Background: Restricted and repetitive behaviors (RRBs) are a broad class of behaviors characterized by frequent action repetition and intense preference for sameness. Research has predominantly focused on RRBs in diagnosed clinical groups, particularly in autism spectrum disorder and genetic disorders. Using a transdiagnostic approach, the current study examined RRBs in a diverse sample of children in relation to developmental and demographic correlates . Separate analyses examined two RRB subtypes; repetitive sensory and motor behaviors (RSMB) and insistence on sameness (IS).Method: Children  in mainstream schools identified by teachers as having behavioral, emotional, and/or cognitive difficulties, were assessed using the Repetitive Behavior Questionnaire-2 (RBQ-2), the British Picture Vocabulary Scale (BPVS), Lucid Ability Scale, the Welsh Index of Multiple Deprivation (WIMD) and the Screen for Child Anxiety Related Emotional Disorders (SCARED). Recruitment excluded diagnosed clinical conditions. The Strengths and Difficulties Questionnaire (SDQ) was used to assess children’s difficulties.Results: RRB scores were of high frequency and the scores for the IS were higher than for RSMB. The severity of anxiety symptoms and male sex were significantly associated with both RRB subtypes, and younger age and SES scores were associated with IS. Elevated RRB total and subtype scores were significantly related to SDQ scores for emotion, conduct, hyperactivity, and peer-relations.Discussion: The study provides the first evidence of RRBs in a diverse sample of young children with emerging difficulties in behavior, cognition, and/or emotion. The results contribute to proposals about psychological development in RRB and indicate that RRBs are best represented on a continuum of severity found across children in the early school years. The results support previous findings of a relation between RRB and anxiety reported in clinical samples and importantly, they indicate that it is time to move beyond the study of categorically defined groups and consider correlates of RRBs that include broad indices of mental health and well-being. Restricted and repetitive behaviors (RRB) form a broad class of behaviors that are characterized by frequent action repetition and an intense preference for sameness. Restrictedness is apparent in the narrowness of focus, inflexibility in interests, and activities and insistence that aspects of the environment stay the same. Repetition is manifested in rhythmic motor stereotypies, repetitive speech, routines, and rituals  rather than to the RSMB subtype . At the visit to NDAU, each child was given a battery of task-based assessments and their parents/guardians completed questionnaire measures. The research procedures were approved by Cardiff University’s Ethics Committee (EC.16.10.11.4592GR). Parents/guardians gave written informed consent on behalf of the child and the child gave their assent.The RBQ-2  to 1,909 (least deprived). Deprivation indices include income and employment. The range of rank and quintile scores in the sample is shown in p < 0.05. Initial data-screening was conducted to assess missing data and the distribution of scores. A missing value analysis using Little’s Missing Completely at Random test was not significant (p > 0.05). For RBQ-2, 24 participants (9.2%) were missing one item, and 2 participants (0.8%) were missing two items. For SDQ, 11 participants did not have any data (4.2%), one participant had nine missing items (0.4%), and another participant had 17 missing items (0.4%). For the SCARED, 18 participants did not have any data. Of these four were missing SDQ scores and three were missing a Lucid or SES score. Only the SDQ total was normally distributed; the remaining variables violated assumptions of normality according to Shapiro-Wilk statistic and non-parametric analyses were used to replace parametric analyses as appropriate if results differed.Data analyses were carried out using SPSS Version 26  and all the variables . Associations between sex and other (continuous) variables were explored by computing a point-biserial correlation . Bonferroni correction was applied for multiple comparisons (0.05/9 = 0.005). Regression models were then used to examine the contribution made by the demographic variables  and developmental variables  with each subscale of RRBs (RSMB and IS), to determine the relative influence of these variables. Where predictor variables made a significant contribution to the regression models, follow-up tests were conducted to explore these effects. For the regression models, there was no independence of residuals, as measured by the Durbin-Watson statistic. Homoscedasticity was present, as assessed by visual inspection of a plot of studentized residuals vs. unstandardized predicted values . With Bonferroni correction applied the Characteristics of the children including all demographic and developmental variables under study; age, sex, SES, verbal, non-verbal ability, and anxiety are shown in t(259) = −5.07, p < 0.001), and this difference applied to both older and younger children. The same pattern of findings was found using non-parametric tests .r = −0.168, p = 0.007). The RRB mean score for males was 1.65 (0.53) compared with 1.46 (0.46), for females, and the mean IS score for males was 1.81 (0.59) compared with 1.61 (0.57) for females. Mann Whitney tests found significant sex differences at p = 0.003 for RSMB and p = 0.007 for IS. As females  had higher anxiety scores than males  = −2.131, p = 0.034) while males had higher RRB scores than females . In addition to the correlations above, Correlations  were runales see , partialF = 4.711, p < 0.001, R2 = 0.136, adjusted R2 = 0.107. B = 0.282) whereby higher anxiety scores predicted higher incidences of RSMB. Males (B = 0.191) had higher incidences of RSMB. The hierarchical regression for the IS subscale was also significant, F = 0.9067, p < 0.001, R2= 0.232, adjusted R2 = 0.206. Sex (B = −0.184), SES (B = −0.167), verbal reasoning (B = −0.145), and anxiety (B = 0.394) significantly contributed to the final model. With respect to the IS subtype, like the pattern observed for RSMB, males and higher anxiety scores were associated with higher incidences of IS. Lower SES, as measured by WIMD rank, and poorer scores on the Lucid verbal reasoning task were associated with higher reported IS behaviors. However, follow-up