regional regulations governing pharmacovigilance and food safety were followed. This study was approved by the Committee for Technical Investigation in Regional Medicine in the Madrid Community (CEIm-R) on 11 May 2018 under the name INNOVA 2020 version 2.0 (EC 42.18). During the course of this study, all personal information was kept confidential. The data were processed in accordance with the Spanish Organic Law 3/2018, of 5 December 2018, concerning the protection of personal data and the guarantee of digital rights. Researchers or institutions involved in the study provided direct access to the data or source documents for monitoring, auditing, and review by CEIm-R. The health authorities were also permitted to inspect the trial. Ruiz-Ojeda et al., 2022, and Plaza-Diaz et al., 2023, provide further details regarding the study protocol ,25.The objective of INNOVA 2020 was to evaluate the equivalence of two starting formulas for infants through a multicenter, randomized, double-blind, parallel, comparative study. A third unblinded group of BF infants was used as an additional reference group for exploratory analysis. There was a common label on both infant formulas, ensuring the blinding of the investigators and participants. The current EU legislation (EC Regulation No. 1924/2006) does not require specific clinical tests to demonstrate that infant formulas are nutritionally and healthfully beneficial .In the study, a pediatrician informed parents that their children could participate as early as 15 days of age. As soon as they agreed to participate, they attended the health center for a baseline visit a week later (at 21 days of age). The pediatrician requested relevant information from the mother’s medical history during the 15-day meeting with the parents. It was necessary to obtain this information for the study, and it was not included in the pediatric history. When a visit took place within the scheduled time, it was considered valid with a margin of 3 days for a 21-day visit, 1 week for a 2-month visit, and 2 weeks for a 4-, 6-, or 12-month visit. More information regarding inclusion and exclusion criteria, withdrawal of participants, and study procedures can be found in Ruiz-Ojeda et al., 2022 .https://clinicaltrials.gov/ct2/show/NCT05303077, accessed on 1 April 2023) on 31 March 2022, which was last updated on 7 April 2022.According to the guidelines published by the AAP Task Force on Clinical Testing of Infant Formula , the stuo® Innova 1 Group 1: Nutribéno® Standard Group 2: NutribénoGroup 3: BF Infants were recruited from primary care pediatric clinics by the pediatricians participating in the trial. A pediatrician informed and invited parents of 15-day-old infants who regularly visited their offices for routine medical examinations to participate in the study. In the formula-feeding group, infants who were unable to BF (for a variety of reasons) were invited to participate. For every two infants supplemented with infant formula, a candidate BF subject was recruited at each center. This was necessary in order to maintain balance between the three arms of the study. Infants who met the inclusion and exclusion criteria of the study were included in the BF group .The experimental product object of this trial (INN) and the STD formula comply with the recommendations of the ESPGHAN and with Regulation 609/2013 of the European Parliament and of the Council regarding foods intended for children, infants, and young children; foods for special medical purposes; and complete diet substitutes for weight control . The supTo ensure the stability of the fecal samples, ADM-Biopolis provided a kit that included a buffer for sample stabilization. Durviz S.L., Valencia, Spain, provided a collector tube with components of 0.02 M EDTA, 0.025 M sodium citrate dihydrate, and 5.3 M ammonium sulfate . In accordance with the specifications of the manufacturer, DNA remains stable at room temperature (15–25 °C) for several months and at −20 °C or −80 °C indefinitely. Following the original codes provided by the researchers, the samples were processed and sequenced, and the group was assigned in the final bioinformatics analysis.Following a modified protocol from Yuan et al. , an optiA PCR amplification of the extracted DNA was performed using primers that target the hypervariable regions of 16S, V3, and V4  and a prRaw sequences were demultiplexed using Illumina bcl2fastq2 Conversion Software v2.20, and raw data were imported into QIIME 2 2020.8 open-source software  by usingUsing the vegan library , the divPICRUSt2  was used2SO4 at a flow rate of 0.6 mL min−1. Identification was performed by comparison with the retention time of standards, and calibration curves were used for quantification.An ELISA kit was used to determine the levels of Calprotectin and IgA, following the instructions of the manufacturer . Lactic acid and SCFAs  were determined using high-performance liquid chromatography (HPLC). An Alliance 2695 HPLC system coupled to a refractive index detector  was used. The column used was an Aminex HPX-87H (300 mm × 7.8 mm) from Bio-Rad  at a temperature of 60 °C. Isocratic elution was performed with 5 mM HA Rivera-Pinto analysis identifies microbial signatures, i.e., groups of microbes that predict phenotypes of interest. These microbial signatures may be used to diagnose, prognosticate, or predict therapeutic responses based on an individual’s unique microbiota. As a consequence, identification of microbial signatures requires both modeling and variable selection, i.e., modeling the response variable and selecting the taxa that provide the highest level of classification or prediction accuracy. We evaluated specific signatures at the phylum and genus levels as part of the Rivera-Pinto method and Selbal algorithm, a method of selecting a sparse model that adequately explains the response variable of interest. Based on data collected from two groups of taxa, geometric means are used to calculate microbial signatures. As the name implies, these groups are those with relative abundances, or balances, that are related to the response variable of interest .p-value was calculated. The different letters indicate significant differences (p < 0.05) calculated using an independent sample median test and Bonferroni correction for multiple testing.Data are expressed as medians and ranges. Using the independent sample median test, the p < 0.05 was considered statistically significant. Rivera-Pinto and Selbal algorithms were applied to identify specific signatures at phylum and genus levels; based on geometric means of data from two groups of taxa with relative abundances, or balances, that are related to the response variable of interest, this method identifies microbial signatures [The functional pathways profile data and the SCFAs are presented as means and standard errors of the means. According to the independent sample median test, gnatures .This study examined the relationships between diversity indices, microbiome variables, metabolic parameters, SCFA levels, and clinical outcomes using Pearson’s correlations (bronchiolitis and gastrointestinal symptoms were published elsewhere , as thesAs a result of our study, we found that the INN formula had a similar impact as the BF formula on the fecal microbiota, in silico metabolic pathways, and certain biochemical parameters related to immunity at 12 months. The addition of novel ingredients to starting formulas represents a growing field of research that should always be evaluated using randomized clinical trials. Future intervention studies should investigate the mechanisms of microbial action through which the diet affects the development of the gut during the first year of life and beyond.