partial correlations showed that while the IS-anxiety relation remained significantly high when both SES was controlled  or when Lucid verbal was controlled , partial correlations were not significant for either the IS-SES relation or for the IS-Lucid verbal relation when anxiety was controlled .A hierarchical linear regression revealed that only sex and anxiety significantly contributed to the RSMB subscale, Finally, further analyses explored the relation between RRBs and the emotional and the behavioral profile of this sample using the parent SDQ. Using a transdiagnostic approach, the current study examined RRBs in a diverse sample of children in relation to a range of developmental and demographic correlates. Traditionally RRBs have been researched through a lens focused on specific diagnosed groups  or else on matched neurotypical control groups or on community samples. Although children in the current sample were recruited for the purpose of assessing and supporting their difficulties at school, unlike recruitment for most studies, they were not selected according to membership of a clinical category. Setting aside diagnostic categories gave us the opportunity to produce evidence documenting the range of variation of RRB in a sample of this kind for the first time.First, we found that parents of children in this sample frequently endorsed extreme scores for their children. It can be seen from Second, this research contributed new findings relevant to the developmental theory of RRB , externalizing scale , and each of individual subscales . The resThis research has important limitations regarding its design and methodology. It includes only a single measure of RRB and a single parent informant. In addition, it includes a single and distinctive sample referred for a particular purpose and a sample with a strong sex imbalance, an age range limited to the early school years, and a low SES. All these factors are dangers to the generalizability of the study. However, many previous studies of small samples also lack generalizability in comparison to the current sample, because participants are seldom recruited from lower SES environments. A further consideration is whether the study should have included an assessment of ASD symptoms to clarify the interpretation of the results. If high numbers of children in this sample had elevated autism traits, indicating a likelihood for a future diagnosis of ASD, this could be seen to undermine the distinctiveness of a proposed transdiagnostic approach. On the other hand, the purpose of the study was to focus exclusively on describing only one ASD-related domain, RRBs in children that had not been selected with high levels of RRBs as part of their diagnosis and this purpose was met. Nevertheless, further research is clearly needed to identify the role of the other ASD domain, social communication, in the RRB-anxiety relation. Meanwhile, the results to date serve best as pointers towards new directions for the future of RRB research and raise several questions for future attention. For example, new research studies will help us understand more about anxiety and mental health in relation to RRBs and whether social communication difficulties play a role in this relation, irrespective of ASD diagnosis.The strong association between RRBs and the measures of mental health raises the question of whether RRBs might be a proxy for a broader construct of psychopathology instead of being a distinct and specific construct. This would be consistent with  that are characterized by developmental delay as part of their diagnostic criteria, compared with those without early language or cognitive delay.Finally, the results open the potential to rethink previous concepts and assumptions regarding RRBs. One question is whether the conceptualization and measurement of RRB which is drawn from developmental psychology theory but most heavily influenced by research on ASD, best represents children’s development more broadly regardless of children’s clinical label or category. As Burack et al.  point ouTo conclude, despite its limitations, this study provides the first evidence of RRBs in a diverse sample of this kind. The results support evidence that irrespective of the diagnostic status and nature of the specific population , anxiety serves as a crucial correlate, and potential mechanism, behind diverse RRB expressions. Importantly, the study contributes new evidence about other lesser-known correlates of RRB. The clear associations between RRBs and the SDQ subscales including conduct, hyperactivity, and peer relations as well as emotion, indicate that it is time to move on from traditional approaches to RRBs. While our results confirm the significance of emotional difficulties for RRB in the early childhood years, a broader interpretation of RRBs is needed beyond existing clinical and developmental explanations. We conclude that children’s RRBs are best represented on a continuum of severity incorporating all populations and that repetitive behaviors in these populations in the early school years are associated not only with anxiety but with broad indices of mental health and well-being.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by EC.16.10.11.4592GR. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.SL and JK designed the study. SL led the article preparation. JK curated the data and carried out the statistical analysis. MU and DH contributed to the analysis plan and interpretation. SG led all aspects of the sample recruitment and data collection. JK, SL, MU, DH, and SG contributed to the manuscript drafts. SL, SG, and DH contributed to funding acquisition. All authors contributed to the article and approved the submitted version.