With the continuous development of China's economy and the improvement of residents' living standards, it also brings increasing costs of labor and rent. In addition, the impact of the pandemic on the entity industry has brought opportunities for the development of new retail models. Based on the booming development of artificial intelligence, big data, and mobile payment in the new era, the new retail industry using artificial intelligence technology has shown outstanding performance in the market. Among them, intelligent vending machines have emerged in the new retail model. In order to provide users with a good shopping experience, the product detection speed and accuracy of intelligent vending machines must be high enough. We adopt Faster R-CNN, a mature object detection algorithm in deep learning, to solve the commodity settlement scenario of intelligent vending machines. In recent years, deep learning-based computer vision methods have received extensive research attention, especially the ResNet proposed by He et al. , which aThe object detection of retail product checkout in intelligent vending machines faces several challenges. One challenge is that it is difficult to predict user behavior, and the products in checkout images may be stacked, placed in abnormal ways, or obscured by obstacles (such as hands). The challenges mentioned above may result in the algorithm receiving insufficient information. Therefore, it is essential to ensure that the accuracy of product detection meets the requirements in such cases. Another challenge is the detection speed of the algorithm, which is crucial for improving the user experience. This article addresses these two issues by selecting a unique dataset for training on single-target commodities from multiple angles and perspectives and verifying it on multi-target items. Meanwhile, ResNet50 is chosen as the backbone neural network of Faster R-CNN to improve feature extraction for each product's angle and enhance the overall performance and prediction speed of the model. The Faster R-CNN based on ResNet50 used in this article achieves good accuracy and acceptable response speed in the intelligent vending machine product checkout scene.Intelligent vending machines have advantages such as flexible stocking and low costs compared to traditional vending machines. Classic vending machines have complex manufacturing processes and high prices, are limited by the structure of the vending channel, and have a specific failure rate. At present, there are three different technical solutions for intelligent vending machines, namely gravity induction  is to generate region proposals, which are candidate regions that may contain objects. These region proposals are then fed into a subsequent classification network for object detection.The RPN operates on a feature map and uses a convolutional neural network over the feature map, generating multiple anchor boxes of different sizes and aspect ratios, as shown in The loss function of RPN consists of two parts: classification loss and bounding box regression loss. In the classification loss function, we calculate a binary classification loss for each anchor box, representing the error of classifying it as foreground (containing an object) or background (not including an object). For each anchor box, the corresponding binary classification loss is:p represents the predicted probability of the anchor box being classified as foreground, y represents the ture label.When y = =1, it represents true lable of the anchor box is foreground, and when y = =0, the true label is the background. In the bounding box regression loss function, we calculate a smooth L1 loss for each anchor box that is classified as foreground, which represents the difference between the predicted bounding box coordinates and the true bounding box coordinates. For each foreground anchor box, its corresponding L1 loss is:Where t* represents the true bounding box coordinate offset, t represents the predicted bounding box coordinate offset, and i represents the dimension of the coordinate axis. The N represents the number of anchor boxes classified as foreground.After computing the loss functions for both components, we add them together to obtain the final RPN network loss function:Here, p and t denote the classification prediction and bounding box regression prediction of the RPN network, while and t* represent the true bounding box coordinate offsets. Ncls and Nreg correspond to the numbers of all and foreground anchor boxes, respectively. λ is a hyperparameter that balances the classification loss and bounding box regression loss.Since the dimensions of the images are not the same, it means that the corresponding feature map sizes are also different. The purpose of ROI pooling is to unify the feature map sizes, making it easier for subsequent neural network processing. The implementation of ROI pooling involves dividing the feature map into 7 × 7 regions and performing max pooling within each region.The feature map image outputted by the ROI Pooling layer is a three-dimensional tensor of size 7 × 7 × 2048. We flatten it into a one-dimensional vector of size 1 × 100,352. Then, we concatenate these vectors in the order of their corresponding ROIs in the input image, forming a two-dimensional tensor of size 64 × 100,352 This two-dimensional tensor serves as the input to the fully connected layer for classification and regression tasks.https://www.kaggle.com/datasets/diyer22/retail-product-checkout-dataset). This dataset provides rich image data of products during the checkout process and is currently the largest dataset regarding the number of images and product categories. It includes 200 common product categories in daily life, with a training set of 48,000 single-product images, a test set of 24,000 multi-target product images, and a validation set of 6,000 multi-target product images.The dataset used in this article is a large-scale retail product checkout dataset publicly available on Kaggle , AP (IOU = 0.5), AP (IOU = 0.75), AP , AP (Medium Area), and AP (Large Area), AR , AR (Max = 1), AR (Max = 10), and AR (Max = 100). Among them, AP(IOU = 0.5) is the most commonly used metric. The experimental results are shown in This section presents the model's prediction performance under different difficulty levels, and the detection of the goods is good. See After years of development, object detection technology has made rapid progress, and there are now many mature and efficient object detection algorithms such as Faster R-CNN, YOLO, SSD, and others. In this paper, we successfully applied Faster R-CNN for object detection in the context of commodity settlement and achieved good results. Using object detection in computer vision as a commodity settlement recognition task for intelligent vending machines is reliable, low-cost, and efficient.The Faster R-CNN object detection model based on ResNet50 constructed in this paper achieved good results on a large commodity dataset, with precision meeting the requirements on recognized targets and a very low probability of misclassification. However, there are still cases of missed detections in multi-object scenarios, which I believe can be improved through further training. At the same time, the model constructed in this paper has already met the recognition speed requirements for intelligent vending machines, but there is still room for improvement.https://www.kaggle.com/datasets/diyer22/retail-product-checkout-dataset.Publicly available datasets were analyzed in this study. This data can be found here: JX: Conceptualization, Investigation, Software, Writing—original draft, Writing—review & editing. ZC: Writing—original draft, Writing—review & editing. WF: Writing—review & editing, Funding acquisition.


Caregiver preparedness is defined as the perceived preparation of caregivers to care for the physical and emotional needs of the patient.This study investigated caregiver preparedness and its influences on caregiver burden, depression, and quality of life (QoL) in caregivers of individuals with disabilities.We conducted a multicenter cross-sectional survey study on caregivers caring for patients with disabilities. Sociodemographic characteristics were collected via questionnaires. The Preparedness for Caregiving Scale (PCS), Burden Interview (BI), Center for Epidemiologic Studies Depression Scale (CES-D), and EuroQol-Visual Analogue Scale (EQ-VAS) were administered.p < 0.001), CES-D , and EQ-VAS . The CES-D was significantly associated with the PCS after controlling other variables. However, PCS did not show any correlation with the duration of caregiving or amount of time spent per day on caregiving.A total of 151 caregivers were enrolled. The mean age of caregivers was 53.7 ± 12.4 years, and 80.8% were female. The majority of participants were the main caregivers of patients with stroke, spinal cord injury, or traumatic brain injury. The mean PCS score was 2.1 ± 0.9, demonstrating significant relationships with BI (r = −0.512, The clinical implications of this study are that higher caregiver preparedness is a predictor of less caregiver burden and depression, and better QoL. However, preparedness did not increase as the duration or time spent on caregiving was extended. Therefore, efforts to enhance the caregivers’ preparedness are required to reduce caregiver burden and improve health outcomes for both caregivers and patients. According to the World Report on Disability by the World Health Organization, approximately 15% of the world’s population lives with some form of moderate to severe disability; 2–4% of whom experience significant difficulties in functioning . Many ofCaregiver