R = 0.220, P = .012), middle-shear , and high-shear viscosity , as well as plasma viscosity . Lp(a) was not associated with whole blood viscosity at low, middle, and high shear rates, but was associated with WBRV at low shear  and middle shear rates . Lp(a) is associated with high WBRV, which may impart more insights into the role of Lp(a) in cardiovascular disease.Lipoprotein(a) [Lp(a)] has been confirmed as a causal risk factor of atherosclerotic cardiovascular disease, but its role on circulation is not completely clear and is still being explored. Therefore, this study attempts to explore the relationship between Lp(a) and whole blood reducing viscosity (WBRV), to better understand the role of Lp(a) in circulatory and cardiovascular diseases. We retrospectively analyzed the data of consecutive subjects in the physical examination center of the Affiliated Hospital of Ningbo University Medical College from January 2022 to May 2022. Pearson or spearman correlation analysis was used to test the statistical relationship between 2 continuous variables according to whether they are normal; 131 participants were retrospectively enrolled in this study. The low-density lipoprotein concentration was associated with whole blood viscosity at low-shear ( In this study, we explored the relationship between Lp(a) and reduced BV.Lipoprotein(a) (Lp(a)) has been confirmed as a causal risk factor of atherosclerotic cardiovascular disease.From January 2022 to May 2022, consecutive patients who completed physical examination in the Physical examination Center of the First Affiliated Hospital of Ningbo University were retrospectively reviewed. Inclusion criteria: Patients’ physical examination items included BV and Lp(a). Patients with incomplete data were excluded. The studies involving human participants were reviewed and approved by medical ethics committee of Affiliated Hospital of Medical College of Ningbo University. Written informed consent for participation was waived for this study by medical ethics committee of Affiliated Hospital of Medical College of Ningbo University due to the retrospective nature of the study. The formulation of this study scheme was in accordance with the requirements of the Declaration of Helsinki of the World Medical Association.2. Venous blood was collected after overnight fasting (>8 h). BV was measured using an automated blood rheology analyzer . BV levels at 5 s−1 are reported as low-shear viscosity, BV measurements at 30 s−1 are reported as middle-shear viscosity, and BV measurements at 200 s−1 are reported as high-shear viscosity. For plasma viscosity the average of measurements at shear rates of 200 s−1 was calculated.Weight and height were measured using a standardized approach, followed by the calculation of body mass index in kg/mWhole blood reductive viscosity (WBRV) refers to the whole BV value when the hematocrit (HCT) is 1, also known as the unit HCT viscosity, or is defined as the contribution of the unit HCT to the relative viscosity of the whole blood.Whole blood reduction viscosity was calculated by the following formula:WBV-PV is the increase of viscosity in plasma due to the addition of human blood cells, so (WBV-PV)/PV is the increase rate of viscosity increase to original viscosity. The higher of the ratio, the greater the influence of red blood cells on BV. The volume of red blood cells in the whole blood reflects the concentration of red blood cells, and its volume percentage is generally called HCT. The ratio divided by HCT is converted into the influence of unit HCT on BV. According to the formula, the whole blood reduced high shear viscosity, whole blood reduced middle shear viscosity, and whole blood reduced low shear viscosity can be calculated. Obviously, WBRV is a dimensionless value without units.P < .05.All statistical analyses were performed using SPSS 26.0 for Mac  and GraphPad Prism version 9.0 for Mac . Data were checked for normality with the Kolmogorov–Smirnov test and shown as mean ± SD or median [P25–P75] depending on the distribution. Categorical variables are displayed as percentages and absolute numbers. Select Pearson or spearman correlation analysis to test the statistical relationship between 2 continuous variables according to whether they are normal. Level of significance was set at 2, and 81% were men. Lp(a) ranged from 15 to 773 mmol/L.Overall, 131 participants were enrolled in this study. Table R = 0.220, P = .012), middle-shear , and high-shear viscosity , as well as PV   and middle shear rates   and WBV, concentrations of Lp(a) were associated with WBRV at low-shear and middle-shear rates. Specifically, the increase of high-density lipoprotein is related to the decrease of BV, while the increase of LDL and triglyceride leads to the opposite phenomenon. In a prior cross-sectional study, patients with type IIa hyperlipoproteinemia, a positive correlation was shown between LDL concentrations and plasma viscosity (P < .01). Another study showed that, compared to normolipidemic subjects, the PV (P = .007) and WBV (P = .013) of hyperlipidemic subjects were higher, and it was also found that PV was directly associated with LDL cholesterol in simple correlation analysis.,11 BV depends on HCT and is a function of HCT. WBRV is defined as the influence of unit HCT on BV. In this study, we found the correlation between Lp(a) and reducing viscosity, not viscosity.It has long been believed that the main physiological determinants of whole blood rheology tend to be the HCT and the fibrinogen concentration. Many recent studies have shown that lipid levels are important for hemorheology. In addition, there is an increasing body of evidence identifying Lp(a) as a strong, independent, and potentially causal risk factor for calcific aortic valve stenosis.,14 To our knowledge, this is the first study that explores the relationship between WBRV and Lp(a).Lp(a) is a LDL cholesterol-like particle bound to apolipoprotein(a) and has been confirmed as a causal risk factor of atherosclerotic cardiovascular disease by genome-wide association, epidemiology, and clinical studies.Our study had several limitations. First, it is a cross-sectional study and cannot make a causal analysis. Second, data such as fibrinogen that will affect BV have not obtained due to the retrospective nature; the results may be biased. Third, due to the inclusion of a physical examination population and the retrospective nature, we were unable to obtain patient medication history and other risk factors.Lp(a) is associated with high WBRV, which may impart more insights into the role of Lp(a) in cardiovascular disease.The authors would like to thank all the medical staff working in the cardiology department of the hospital for their support and cooperation.Conceptualization: Haibo Zhu.Data curation: Sheng Jing.Formal analysis: Sheng Jing.Investigation: Sheng Jing, Haibo Zhu.Methodology: Sheng Jing, Haibo Zhu.Project administration: Sheng Jing, Haibo Zhu.Resources: Sheng Jing.Software: Sheng Jing.Supervision: Haibo Zhu.Writing – original draft: Sheng Jing.Writing – review & editing: Haibo Zhu.


Hypertension is the leading preventable risk factor for cardiovascular disease and all-cause mortality worldwide. However, studies have shown increased risk of mortality from heart disease and stroke even within the normal blood pressure (BP) range, starting at BPs above 110–115/70–75 mm Hg. Nutraceuticals, such as vitamins and minerals, have been studied extensively for their efficacy in lowering BP and may be of benefit to the general, normotensive population in achieving optimal BP. Our study investigated the effects of six nutraceuticals  on both systolic blood pressure (SBP) and diastolic blood pressure (DBP) in this population. We performed a systematic review and pairwise meta-analysis for all six supplements versus placebo. Calcium and magnesium achieved significant reductions in both SBP and DBP of −1.37/−1.63 mm Hg and −2.79/−1.56 mm Hg, respectively. Vitamin E and potassium only yielded significant reductions in SBP with values of −1.76 mm Hg and −2.10 mm Hg, respectively. Vitamins C and D were not found to significantly lower either SBP or DBP. Future studies should determine optimal dosage and treatment length for these supplements in the general, normotensive population. Approximately 1.39 billion people in the world have hypertension, the leading preventable risk factor for cardiovascular disease and all-cause mortality worldwide . Given tAside from prescription antihypertensives, there is ample literature regarding the BP-lowering ability of various nutraceuticals ,7. TheseThe effectiveness of these six nutraceuticals in lowering BP, when taken as dietary supplements, has been the focus of numerous randomized controlled trials (RCTs) and meta-analyses. In fact, the most recently published meta-analyses suggest that all but vitamin D and calcium are capable of achieving a 2 mm Hg systolic BP reduction ,18,19,20This study aims to investigate the effects of the above six nutraceuticals  on systolic and diastolic BP in the general, normotensive population using a pairwise meta-analysis for each supplemental compared to placebo. We chose these six based on our prior knowledge of the literature. The overlap of supplements mentioned in the two aforementioned review articles on nutraceuticals with a blood pressure-lowering effect was also used in this decision ,7. FurthThis study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement . The prop-values and 95% confidence intervals); and (5) at least two weeks in duration. It should be noted that our study did not consider the following as medical conditions: being elderly, postmenopausal, obese, at-risk of a medical condition (such as being prediabetic) or having baseline deficiency of a supplement. Aside from these, all other medical conditions were cause for exclusion if they affected more than 50% of the study population, including hyperlipidemia, alcoholism, smoking, and psychiatric conditions. Studies were included if they were (1) published in English; (2) randomized controlled trials (RCTs) of one, or more if not used solely in combination, of the six supplements with dosing versus placebo; (3) focused on a general, adult participant population with <50% having a common medical condition; (4) trials that reported the mean effect with variance of these supplements on systolic, diastolic, or mean arterial pressure  they were not published in English; (2) they did not follow a RCT study design; (3) the supplement dosing was not given, was administered via fortified foods or through dietary changes, or was calculated by urinary excretion or other indirect measures; (4) they focused solely on patients with specific medical conditions or had ≥50% of participants sharing a common medical condition; (5) participants were less than 18 years old or pregnant; (6) the average baseline systolic BP was ≥140 or baseline diastolic BP was ≥90; (7) they did not provide data on pre- and post-intervention BP, or sufficient data to calculate this; (8) additional interventions were administered alongside the supplement, such as an exercise program or sodium restriction; and/or (9) the studies were less than two weeks in duration.A systematic search of literature was conducted on Cochrane, Embase, MEDLINE (PubMed), and Web of Science for placebo-controlled RCTs of the six supplements examining their effects on BP. The dates searched were inception to 22 July 2022. The search strings were constructed by a medical librarian using a combination of keywords and Medical Subject Headings (MeSH terms). The keywords and MeSH terms used in this search are listed in The RCTs obtained through this search were imported into Covidence, which automatically screened for duplicates . Two indTwo independent researchers (JLD and CJG) completed extraction of the basic characteristics of included studies, with subsequent review by the first author (BJB). This included the last name of the first author, year of publication, type of trial, baseline BP of participants and their past medical history, length of the trial, supplement dosing, sample size for intervention and placebo groups, and whether there were any adverse outcomes. Disagreements were settled through discussion.The first author (BJB) extracted all data in relation to systolic blood pressure (SBP) and diastolic blood pressure (DBP) for all arms of the trials. This included mean baseline and final BP values for each group, effect sizes for each arm of the trial, and overall treatment effect sizes (supplement minus placebo). The corresponding variances, 95% Confidence Intervals (CIs), and sample sizes for each arm of the trial were also extracted. This was subsequently verified by at least two other authors  for accuracy.Quality assessment was performed using the Risk of Bias 2 tool from the Cochrane Handbook for Systematic Reviews of Interventions . This top-values, and/or t-statistics. When the effect size and its SE were not provided, the effect size was calculated by subtracting the mean changes between the two groups. The SE was then estimated by multiplying the pooled standard deviations of the two groups by the square root of the sum of the reciprocals of their sample sizes. Our effect sizes are the overall effect size of the supplement versus placebo across all dosages and treatment lengths, with the intention of providing insight into whether these nutraceuticals have any effect on BP in this population.The primary endpoints were the effect size between the intervention (supplement) and placebo groups in regard to change in systolic blood pressure (SBP) and diastolic blood pressure (DBP). This was represented by the mean BP changes from baseline in the intervention group minus the changes in the placebo group. Its standard error (SE) was either reported or calculated from 95% CIs, In parallel trials that did not provide mean change from baseline data for each arm of the trial, this was calculated by subtracting the baseline mean BP values from the final mean BP values. The standard deviations of these changes were then imputed according to Chapter 6 of the Cochrane Handbook for Systematic Reviews of Interventions (Cochrane Handbook), assuming a correlation coefficient of 0.7 . A sensiFor cross-over studies, the final mean BP values of the two groups were used to calculate