burden has been recognized, and the need for efforts to reduce it has also been addressed. It is well-established that caregiver burden is associated with poor health-related quality of life (HRQoL) , 5 and wCaregiver preparedness is defined as perceived readiness for the caregiving role , 14. ThiFamily caregivers often engage in caregiving without any preparation for their tasks owing to an unexpected diagnosis of a disease and trauma in their family member. Regardless, caregivers of patients were requested to manage patient symptoms, including pain, fatigue, dyspnea, and fever . AdditioConcerns regarding the need to enhance caregiver preparedness have emerged to reduce caregiver burden and improve the quality of caregiving for patients with various diseases or conditions. However, there have been no studies addressing the preparedness with other outcome measures including caregiver burden, depression, and QoL in caregivers of individuals with disabilities. This study aimed to investigate caregiver preparedness using the PCS and its influences on caregiver burden, depression, and QoL in those caring for individuals with disabilities.2.2.1.We conducted a multicenter cross-sectional survey between October and December 2020 in three hospitals: one tertiary university hospital and two rehabilitation hospitals. The inclusion criteria were as follows: informal caregivers of patients with disabilities, including stroke, traumatic brain injury, and spinal cord injury, and those who provided informed consent. Informal caregivers included family member, relatives, and friends. Disability was defined as activity limitation due to diagnosis of specific diseases. The exclusion criteria were as follows: caregivers who received payment for caregiving and those who could not understand or complete the questionnaire. The institutional review board of each institution reviewed and approved the study protocol. Written informed consent was obtained from all participants included in this study.2.2.A face-to-face survey was conducted with caregivers caring for patients with disabilities who were either receiving rehabilitation in an inpatient unit or visited the outpatient rehabilitation clinic. All data were collected via self-administered questionnaires with the assistance of a researcher. For example, the researcher responded to participants’ enquiries on the questionnaire and assisted in completing it.The questionnaire used in this study was developed by a team composed of physiatrists, psychologist, occupational therapist, and rehabilitation nurse. It consisted of sociodemographic variables of the caregivers and patients, time burden of caregiving, caregiver preparedness, burden, depression, and QoL of them. Caregivers’ sociodemographic characteristics included age, sex, education level, relationship with the patient, whether they were the main caregiver or not, and income. The main caregiver was defined as an individual who spent the majority of their time with the patient and made decisions for the patient. Patients’ demographics included age, sex, education level, primary diagnosis that caused the disability, duration of disease from onset (months), comorbidity index using the Charlson Comorbidity Index (CCI) , ModifieFurthermore, the time burden of caregiving was investigated based on the duration of caregiving (months), amount of time spent per day on caregiving (hours), and presence of a family member who provided help.2.3.Caregiver preparedness, the PCS consists of eight items that ask caregivers to evaluate how well prepared they think they are to take care of the care receiver’s needs . It was Caregiver burden was measured with the most widely used 22-item version of the Zarit Burden Interview (ZBI or BI) . The BI The Center for Epidemiologic Studies Depression Scale (CES-D), a self-report tool to evaluate depressive symptoms in the general population, was used as a measure of depression . This scHealth-related quality of life (HRQoL) was assessed using the EuroQol-Visual Analogue Scale (EQ-VAS). Responders provide a global assessment of their health ranging from 0  to 100  .2.4.p < 0.05. Post-hoc statistical power was calculated based on medium effect size of 0.15 using G*Power 3.1.9.7 .Statistical analyses were conducted using SPSS ver. 17.0 for Windows . Data were analyzed using descriptive statistics for sociodemographic variables, time burden for caregiving, and outcome measures including PCS, BI, CES-D, and EQ-VAS scores. Correlations between the PCS score and other outcome measures and time burden values were assessed using Pearson’s correlation coefficients. Additionally, influence of the PCS on other outcome measures was evaluated using multivariate analysis of variance. Multiple linear regression analysis was conducted to identify the marker that independently influenced the PCS score. After confirming a significant association by univariate linear regression, a multiple linear regression model was generated for all outcome measures including BI, CES-D, EQ-VAS, and MBI. The statistical significance level was set at 3.3.1.A total of 151 caregivers participated in this study. 3.2.The time burden of caregiving is presented in 3.3.3.4.Pearson’s correlation analysis was conducted between the PCS and other outcome measures as well as the time burden of caregiving . The PCS3.5.p < 0.001; Among the sociodemographic variables, time burden, and outcome measures, the MBI, BI, CES-D, and EQ-VAS showed significant associations with the PCS in the univariate linear regression analyses. A multiple linear regression model was applied using these outcome measures as independent variables. After controlling for other factors, depression was identified as the most significant independent factor for PCS score (β = −0.035, standard error [SE] = 0.007, 4.The present study showed that caregiver preparedness was significantly associated with caregiver burden, depression, and QoL. Among these markers, depression was the only statistically significant independent factor associated with caregiver preparedness, although the effect size seems to be small. However, the duration of caregiving and amount of time spent on caregiving were not related to caregiver preparedness. Although a caregiver had cared for a patient for a long time and spent most of their time on caregiving, this did not mean that they were well-prepared for this role.Forty-three percent of caregivers were the patients’ offspring of in this study. This reflects cultural characteristics emphasizing the filial role of offspring for caregiving in East Asia. Additionally, family caregivers often perform caregiving without any training or education. A lack of preparation for caregiving could lead to considerable burden, anxiety and depression in family caregivers. In a study of caregivers of patients with cancer, there was a significant negative correlation between preparedness and burden . FurtherAmong the outcome measures, depression was only significantly related to caregiver preparedness after controlling for other factors in this study. In a study examining the influence of preparedness on depression and QoL in caregivers of patients with heart failure, caregiver preparedness measured by the PCS was significantly correlated with depression, assessed using Hospital Anxiety and Depression Scale . In addiThe amount of caregiving experiences does not guarantee the caregiver’s ability or preparedness for caregiving. A previous study investigated caregiver preparedness at the time of the care recipient’s discharge from medical institutions, as well as 7–10 days, and 1 month after discharge ; caregivResilience is defined as the process of adapting to difficult or challenging life experiences, and an ability to overcome stressful situations . Higher Based on the current and previous studies, enhancing caregiver preparedness is extremely important, as preparedness improves caregiver burden and QoL, as well as the health outcomes of patients. A meta-analysis reported that interventions for family caregivers, such as psychoeducation, supportive care, self-care, and educational programs, significantly increased preparedness for caregiving . These iStatistical power was adequate in this study. However, there are some limitations. First, all participants were caregivers of patients undergoing rehabilitation for a few specific conditions. Therefore, the findings cannot be generalized to caregivers of patients with various diseases or conditions. Second, this was a cross-sectional study, therefore, changes in preparedness over time could not be evaluated. Third, the resilience of the caregivers was not assessed.In conclusion, higher caregiver preparedness was found to be a predictor of less caregiver burden and depression, and better QoL for caregivers. Notably, depression was a significant independent factor related to caregiver preparedness. However, preparedness was not increased with caregiving duration or time input. Additional efforts are necessitated to improve preparedness of caregiving, such as caregiver education and providing resources via web-based or community center. Therefore, strategies for enhancing preparedness of the caregivers are essential to reduce caregiver burden and improve quality of care.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Institutional Review Board of Konkuk University Medical Center, Seoul, Korea; Institutional Review Board of National Traffic Injury Rehabilitation Hospital, Yangpyeong, Korea; Institutional Review Board of National Rehabilitation Center, Seoul, Korea. The patients/participants provided their written informed consent to participate in this study.KU, MO-P, and JL: conceptualization and project administration. KU, HJ, MW, HK, BL, EK, JK, and SL: data curation, investigation, and methodology. KU and JL: formal analysis and writing. All authors contributed to the article and approved the submitted version.This study was supported by the Rehabilitation Research & Development Support Program [#NRCRSP-EX20013], National Rehabilitation Center, Ministry of Health and Welfare, Korea.