the mean differences, as all participants shared the same baseline values. Our methodology followed Chapter 23 of the Cochrane Handbook . The SEsQ statistic at the significance level of 0.1 [Q statistic would indicate use of the random-effects model results. The I2 statistic was also reported to explain the percentage of variability accounted for by the between-study variation [The overall effect sizes and the 95% CIs for each intervention were estimated and reported under both common- and random-effects settings. Heterogeneity was assessed by l of 0.1 . A signiariation . This beariation . The pubariation . Contourariation ,31. Statariation .n = 4497), Embase (n = 6585), MEDLINE (PubMed) (n = 4579), and Web of Science (n = 537). Covidence automatically removed 7352 duplicates, leaving 8846 articles for screening. After title/abstract screening removed 8439 articles, full texts were obtained for the remaining 407 articles. Analysis for their adherence to the inclusion criteria resulted in 82 eligible studies [The literature search yielded 16,198 total articles from the four databases: Cochrane (nce n = 5. CovidenMed) n = 79, and Wence n = 7. Covideed) n = 49, and Wease n = 65, MEDLINse n = 65, MEDLINE studies ,113,114. studies ,78,80,84 studies ,123,124,The 87 RCTs were published from 1982 to 2022 ,123,124.All six supplements consisted of a mixture of parallel and cross-over studies, except for vitamin D which consisted of only parallel trials. Additionally, all 87 trials (100%) included data on SBP, while DBP was also measured in all but four (95.4%). Of these four trials, two were of vitamin E and one for both vitamin C and vitamin D. A healthy population was predominant for all six supplements. Vitamin C, vitamin D, and vitamin E were represented in 5, 29, and 7 trials, respectively, with sample sizes of 122, 4897, and 302. Calcium, magnesium, and potassium were represented in 21, 18, and 12 trials, respectively, with sample sizes of 4534, 1575, and 1096. As noted, not all studies measured DBP, resulting in slight decreases in the sample size used in its analysis. There was a wide range of dosages and treatment lengths for all six supplements. A comprehensive summary of the basic characteristics of included studies broken down by supplement is depicted in The complete results of the Cochrane Risk of Bias screening by study can be found in A summary of the risk of bias judgments by supplement can be found in I2 = 16%; p-value for Q statistic: 0.30). Vitamins C and D did not show a significant reduction in SBP versus placebo with values of −1.45 mm Hg  and −0.47 mm Hg , respectively. Both of these vitamins also had low heterogeneity , so a common effects model was used for them.The pooled results for the difference in the change of SBP for the vitamins versus placebo are shown in I2 = 25%; p-value: 0.13). Magnesium had an average reduction in SBP of −2.79 mm Hg  using the random effects model due to high heterogeneity . Potassium also used the random effects model due to high heterogeneity  and was found to reduce SBP by an average of −2.10 mm Hg .The pooled results for the difference in the change of SBP for the minerals versus placebo are shown in I2 = 0%; p-value: 0.96 and I2 = 0%; p-value: 0.51, respectively) and thus their effects on DBP were determined using the common effects model. These effects were −0.47 mm Hg  and +1.17 mm Hg , respectively. Vitamin D resulted in an increase in DBP versus placebo of +0.11 mm Hg  using the random effects model due to high heterogeneity .The pooled results for the difference in the change of DBP for the vitamins versus placebo are shown in I2 = 78%; p-value: < 0.001). Calcium reduced DBP by a mean difference of −1.63 mm Hg  with high heterogeneity amongst the studies . Magnesium had a mean difference in DBP of −1.56 mm Hg , again with high heterogeneity .The pooled results for the difference in the change of DBP for the minerals versus placebo are shown in A summary of the effects of the vitamins and minerals versus placebo is provided in A sensitivity analysis was performed by imputing the missing standard deviations of change-from-baseline scores for parallel comparisons assuming a correlation coefficient of 0.5. For cross-over studies, the standard errors of effect sizes were calculated assuming correlation coefficients of 0.5 and 0.9. The results are summarized in p-values of 0.075, 0.069, and 0.001, respectively). The DBP analysis for vitamin C was also noted to have publication bias with Egger’s regression .Contour-enhanced funnel plots of the six supplements with their effect sizes on the horizontal axis and SEs on the vertical axis were constructed to visualize potential publication bias. These plots can be found by supplement for systolic and diastolic BP in Our results provide evidence that vitamin E, calcium, magnesium, and potassium are effective in lowering SBP in the general, normotensive population. Both magnesium and potassium achieved a greater than −2 mm Hg reduction in SBP, with reductions of −2.79 mm Hg and −2.10 mm Hg, respectively. These reductions can be considered clinically significant, as prior studies have found that a −2 mm Hg reduction in SBP could reduce mortality from heart disease and stroke by as much as 7% and 10%, respectively ,125. OurOur reductions in blood pressure were generally lower than the values in previously published meta-analyses of these nutraceuticals. This supports our hypothesis that these studies, which included subjects with uncontrolled hypertension who were receiving these nutraceuticals as an initial treatment, likely saw greater reductions in BP as a result. This discrepancy was largest for vitamin C, vitamin E, and potassium. For example, the most recent published meta-analysis on vitamin C yielded statistically significant reductions of both systolic and diastolic blood pressure of −4.09 mm Hg and −2.30 mm Hg . This isOur results for vitamin D and calcium were similar to those found in the most recent publications ,18. UponAside from calcium, magnesium was the only other nutraceutical to produce a significant reduction in both SBP and DBP. Notably, the −2.79 mm Hg reduction in SBP was greater than the −2.00 mm Hg seen in a meta-analysis of 34 trials that did not control for our general, normotensive population . HoweverPotassium was the only other nutraceutical to produce a reduction in SBP of at least −2 mm Hg. As noted, however, this reduction was only half of what has been seen in studies that were not controlling for a general, normotensive population . This prAlthough vitamin C and vitamin E yielded uninspiring results for BP reduction in this population, our study may have been limited by low power due to the relatively low number of eligible trials and their small sample sizes. Future studies with larger power should evaluate the efficacy of these two vitamins amongst this general, normotensive population, especially with their promising results in previous studies. If conducted, these studies should focus on vitamin C at a dosage of ≥500 mg/day and a duration of ≥6 weeks, as subgroup analysis in the prior meta-analysis found these to yield the greatest reductions in BP . VitaminWhile we did not investigate ideal dosage and treatment length in our study, prior studies provide insight into these. A systematic review provided the recommended daily intake for the supplements used in our study . These aOur results are important because they shed light onto what the general, normotensive population can take to achieve optimal BP. We are the first study to provide data on multiple vitamins and minerals for this purpose, allowing access for easy comparison of efficacy versus placebo in this population. We achieved high power with large sample sizes for vitamin D, calcium, magnesium, and potassium that we hope adds credibility to our results and promise for its generalizability. Furthermore, while proving to be effective in lowering BP, these six supplements are considered natural and part of a balanced diet. This may help appeal to individuals who are hesitant to take pharmaceuticals for controlling BP, although these supplements should not be viewed as alternatives in those requiring antihypertensives. Current clinical practice guidelines recommend initiating antihypertensives when SBP is ≥140 and/or DBP is ≥90 in patients with primary hypertension without other co-morbidities warranting sooner intervention ,135. TheAdditionally, no adverse events were reported in any of our 87 included trials, while mild side effects were seen with the supplement group in only six, with magnesium and vitamin D accounting for three each. These side effects included mild diarrhea in the three magnesium trials and a range of symptoms in the vitamin D trials from headache to abdominal pain to constipation/diarrhea. Overall, these supplements appear to be an inexpensive and safe option for better BP control when patients don’t qualify for antihypertensives. While all six would be eligible options for the general, normotensive population, particular attention should be given to the four  that showed efficacy in lowering BP. This is especially true for magnesium and potassium because of their clinically significant reduction in SBP, with magnesium exhibiting efficacy in lowering DBP also. Due to this efficacy, magnesium appears to be the most promising of our six supplements in this population.Our study is not without limitations, the most glaring of which is that we did not control for subgroups, including differences in patient populations, dosages of supplements, and treatment length. While we had strict inclusion and exclusion criteria, differences in efficacy likely exist amongst patient population subgroups, as well as the various dosages and/or treatment lengths. Ultimately, we were willing to accept this limitation going into the study, as we hoped this paper could serve mainly as a preliminary, foundational analysis of how these six nutraceuticals could be used amongst a general, normotensive population. The interpretation of our results is thereby limited, as we can only state the mean reductions in SBP and DBP for the supplements against placebo across a range of patient populations, dosages, and treatment lengths. However, we hope that our compiled references, data points, and findings will be used to guide more specific analyses in the future. As mentioned, future studies should investigate optimal dosage and treatment length, as well as the long-term efficacy and safety of these supplements. Priority should be given to those that showed significant reductions in this population: vitamin E, calcium, magnesium, and potassium. Combinations of supplements could also be explored to explore for additive and/or synergistic effects, as we excluded these studies in our study to determine the individual efficacy of each nutraceutical versus placebo.Additionally, publication bias was noted in some of our analyses, as evidenced by the asymmetry in their funnel plots. This occurred in the meta-analyses of SBP with vitamin E and DBP for calcium and magnesium, with confirmation for all three provided by Egger’s regression. The Egger’s regression also highlighted potential publication bias in the meta-analysis of DBP for vitamin C. Given these risks of bias, the pooled results of these analyses should be considered with caution. On the same token, significant heterogeneity was seen in certain analyses, thus its effect on the analyses cannot be ignored when considering the validity of the results.In conclusion, to our knowledge, this is the first study to run pairwise meta-analyses on the BP lowering capacity of all six of these nutraceuticals versus placebo in the general, normotensive population. Our results displayed evidence for vitamin E, calcium, magnesium, and potassium being effective at lowering SBP in this population, with both magnesium and potassium achieving a greater than 2 mm Hg reduction. Additionally, calcium and magnesium were determined to be effective at lowering DBP in this population. Given these findings, magnesium seems to be the most effective of the six nutraceuticals studied in lowering BP in this population. Future studies should look further into the use of these nutraceuticals to determine optimal dosage and treatment length, long-term safety and efficacy, and potential additive and/or synergistic effects.


Brassica. However, broccoli sprouts are the chief source of sulforaphane and are 20 to 50 times richer than mature broccoli as they contain 1,153 mg/100 g. SFN is a secondary metabolite that is produced as a result of the hydrolysis of glucoraphanin (a glucosinolate) by the enzyme myrosinase. This review paper aims to summarize and understand the mechanisms behind the anticancer potential of sulforaphane. The data was collected by searching PubMed/MedLine, Scopus, Web of Science, and Google Scholar. This paper concludes that sulforaphane provides cancer protection through the alteration of various epigenetic and non-epigenetic pathways. It is a potent anticancer phytochemical that is safe to consume with minimal side effects. However, there is still a need for further research regarding SFN and the development of a standard dose.Sulforaphane (SFN) is an isothiocyanate with multiple biomedical applications. Sulforaphane can be extracted from the plants of the genus  As per the World Health Organization, in 2020, cancer is the sole reason for the death of more than 10 million individuals . The iso2This comprehensive review aims to provide updated information on the anticancer mechanisms of sulforaphane. The most relevant and recent data regarding the anticancer activity of sulforaphane were obtained through an online search of the following scientific databases—PubMed/MedLine, Scopus, Web of Science, and Google Scholar—using the next MeSH terms: “Brassica/chemistry”, “Chemoprevention”, “Isothiocyanates/metabolism”, “Isothiocyanates/pharmacology”, “Isothiocyanates/therapeutic use”, “Neoplasms/drug therapy”, “Neoplasms/prevention & control”, “Biological Products/therapeutic use”. The chemical structure has been validated using Pubchem and the taxonomy of the plant according to WorldFloraOnline , 8. The 3Brassica such as broccoli, brussels sprouts, kale, and cauliflower -poly(ethylene glycol)-poly(caprolactone). The results revealed that the PCL-PEG-PCL-encapsulated SFN enhanced the cancer cell apoptosis more efficiently than the free sulforaphane in the in vitro trial. Additionally, the study validated that the