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Soil bacterial communities are intricately linked to ecosystem functioning, and understanding how communities assemble in response to environmental change is ecologically significant. Little is known about the assembly processes of bacteria communities across agro-ecosystems, particularly with regard to their environmental adaptation. To gain further insights into the microbial community characteristics of agro-ecosystems soil in the Panxi area of Sichuan Province and explore the key environmental factors driving the assembly process of the microbial community, this study conducted field sampling in major farmland areas of Panxi area and used Illumina MiSeq high-throughput sequencing technology to conduct bacterial sequencing. Soil organic matter (SOM), alkali-hydrolyzed nitrogen (AN), available phosphorus (AP), available potassium (AK) and other environmental factors were determined. The membership function method and principal component analysis method were used to evaluate the fertility of the soil. The results revealed minimal differences in alpha diversity index among samples with different comprehensive fertility indices, while NMDS analysis showed that community differences between species were mainly reflected in high fertility and low fertility . Proteobacteria, Acidobacteria and Actinobacteria were the main types of microbial communities, accounting for more than 60% of the relative abundance. Proteobacteria accounted for a higher proportion in the high fertility samples, while Acidobacteria and Actinobacteria accounted for a higher proportion in the middle and low fertility samples. Both the neutral theoretical model and zero model analysis showed that the microbial communities in tobacco-planting soil with different comprehensive fertility indices presented a random assembly process. With the increase in environmental distance difference, the diversity of the microbial community in medium and low-fertility soil also increased, but there was no significant change in high-fertility soil. Redundancy analysis showed that pH and SOM were the key factors affecting microbial community composition. The results of this study can provide a theoretical reference for the study of environmental factors and microbial communities in tobacco-growing soil. This region is a subtropical monsoon climate zone with distinct dry and wet, abundant solar and thermal resources, abundant rainfall, large daily temperature difference and small annual temperature difference. With unique ecological conditions of high-quality flue-cured tobacco planting, it is one of the country’s high-quality flue-cured tobacco production areas. The study area has complex and diverse landforms, high in the northwest and low in the southeast, with interleaved mountains, deep valleys, plains, basins and hills. The total area of tobacco planting in the 13 main tobacco-producing counties in the Panxi region is 75,300 hectares, which is mainly distributed between 1,000 and 2,500 m above sea level, and the proportion of tobacco planting accounts for more than 65% of the cultivated land area in this region .2.2.To avoid the influence of fertilization on the representativeness and evenness of sampling, sampling was conducted after tobacco leaf harvest. A total of 123 representative tobacco fields were selected, and a 5-point sampling method was used to collect topsoil  in each tobacco field. For the specific sampling point information, see 2.3.Soil abiotic properties factors, including soil organic matter (SOM), pH, total nitrogen (TN), available nitrogen (AN), available phosphorus (AP), available potassium (AK) were measured as previously described . Water s2.4.The extraction of soil DNA was conducted from each soil sample using a PowerSoil DNA Isolation Kit  following the manufacturer’s instructions. The total genomic DNA was extracted from 1.5 g of fresh soil (0.5 g × 3) and then mixed. The NanoDrop  was employed to quantify and assess the quality of DNA samples. Using a 2% agarose gel electrophoresis to confirm the integrity of the DNA extracts and storing all extracted DNA from soil in −80°C refrigerator . Using P2.5.The QIIME  workflow was employed to identify the interrogative sequence. The UCHIME (v5.2.236) algorithm was used to filter raw flowgrams and remove noise and chimeras . Complet2.6.p < 0.05) was used to separate the means between different treatments within respective sampling instances. Correlations between the soil bacteria species compositions and soil properties were determined using redundancy analysis (RDA) with CANOCO version 5.0. Pearson correlations and Mantel test were visualized using R software via the “linkET” package  to examine differences between means. In this case, the least significant difference . Hub and connector taxa were determined by among-module connectivity (Pi) and within-module connectivity (Zi), with nodes categorized into module hubs (Pi < 0.62 and Zi > 2.5), connectors (Pi > 0.62 and Zi < 2.5), network hubs (Pi > 0.62 and Zi > 2.5) and peripheral nodes (Pi < 0.62 and Zi < 2.5), as proposed previously  on crops. The weight of each index was calculated by the principal component analysis method, and then the comprehensive evaluation index value of soil fertility was calculated according to the additive and multiplication principle of fuzzy mathematics, with the following equations :where Wi and Ni represent the membership value and weight value of the ith soil fertility factor, respectively. The common membership function can be divided into S-type and Parabola-type functions. For the convenience of calculation, the curve function is converted into a broken line function, and the corresponding function expression and broken line graph are shown in Equations 2, 3 .S-type function:Parabola-type function:1, O2, and U are detailed in The membership function types of each factor and the specific values represented by L, O3.3.1.p < 0.05), and the major differences were observed between LF and HF  with connectors hubs, module hubs and peripheral species in all groups. In LF group, SOM, pH, TN, AN, WSCa, WSMg, WSCl, ACu, AZn, AFe, Mn had significant correlations with the keystones, in MF were pH, AP, AK, WSMg, WSCl, AZn, AMn, and in HF were pH, TN, AP, WSCl, ACu, AFe, AMn.Pairwise comparisons of environmental factors are shown that pH was negatively correlated with other factors except WSCa and WSMg  successfully estimated a large fraction of the relationship between the occurrence frequency of OTUs and their relative abundance variations –C, with M success4.In this study, we have demonstrated that an increase in soil comprehensive fertility index is positively correlated with microbial alpha diversity. Furthermore, our results indicate that the Shannon and Chao1 indices were significantly higher in HF soils compared to MF and LF soils. These findings suggest that enhancing soil fertility can provide a more nutrient-rich environment for microbes, leading to increased diversity . The difThe results of VPA indicate that there are numerous variations that cannot be accounted for by soil properties alone. Notably, the explanation rate of microelements was found to be dominant in LF soil, while that of macroelements was dominant in HF soil. This was mainly due to the fact that the important role of microelements is more obvious due to the imbalance of soil nutrients when the integrated fertility is low, and low soil fertility will further lead to increased plant demand for microelements. This also indicates that in addition to the influence of soil properties on microbial communities, microbial communities themselves also have interactions . Co-occu2 was slightly higher in the HF than LF soils, and according to the calculated Nm values, bacteria dispersal between the sampling sites in HF is likely higher than LF counterparts  is a neutral-based process model, which is a valid approach for inferring stochastic processes acting on community assembly, and has been successfully applied to a wide range of ecological phenomena. This model allows researchers to quantify the importance of processes which are difficult to observe directly but can have large influence on microbial communities  can be found at: CY and YZ contributed to the study’s conception and design. Material preparation were performed by ZZ, YC, and GY. Data collection and analysis were performed by YX, TL, and HD. The first draft of the manuscript was written by YX and TL. All authors contributed to the article and approved the submitted version.This work was funded by the Key Project of China National Tobacco Corporation (11202102037). The funder has no involvement in the study design, analysis, interpretation of data, writing of the article or the decision to submit it for publication.TL, HD, ZZ, and YZ were employed by Zhengzhou Tobacco Research Institute of CNTC. YC was employed by Liangshan Branch of Sichuan Tobacco Company. GY was employed by China Tobacco Henan Industrial Co., Ltd.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The high multimorbidity and lower socioeconomic status (SES) of older adults, can lead to catastrophic health expenditures (CHEs) for older adults’ households. However, whether widowed older adults will bear such a financial burden has yet to be explored. The aim of this study was to investigate the influence of multimorbidity patterns and SES on CHE in Chinese widowed older adults.Data was obtained from the 2018 China Health and Retirement Longitudinal Study (CHARLS). This is a cross-sectional study. A total of 1,721 widowed participants aged 60 years and older were enrolled in the study. Latent class analysis was performed based on 14 self-reported chronic diseases to identify multimorbidity patterns. The logistic model and Tobit model were used to analyze the influence of multimorbidity patterns and SES on the incidence and intensity of CHE, respectively.per capita income), respondents with a middle school and above education level were more likely to generate CHE compared to those who were illiterate. Respondents who were in the unemployed group were more likely to generate CHE compared to agricultural workers. In addition, respondents aged 70–79 years old, geographically located in the east, having other medical insurance, or having fewer family members are more likely to generate CHE and have higher CHE intensity.About 36.72% of widowed older adults generated CHE. The incidence and intensity of CHE were significantly higher in the cardiovascular class and multisystem class than in the minimal disease class in multimorbidity patterns . Among SES-related indicators (education, occupation and household Widowed older adults are at high risk for CHE, especially those in the cardiovascular and multisystem disease classes, and those with low SES. Several mainstream health insurances do not provide significant relief. In addition, attention should be paid to the high-risk characteristics associated with CHE. It is necessary to carry out the popularization of chronic disease knowledge, improve the medical insurance system and medical service level, and provide more policy preferences and social support to widowed older adults. Catastrophic health expenditure (CHE) is generally defined as a household’s health expenditure as a percentage of total expenditure or income level reaching a threshold that has a catastrophic impact on the family’s financial situation and quality of life . The occMultimorbidity refers to the occurrence of two or more chronic diseases in an individual at the same time , and it per capita, have been declared to have a significant impact on household CHE for older adults patients with chronic diseases. Equity in policies that reduce the incidence of CHE must be promoted by addressing socioeconomic factors that impact healthcare outcomes for older adults , a nationally representative longitudinal survey of Chinese adults aged 45 years and above . The basIn this study, we used the data of CHARLS 2018, the fourth wave of its survey data, with a total of 19,816 respondents. Participants who met the required criteria  were included in the study, and 1,721 participants were finally included.The dependent variables in this study were the incidence and intensity of CHE. Build on previous research , 43–45, Annual household health expenditure was regarded as out-of-pocket (OOP) medical expenditure. We used pooled binary variables to determine the presence or absence of CHE in a participant’s household:Among them, The strength of CHE indicates the extent to which OOP payments affect family life . It is eAmong them, The CHARLS 2018 survey collected information on whether participants had been diagnosed with any of the following 14 chronic conditions: hypertension, dyslipidemia, diabetes, cancer or malignant tumor, chronic lung disease, liver disease, heart disease, stroke, kidney disease, stomach and other digestive disease, emotional and psychiatric problems, memory-related disease, arthritis or rheumatism, and asthma. All the diseases were treated as dichotomous variables. LCA was used to identify multimorbidity patterns and to identify the category to which participants belonged.per capita income. It has been shown that a higher level of education of an individual is associated with a lower frequency of use of medical services but a greater willingness to pay for medical services when needed , age group , residence , geographic location , type of health insurance , any financial support from family members or relatives and friends (yes or no), provision of any financial support to family members or relatives and friends (yes or no), difficulties in activities of daily living , and number of family members.Logistic regression model is one of the most important and widely used nonlinear statistical models to analyze dichotomous variables. In this model, the dependent variable is binary (y = 0 or y = 1), and the outcome variable has a nonlinear relationship with the independent variables. Tobit regression model is a kind of linear regression model, which is characterized by the truncation phenomenon of its dependent variable. Truncation means that some observations are not observed, that is, they are limited to a certain range of values. Tobit regression model can transform the truncated data into a probability model, and then perform statistical analysis on the truncated data.Multimorbidity patterns as well as category affiliation of individuals were determined by performing LCA on chronic disease information from 1,721 participants. The use of LCA to identify case subclasses in multivariate categorical data can achieve excellent results . The staDescriptive statistics were performed for each variable using the frequency distribution, and the differences between the two groups were compared using the chi-square test. Logistic regression model was used to analyze the influence of multimorbidity patterns and SES on the incidence of CHE. Tobit regression model was used to analyze the influence of multimorbidity patterns and SES on CHE intensity. CHE intensity was a continuous variable of no less than 0, and more than 60% of the participants had CHE intensity equal to 0, so the Tobit regression model applicable to the truncated data was utilized .p values of less than 0.05 were envisaged for indicate statistical significance.LCA was performed using Mplus version 8.3, and Stata version 16.0 was used for all statistical analyses. Two-sided Of 1,721 participants, 73.39% were female. Most were in the 70–79 age group (39.45%), and more than four out of five (81.12%) lived in rural areas. About 6.16, 28.82, 28.82 and 36.20% of the subjects resided in northeastern, eastern, central and western China, respectively. Most participants (64.85%) were enrolled in NCRCMS. 89.77% received financial support from family members, and 50.49% provided financial support to family members. Nearly one-fifth (19.99%) of the subjects had difficulty in ADL. A total of 632 participants (36.72%) had CHE. The mean intensity of CHE was 0.108 with a standard deviation of 0.182 .In identifying multimorbidity patterns, we examined class 2–5 models by LCA. The three-level model appeared to be the best-fitting model  and showper capita were grouped into a single category. Whereas the others were divided into five equal groups from lowest to highest  of the participants were illiterate. In terms of occupation type, more than half (55.20%) of the participants were unemployed. Participants who did not provide information on household income  highest .p = 0.006), age (p < 0.001), geographic location (p = 0.012), multimorbidity patterns (p < 0.001), education (p = 0.012), occupation (p = 0.003), household per capita income (p < 0.001) and number of family members (p < 0.001) were significant differences between the group with CHE and the group without CHE (Gender (hout CHE . Among tp < 0.001). Specifically, subjects in the cardiovascular class were most likely to generate CHE , followed by multisystem class . In SES, education level of middle school and above was a protective factor for CHE , and unemployed occupation type presented a risk factor for CHE . In addition, the incidence of CHE was higher in participants aged 70 to 79 years, geographically located in the East, with other insurance type, or with a relatively small number of family members  and multi-system cluster  were significantly higher than that of the minimal disease group. In SES, Education level of middle school and above , and the unemployed  had a higher CHE intensity. In addition, CHE intensity was significantly higher among participants who aged 70–79 years, geographically located in the East, had UEBMI, NRCMI or other MIs, or who had a relatively small number of family members . The patients/participants provided their written informed consent to participate in this study.ZW conceived the idea, analyzed the data, and wrote the manuscript. ZZ provided advice on research methods and discussion of the manuscript. All authors contributed to the article and approved the submitted version.The research was supported by supported by Key Research Center for Humanities and Social Sciences in Hubei Province  and Humanity and Social Science Youth Foundation of Ministry of Education of China (17YJCZH015).