SFN encapsulation with triblock copolymer was safe and can be used for effective and targeted sulforaphane delivery to cancerous cells . The study evaluated the capability and potential of encapsulated sulforaphane on SK-MEL-28 (melanoma) cell linings. The in vitro analysis revealed that BM vesicles containing SFN had high absorption and metabolism in cancerous cells. Furthermore, encapsulated sulforaphane efficiently reduced cancer and its markers  of the genus liflower . As per liflower , 9. Receus cells . A studyus cells . Similar markers .4in vitro study also disclosed that benzyl sulforaphane (a derivative of SFN) is more efficient in preventing and treating liver carcinoma by restraining the Akt/MAPK pathways and triggering the Nrf2/ARE signaling pathways (in vitro study on five different cell linings isolated from liver hepatocellular carcinoma (HepG2), human breast adenocarcinoma (MCF-7), human lung adenocarcinoma (A549), human neuroblastoma (SH-SY5Y), and human colon cancer (HCT-116). The data revealed that the sulforaphane derivative synthesized by introducing the benzyl group at the side chain of sulforaphane (benzyl sulforaphane) showed enhanced anticancer activity than any other derivative and SFN itself. The benzyl derivative of sulforaphane triggered cell cycle arrest apoptosis and Nrf2 activation more efficiently than SFN  butyl group that is attached to a nitrogen atom , 13, 14.pathways . Similarthan SFN .55.1Since the discovery of sulforaphane, many scientific studies outlining its health benefits have been published; it is a biologically active phytochemical that has many biological properties, such as anti-inflammatory, anticancer, cardioprotective, antioxidative, cytoprotective, DNA protective, and antimicrobial properties. Additionally, it is also a potent immune booster and detoxifier , 14. Tai.e., SFN not only targets the cancer suppressor genes but also stimulates the transcriptional activity of long terminal repeats. The study also confirmed that the consumption of broccoli sprouts causes the inhibition of histone acetylation (DNA methyl transferases (DNMTs) are a family of enzymes that catalyze the transfer of the methyl group to the DNA. The suppression of these enzymes enhances the process of apoptosis and cell cycle arrest. SNF actively downregulates the function of DNMTs  and protects against cancer , 59, 60 tylation   which induced oral cancer in mice  is a transcription factor that regulates the cellular defense mechanism . The act markers , 66, 67. in mice . Several A and B .5.2Hormesis is a phenomenon characterized by a biphasic dose or concentration–response, where low doses or concentrations of a compound can stimulate a beneficial effect, while high doses or concentrations can lead to inhibitory effects .This means that, at low doses, a compound may have a stimulatory effect, while at high doses, it may have an inhibitory effect. The review of Calabrese et al. explained this hormetic effect of sulforaphane and revealed that SFN induces hormetic dose responses in studies through the upregulation of the Nrf2/ARE pathway. This biphasic response is well integrated, concentration dependent, and specific to targeted cell types. The hormetic response of sulforaphane can decrease the incidence and severity of various human-related pathologies, and it has also been found to be involved in the enhancement of stem cell proliferation. Similar hormesis-based chemoprotection has been reported with other dietary supplements such as curcumin, ginkgo biloba, ginseng, green tea, and resveratrol. The activation of the Nrf2 (nuclear factor erythroid-derived 2)/ARE (antioxidant response elements) pathway is likely a principal and underlying mechanism of hormesis, which can limit age-related damage, numerous disease processes progression, and induction of toxicities due to chemicals and radiations .6in vitro study. The data unveiled that the combination of sulforaphane and fluorouracil is more effective in enhancing the process of apoptosis than fluorouracil alone. In the in vitro analysis, it was confirmed that combination arrests the cancerous cell cycle in the S-phase in the colon cell linings, especially HT-29 and Caco-2 (Sulforaphane can also be used with conventional cancer treatments to achieve an enhanced effect. The group of Małgorzata Milczarek shed light on the development of new combinations by conducting an d Caco-2 . Similard Caco-2 . Recentld Caco-2 . Similard Caco-2 .7Helicobacter pylori. As per the group of Akinori Yanaka, the consumption of broccoli sprouts consecutively for 2 months can downgrade the colonization of the bacterium. This poses a cancer-preventive effect because of the reduction in oxidative stress caused by H. pylori (Broccoli is rich in glucoraphanin which is a precursor of sulforaphane. To study the effect of sulforaphane, a randomized control trial on the prevention of prostate cancer was designed by a group of investigators. The study showed that sulforaphane significantly reduced the progression of prostate cancer and disease severity after the broccoli soup intervention for at least 1 year by altering the gene expression . Melanom. pylori . Additio. pylori , 79–84. 8Conventional chemotherapeutic drugs such as paclitaxel, fluorouracil, tamoxifen, and raloxifene are a few commonly used chemo-preventive medications; but, besides their beneficial effect, such chemotherapy also poses several harmful effects . For thi9Natural bioactive compounds currently have numerous applications in cancer chemotherapy. Furthermore, the vast spectrum of natural compounds provides important compounds for therapeutic refinement through molecular modifications. Many anticancer compounds are either natural products or substances derived from natural products. The conjugation of toxic natural products with monoclonal antibodies or with macromolecular carriers can lead to more precisely targeted therapies. As only a small percentage of higher plants have been systematically investigated, research on natural compounds as chemotherapeutic agents arouses further interest as well as multidisciplinary scientific collaborations. The results of preclinical studies showed that sulforaphane provides cancer protection through the alteration of various epigenetic and non-epigenetic pathways. The therapeutic limitations of the use of sulforaphane in cancer are represented by the complete lack of knowledge of the potential anticancer effects at the cellular level and the effects on the immune system, the lack of translational studies to establish the effective doses in humans, and the interactions with conventional chemotherapy medication. However, considering everything together, the results of preclinical and clinical studies point to new therapeutic perspectives towards the possible development of new sulforaphane-based anticancer drugs.All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis, and interpretation, or in all these areas, that is, revising or critically reviewing the article; giving final approval of the version to be published; agreeing on the journal to which the article has been submitted; and confirming to be accountable for all aspects of the work. All authors have read and agreed to the published version of the manuscript.