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This study aimed to investigate the prevalence, to analyze trajectory model based on EPDS scoreParticipants from four maternity hospitals in Chengdu, China were recruited when they had their first pregnancy medical check-up during March 2019 to May 2020. All participants were required to fill in Edinburgh Postnatal Depression Scale Chinese version (EPDS) once during three trimesters and provided information about their health status, social-demographic etc. The trajectory model, chi-square test and multivariate binary logistic regression were used to analyze all collected data.P = 0.007, OR = 0.33, 95% CI 0.147 ~ 0.74), good relationship with parents-in-law , planned pregnancy  were the protective factors while lower education level , fear about dystocia , recent major negative life events  were the risk factors of medium-risk group. Good marital relationship , good relationship with parents-in-law  were also protective factors of high-risk group, but the risk factors for high-risk group were medical history , pregnancy complications , worry about dystocia , recent major negative life events . No protective or risk factors were identified for low-risk group.A total of 4560 pregnant women were recruited, while 1051 women completed the study. The prevalence of depression symptoms during the first, second and third trimesters were 32.92% (346/1051), 19.79% (208/1051) and 20.46% (215/1051) respectively. According to the results of the latent growth mixture modeling, the trajectory model of three categories based on EPDS score were identified in this study: low-risk group , medium-risk group  and high-risk group . Good marital relationship (Even the incidence and levels of depression in the first trimester of pregnancy were the highest, the probability of pregnancy women get depression during gestation period were higher than other population. Therefore, it’s important to monitor the psychological status of pregnant women during the whole pregnancy, especially in the first trimester. The study suggested a good partner relationship and good relations with parents-in-law both protected pregnant women from depression and promoted the well-being of mothers and children. Antenatal depression (AD) is one of the most prevalent psychiatric disorders, which may lead to devastating impacts on both mothers and infants’ health . The preThe recent meta-analysis reported the prevalence of AD is 18.1% in high-income countries (HICs), 24.2 to 30.8% in Low- and Middle-Income Countries (LMICs). StudiesRelevant factors from studies were summarized into the following major categories: pregnant.women’s demographic characteristics ; psycho-social factors ; health-related factors ; as well as lifestyle and cognitive aspect  , 21. ComMost of studies only investigated the prevalence of AD when pregnant women during her third trimester, while quite few studies cared about the situation of AD in first and second trimester. There were little studies tracked the incidence of AD across first to third trimester, especially the trajectory of depression during pregnancy which may help to understand the development of AD.Thus, the current study aimed to establish the prevalence and trajectory model of AD based on EPDS score across the whole pregnancy. Meanwhile to explore the possible influence factors of AD among pregnant women. Ultimately, this study also aimed to screen the pregnant women who have depression and try to provide them with intervention, as well as set up measurements for improving the mental health of pregnant women in Chengdu across all trimesters.+6 weeks and before); 2) being able to listen, read and write. Exclusion criteria: 1) pregnant with a history of mental diseases or mental disorders; 2) failing to complete the study; 3) obvious errors or missing data more than 20% in the survey.This study was a prospective multi center cohort survey. Multi-stage stratified convenient sampling was adopted in the research. Stage 1: From the official website of Chengdu Municipal Health Commission, four maternity hospitals at different levels  were selected by using the method of stratified convenient sampling. Stage 2: We recruited pregnant women by posters who attended their first pregnancy medical check-up  and had follow-up at four selected antenatal maternity hospitals between March 2019 and May 2020, by using the method of convenient sampling. Inclusion criteria: 1) women diagnosed with pregnancy  with the researcher in a private consultation room. An interval for each collection was at least four weeks. The questionnaires consisted of two parts: I. General information (self-designed questions): (a) social-demographic data included age, education, marriage and occupation, etc.; (b) Social support factors in recent three months included marital relationship, relations with parents-in-law, household income, recent major life events and taking care of children, etc.; (c) Obstetric information included disease history, times of pregnancy, times of delivery, appetite, sleep and pregnancy complications, etc.; (d) Cognitive factors included pregnancy plan, fear of dystocia, etc.; II. Instrument of assessment of AD: Edinburgh Postpartum Depression Scale (EPDS) was developed by Cox et al.  in 1987,The study was approved by the human research Ethics Committee of four maternity hospitals (No. 2019002). During the survey, the main concepts and purposes of the study were elucidated to the participants, and the consent was obtained. The subjects were informed that the questionnaire was anonymous and they could abandon the survey at any time. The raw data were saved with password and data is only used for research purpose.p-value of less than 0.05 was considered statistically significant.EpiData software version 3.1 was used to establish the electronic database, and logical correction was conducted after data entered by two persons. Categorical variables were expressed as frequencies and percentages. Non-normal continuous variables were expressed as median and interquartile range (IQR). Mean and standard deviation (SD) were used to describe the continuous variables with normal distribution. The chi-square test, the Fisher’s exact test, the Mann–Whitney U-tests, and the Student’s t-test were used to compare the differences between groups. Multivariate binary logistic regression was used to analyze the multiple influencing factors. In this study, latent growth mixture modeling was used to analyze the trajectories based on the EPDS scores of pregnant women and full information maximum likelihood estimation was used to fit the unbalanced data in the analysis sample. The best model was selected according to Bayesian information criterion (BIC). The expected number of people in each group should account for no less than 5% of the total number of people. All the analyses were performed using the SAS software version 9.4 . A + 6 weeks, and the median was 12 weeks; The second trimester was 17 ~ 27+ 6 weeks, with a median of 24 weeks. The third trimester was 30 + 2 ~ 40 weeks, with a median of 35 weeks.The flowchart represented the whole procedure of data collecting was presented in Fig. The results showed that a total of 480 cases (45.67%) were screened for depression in at least a certain period of the entire stages of pregnancy in parallel screening. Among these data, there were 346, 208 and 215 pregnant women  identified as depression in the first, second and third trimester respectively . And the medium risk group had significant differences in planned pregnancy (P = 0.021). The details were shown in Table Compared with "low risk" group, the "medium risk" group and the "high risk" group had significant differences in education level, pregnancy thoughts, medical history, pregnancy complications, relationship with parents-in-law, marital relationship and major negative life events during pregnancy , good relationship with parents-in-law , planned pregnancy  were the protective factors of "medium risk" group, low education level , fear about dystocia , recent major negative life events  were the risk factors of the "medium risk" group. Good marital relationship , good relationship with parents-in-law  were the protective factors of the "high-risk" group, medical history , pregnancy complications , worry about dystocia , recent major negative life events  were the risk factors of "high risk" group. The details were shown in Table This study performed a binary logistic regression model for the single factors that were statistically significant. The results indicated that compared to low risk group, Good marital relationship . In addition, the prevalence of depression symptoms during the second and third trimesters were 19.79% (208/1 051) and 20.46% (215/1 051), respectively. The finding of this study was in line with the study conducted by Lee , which fThe total incidence of depression during pregnancy was 45.67% in current study which was higher than most cross-sectional studies in China. The reason may because this study was a longitudinal research addressing the prevalence of antenatal depression in all trimesters of pregnancy instead of only one trimester. Also, the prevalence of each trimester was higher than the research conducted by Lee . It illuMultivariate analysis among the medium or high risk group and the low risk group illustrated that the good partner relationship and the good relations with parents-in-law were the protective factors for both medium and high risk group, which correspond to the general idea that spouse’s relationship is the foundation of a family. The marriage surviving is inseparable from harmony relationship in the modern society with high divorce rate . CouplesThe multivariate analysis showed that fear of dystocia was the risk factor of pregnant women be depressed in the medium and high-risk group. This might be explained by the character of psychological vulnerability. People who are psychological vulnerable are prone to worry, anxiety or depression about uncertain events. Pregnancy and childbirth are one important but dangerous process in women's life. Although childbirth is much more safe than past, pregnant women may still possible confront with unexpected dangerous, for instance, emergency cesarean section, dystocia, etc. Similar to the results of the study carried out by Song , most prTherefore, pregnant women and their family are encouraged to participate in maternal education classes, and obtain relevant knowledge such as pregnancy health care, delivery, etc. The recommendations related to the appropriate types of exercise are likely to be made. They might experience Doula labor. Secondly, family members and medical workers need to respect the pregnant women's choice of delivery methods.Depression can occur in any stages of pregnancy. The incidence and levels of depression in the first trimester of pregnancy were the highest among the three trimesters of pregnancy. Therefore, it is important to enhance screening of depression in first trimester and enable appropriate interventions as early as possible. The results of current study suggested that it is necessary to establish a good partner relationship and good relations with parents-in-law, to have the confidence of childbirth, to reduce the impact of negative events on pregnant women, so as to improve the symptom of depression during every stages of pregnancy and promote the well-being of mothers and children.The current study had some limitations, first, some items such as the marriage satisfaction was measured by a subjective evaluation instead of accurately measured. In the future study, an objective investigation scale should be recommended. Secondly, the research was limited by the possible selection bias introduced by numbers of women lost to follow up. Although we used the scientific method of multi stage stratified sampling to recruit pregnant women from four hospitals at different levels in Chengdu. But in a way, attrition is inevitable in longitudinal epidemiological studies. Bellón’s  multi-ce


This opinion article highlights the potential alterations caused by insulin resistance and hyperinsulinemia on the cardiovascular system and their negative impact on heart failure (HF), and describes the potential benefits of an early screening with consequent prompt treatment. HF is the final event of several different cardiovascular diseases. Its incidence has been increasing over the last decades because of increased survival from ischemic heart disease thanks to improvements in its treatment  and the increase in life span. In particular, incidence of HF with preserved ejection fraction (HFpEF) is significantly increasing, and patients with HFpEF often are also affected by diabetes mellitus and insulin resistance (IR), with a prevalence > 45%. Concentric left ventricular (LV) remodeling and diastolic dysfunction are the main structural abnormalities that characterize HFpEF. It is well documented in the literature that IR with chronic hyperinsulinemia, besides causing type 2 diabetes mellitus, can cause numerous cardiovascular alterations, including endothelial dysfunction and increased wall thicknesses of the left ventricle with concentric remodeling and diastolic dysfunction. Therefore, it is conceivable that IR might play a major role in the pathophysiology and the progressive worsening of HF. To date, several substances have been shown to reduce IR/hyperinsulinemia and have beneficial clinical effects in patients with HF, including SGLT2 inhibitors, metformin, and berberine. For this reason, an early screening of IR could be advisable in subjects at risk and in patients with heart failure, to promptly intervene with appropriate therapy. Future studies aimed at comparing the efficacy of the substances used both alone and in association are needed. Chronic heart failure (HF) represents the final clinical evolution common to several cardiovascular diseases characterized by different specific etiology and pathophysiology. HF is the leading cause of hospitalizations in individuals aged >65 years. The crude age-adjusted incidence ranges from 1 to 5 cases per thousand person-years, and there is an exponential increase in incidence with advancing age. Its prevalence ranges from 3 to 20 individuals per 1000 people over 65 years of age.Chronic HF is still burdened by high mortality: only 35% of patients are alive 5 years after the first diagnosis of HF. The mortality of subjects with HF is 6–7 times higher than the general population in the same age group . InsulinI.Heart failure with reduced ejection fraction (HFrEF) is defined by an LVEF ≤ 40%.II.Heart failure with mildly reduced EF (HFmrEF) is defined by an EF between 41% and 49%.III.Heart failure with preserved EF (HFpEF) is defined by an LVEF ≥ 50% in the presence of symptoms and signs of HF associated with structural and/or functional cardiac abnormalities and/or increased natriuretic peptides .Chronic HF has been classified into three different phenotypes based on the values of the measured left ventricular ejection fraction (LVEF):HFpEF accounts for about 45% of all HF cases and has been on the rise in the recent years . In factIncreased left ventricular mass (LVM) is a stronger predictor of HF than coronary artery calcium score . IncreasData from clinical studies show that diabetes mellitus (DM) has a prevalence of about 45% in individuals with HFpEF, but IR certainly has a higher prevalence . GeneralIn this opinion article, we describe the potential alterations caused by IR/Hyperins on the cardiovascular system, highlighting its negative impact in HF, and discuss the possibility of early screening and treatment of IR to improve prognosis in HF patients. In this regard, we reviewed the scientific literature, selecting articles on PubMed, Scopus, and Science Direct using the following key terms: heart failure, cardiovascular system, insulin resistance, hyperinsulinemia, diabetes mellitus, treatment of insulin resistance, SGLT2 Inhibitors, metformin, berberine, GLP-1 receptor agonists. We collected and analyzed laboratory and clinical research studies describing the effects of IR/Hyperins on the cardiovascular system, and more specifically in HF. Furthermore, we analyzed the manuscripts describing the potential beneficial effects of reducing IR/Hyperins through treatment with some known substances.IR is a pathological condition characterized by a decrease in sensitivity and response to the metabolic actions of insulin. In fact, at a given concentration of this hormone, the biological effects are clearly less than expected. Increased insulin levels (hyperinsulinemia) are necessary in order to maintain normal glucose tolerance and, therefore, hyperinsulinemia is a defining event of IR ,10.IR turns out to be a key mechanism in the development of type 2 diabetes, systemic hypertension, HF, and other various cardiovascular diseases. IR is the earliest abnormality in the natural history of type 2 diabetes, due to defects of insulin receptor function, and the chronic insulin over-secretion results in progressive pancreatic beta cell dysfunction ,10. SomeThe diagnostic gold standard for IR is the hyperinsulinemic euglycemic clamp, but this test is poorly applicable for screening purposes, because of its difficulty, time of performance and cost. For clinical screening, several easier-to-obtain substitute indices have been evaluated, such as the Homeostasis Model Assessment of IR index (HOMA-IR) and the Triglyceride–Glucose Index (TyG). HOMA-IR is calculated by multiplying the fasting blood glucose value in mmol/L × the fasting insulinemia value in mU/L and dividing the result by 22.5 [(glycemia × insulinemia)/22.5]. The TyG index is obtained by calculating the natural logarithm of the product between the fasting triglyceride (Tg) value in mg/dl and the fasting blood sugar (FBG) value in mg/dl, then dividing the result by 2 [logn (serum Tg × FBG)/2]. Both indices showed good correlation with clamp data. A HOMA-IR index between 0.23 and 2.5 can be considered normal in the adult population, while the cut-off value for the TyG index is 4.5 ,12.Chronic long-lasting hyperinsulinemia, typical of IR, produces damage in target organs, and one of the recognized targets of insulin is certainly the cardiovascular system . Indeed,Insulin is also a growth factor, and both insulin and insulin like growth factor-1 (IGF-1) are able to bind to and activate each other’s receptors, even if with lower affinity. Both the insulin receptor (InsR) and the IGF-1 receptor (IGF-1 R) elicit a common downstream signaling resulting in the activation, by phosphorylation of a tyrosine kinase, of two important pathways: that of phosphoinositide-3 kinase (PI3K/Akt), and that of Shc-Ras-mitogen activated protein kinase (MAPK) . The PI3The main mechanisms by which IR/Hyperins lead to left ventricular failure are summarized in Under conditions of IR, the PI3K-dependent pathway is specifically altered while the MAPK-dependent pathway is altered little or not at all. This is why the hyperinsulinemia that is typically associated with IR, in an attempt to maintain glucose levels in the normal range, ends up increasing the activity of the MAPK pathway, with prevalence of deleterious effects at the cardiovascular level due to mitogenic and proliferative actions, and to over exposure to ET-1, which, in the presence of reduced NO production, results in serious endothelial dysfunction . Chronic2 achieved, compared with patients with HF alone. Unfortunately, no distinction was made between patients with HFrEF and patients with HFpEF in this study [Alzadjali et al. (2009)  demonstris study . There iis study . In factis study . In thesis study . Howeveris study ,27,28. Ois study . Diabeteis study ,31. In tis study . This wais study . In the is study . It is wis study . Echocaris study .Recently, it has been reported that, due to the advancement in HF treatment, a relevant number of patients with HFrEF and HFmrEF have experienced an improvement of LVEF, such that it is almost back to normal value. This condition has been termed HF with recovered EF (HFrecEF). We have seen how IR is highly present in the subjects with HF and is closely related to prognosis. Patients with HF and IR had significantly greater difficulty in improving their LVEF, and so the authors conclude that IR is independently associated with a failure to improve LVEF in subjects with HFrEF . It is wThe metabolic and organic imbalances described are very complex and there are many different therapeutic approaches that may be considered for the treatment of IR/Hyperins.The gold standard for the treatment of IR/Hyperins is certainly constituted by following a balanced diet, low in carbohydrates, low in calories in obese and overweight subjects, and physical activity, when possible, moderate and constant . Among tWhen the intake of carbohydrates is drastically reduced, the consequent modification of the relationship between the concentration of insulin and that of glucagon promotes the mobilization of lipids from tissue deposits and the oxidation for energy purposes.In practice, the drastic reduction in the intake of carbohydrates determines an increase in fat catabolism, with an imbalance between the production of pyruvate, oxaloacetate and acetyl-Coenzyme A (acetyl-CoA). Excess acetyl-CoA is transformed in the liver cells into the three ketone bodies: acetoacetate, hydroxybutyrate, and acetone. Myocardium, skeletal muscle, and brain capture and can use the first two. At the pancreatic level, these contribute to metabolic improvement in patients with IR.Normally, the heart’s large demand for energy is met mainly by the mitochondrial oxidation of fatty acids and glucose. In HF, there is a reduction in mitochondrial oxidative metabolism and glucose oxidation, which makes the heart starved of energy. Ketone bodies can be rapidly oxidized by the heart muscle and can provide a replacement and additional energy source to the failing heart. This mechanism may become an adaptive response of the heart to reduce the severity of HF .However, as is well known from clinical practice, maintaining a correct lifestyle is consistently performed only by a low percentage of patients, while the majority, after a variable duration, return to a detrimental lifestyle. To improve adherence to these indications, patients must be well informed, and reminded often, of the risks they incur by not adhering to these indications. Furthermore, we are also convinced that, to reduce hospital admissions of patients for HF exacerbation, they must be followed consistently at home via telemedicine or through a periodic monthly visit by a nurse specialized in caring for patients with HF .Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a class of oral drugs approved by the US FDA for use with diet and exercise to lower blood sugar in adult patients with type2 diabetes and recently included in the guidelines for treatment of HF . They in1c, body weight, BMI, and blood glucose, while the LV global longitudinal strain  was increased. These data further support the beneficial effects of SGLT2 inhibitors on the heart, although all of these effects have to be confirmed in the long term [Treatment with SGLT2 inhibitors has been shown to favorably affect cardiac remodeling through myocardial, mitochondrial, interstitial, vascular, autonomic nervous system, etc. applications . Resultsong term . In addiong term . Due to p < 0.003) were demonstrated in the subgroup of patients with HFpEF [p < 0.001) improvement in IR indices, accompanied by a significant (p < 0.036) reduction in the minute ventilation/carbon dioxide production (VE/VCO2) slope [2 slope has a strong predictive value in patients with HF, and the risk of mortality is thought to increase significantly when the value is >32.8 [Metformin, an oral antidiabetic belonging to the biguanide class and used for many years in the treatment of type 2 diabetes mellitus, has been amply demonstrated to reduce IR/Hyperins and has shown beneficial effects in patients with HFpEF. In fact, the results of a review and meta-regression analysis study have shown that treatment with metformin reduces mortality in patients with HF, although larger positive effects  slope . The VE/is >32.8 .Many natural substances have shown beneficial effects on IR/Hyperins. Some studies demonstrated the beneficial effects of berberine, quercetin, and silymarin on IR/Hyperins and the cardiovascular system. From the analysis of experimental in vitro and in vivo studies, it clearly appears that these three substances reduce IR and consequent circulating elevated insulin levels. Therefore, these substances could protect the evolution toward overt type 2 diabetes and the development of cardiovascular abnormalities . Both quHydrastis canadensis and Coptis chinensis. A study designed to assess the efficacy of berberine to produce improvements in patients with HF, was carried out on patients with HF divided into two groups: a group of 79 patients treated with berberine and a group of 76 patients treated with a placebo in addition to standard therapy, according to guidelines, for HF. Evaluation of the parameters considered was done basally, after 8 weeks and after an average of 24 months of follow-up. Berberine treatment produced a significant increase in EF and exercise capacity and a reduction in the frequency and complexity of ventricular premature beats. In addition, during the 2-year follow-up, 7 patients died in the berberine group and 13 patients in the placebo group (p < 0.02) [Berberine is a vegetable alkaloid in use for over 2000 years in Chinese and Ayurvedic medicines, which has been shown to have numerous beneficial effects on human health. It is contained in numerous plants, including  < 0.02) .p < 0.05) in HOMA-IR and fasting insulin levels in the berberine-treated group [p < 0.001) as compared with the placebo group. The authors concluded that the treatment could represent an effective strategy to reduce the cardiovascular risk [A further study evaluated the relationship between the clinical effects of berberine at a dose of 1.2 g per day in patients with severe congestive HF and the hematic concentrations of berberine assessed by HPLC. It was shown that berberine decreased the number and complexity of premature ventricular beats and increased EF more in patients whose plasma concentration of berberine was >0.11 mg/L than in those with lower concentrations . In a raed group . Also, ted group . These rlar risk . UnfortuGlucagon-like peptide-1 is a hormone produced by the intestine that stimulates insulin secretion and inhibits glucagon secretion by the pancreas. Among other things, it slows down gastric emptying, increasing the sense of satiety, and reduces appetite by acting directly on the hunger regulation centers in the central nervous system, thus helping to lose weight .Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are substances utilized in the treatment of type 2 diabetes and obesity. The ones currently in use are: semaglutide, albiglutide, delaglutide, exenatide, liraglutide and lixisenatide. Despite the positive reports on the beneficial effects of treatment with GLP-1 RAs in the treatment of diabetes and obesity, the data in the scientific literature on the use of GLP-1 RAs in subjects with HF are contrasting. In fact, a recent meta-analysis study of 54,092 participants of 7 randomized controlled trials on the use of GLP-1 RAs in subjects with type 2 diabetes, of whom 16% also had a history of HF, showed that these drugs may help prevent new onset of HF in the diabetic population, while, on the other hand, in subjects with pre-existing HF, they did not reduce the risk of HF exacerbation or mortality . A furthSome older drugs, still quite often used by patients with HF, while improving the overall prognosis of these patients, can induce or worsen a state of IR/Hyperins. The drugs most commonly used are beta-blockers, thiazide diuretics, and statins. The beta-blockers that have a greater negative action on IR/Hyperins are predominantly those of the first generation, not beta 1 selective and without vasodilating action, such as propranolol ,74. As fDespite the considerable progress in the prevention and treatment of heart diseases, HF is still a very important cause of recurring hospitalizations, with relevant social and health care costs, and it is burdened with a significant mortality. It is also noteworthy, not only for treatment purposes, to highlight the increase in the incidence of heart failure. Among the causes that could have contributed to this increase could be the increase in the incidence of IR and consequent hyperinsulinemia, and diabetes. It is known that IR is closely related to metabolic syndrome, which is in a phase of progressive diffusion and increase in developed and developing countries. Elevated circulating insulin levels from IR could contribute to the development and progressive worsening of HF. In fact, a considerable prevalence of IR has been demonstrated in HF. Hyperinsulinemia, as amply demonstrated in the scientific literature, can, over the years, cause progressive alterations at the cardiovascular level. For this reason, early screening of IR/Hyperins in at-risk subjects and in patients with HF could certainly be useful, given that we now have numerous substances that have been shown to be able to counteract it and, probably, reduce and slow down the progression toward type 2 diabetes and cardiovascular damage. What the best drug and the correct dosage might be, or whether it is better to use a combination of drugs, is not currently known. For these reasons, dose-response trials and head-to-head comparisons are necessary to help optimize the treatment.