Opioid-induced constipation (OIC) has become increasingly prevalent with the rise of prescription opioid use, particularly in patients with advanced illnesses. Existing literature suggests that transcutaneous electrical nerve stimulation (TENS) could be applied to treat cancer pain and reduce OIC incidence. However, there need to be more systematic review studies on the effectiveness of TENS in treating OIC.  In order to fill the gap of TENS in treating OIC in current knowledge, we have conducted a systematic review and network meta-analysis.  The comprehensive computer retrieval PubMed, Embase, Cochrane, China National Knowledge Infrastructure (CNKI), Chinese Biomedical (CBM), and Wanfang Database were used to collect literature for relevant studies of TENS treatment of OIC, in accordance with the standard of literature filtering, data extraction, and quality evaluation. The data were meta-analysed using ReviewManager 5.3 software recommended by Cochrane. I2 = 57%, P=0.03; OR = 0.66 , Z = 3.70, P < 0.01). The results of two studies indicated that TENS significantly improved the quality of life compared to the control group  .  A total of 180 pieces of literature were yielded through original search. Based on the inclusion and exclusion criteria, a total of 9 articles were included in this study. Our analysis of seven studies has revealed that TENS (28.18%) significantly reduces the incidence rate of OIC compared to control (52.45%) ( The administration of TENS therapy holds the potential to mitigate the occurrence of OIC and augment the quality of life for individuals suffering from cancer. Particularly, TENS therapy proves to be appropriate for propagation within community and domestic environments. Nevertheless, advanced clinical randomized controlled trials of superior quality are necessary to authenticate the comprehensive clinical efficiency and safety of this therapy. Further investigation is indispensable to comprehend its mechanism in greater detail and establish the optimum therapeutic strategy. Patients with advanced-stage cancer typically experience cancer-associated symptoms, which can considerably impair their quality of life . The preCurrently, a limited amount of literature is available on the use of TENS for treating OIC, and a systematic review of the research literature was not found. We conducted a systematic review and network meta-analysis to address this knowledge gap.We systematically searched several databases, including PubMed, Embase, Cochrane, China National Knowledge Infrastructure (CNKI), Chinese Biomedical (CBM), and Wanfang Database, from inception to July 1, 2022, without language restrictions. The search terms included “cancer,” “neoplasm,” “tumor,” “constipation,” and “Transcutaneous Electric Nerve Stimulation.” The keywords were combined using Boolean searches and MeSH descriptors. The detailed search strategy is shown in The inclusion criteria for the study were as follows: (a) randomized controlled trials or other controlled studies; (b) cancer patients diagnosed with OIC, regardless of race, sex, age, disease course, and severity; (c) description of the opioid dosage; (d) the treatment group was treated with TENS, while patients in the control group received rehabilitation treatment but did not receive TENS therapy; (e) the results reported the incidence of constipation or constipation scores; (f) double-blind and open-label trial designs were eligible. The exclusion criteria were: (a) non-English and non-Chinese language articles, abstracts from conferences, full texts without raw data for retrieval, duplicate publications, letters, and review articles; and (b) articles that did not meet the inclusion criteria.Two reviewers independently extracted data from the studies and assessed their eligibility for inclusion based on the abovementioned criteria. Any discrepancies between the two reviewers were resolved through consensus or discussion with a third reviewer. The extracted data included: (a) basic study information, such as first author and publication year; (b) study characteristics, including sample size, patient age, analgesic measures, types of cancer, treatment time, TENS-related information ; (c) primary outcome measures of interest, including the incidence of constipation or the effective rate of treating constipation, secondary outcome measures, such as quality of life scores, and the incidence of adverse reactions; and (d) relevant elements of the bias risk assessment.Conducting randomized clinical trials of interventions such as TENS or acupuncture present challenges in achieving blinding, which refers to the extent to which participants and/or researchers must be made aware of which intervention is being administered. Blinding is crucial as it can minimize bias due to the expectations or preferences of participants and researchers. However, blinding may be difficult or impossible in some interventions, such as physical manipulation or sensory stimulation. Although such trials may not be blinded, they are still considered acceptable by researchers –18. The P > 0.10 and I2 ≤ 50% and the random effect model if P ≤ 0.10 and I2 > 50%. In cases where clinical heterogeneity was too significant or insufficient literature to perform a meta-analysis, we used descriptive analysis. We considered P < 0.05 to be a significant difference.We used RevMan 5.3 (Cochrane Collaboration) software to conduct the meta-analyses. For dichotomous variables, we used the odds ratio (OR) and 95% confidence interval (95% CI). The choice between the fixed effect and random effect model in meta-analysis depended on the degree of heterogeneity among the studies, as determined by the previous literature , 23. SpeIn our initial search, we identified 180 pieces of literature, out of which 31 were excluded due to duplication, resulting in a total of 149 studies for title and abstract screening. After this screening, 42 articles were selected for full-text reading, out of which 33 were excluded as they did not meet the eligibility criteria. Finally, a total of 9 studies that met the standards were included in the meta-analysis. A summary of the literature search process is presented in We assessed the risk of bias and concerns regarding the applicability of the included studies using the Cochrane collaboration tool (ROB 2 IRPG 2018 beta v6), and the results are reported in P=0.03; I2 = 57%), and as such, the random-effects model was used. The meta-analysis results are presented in I2 statistic with a random-effect model, was I2 = 57%, P=0.03. Overall, TENS significantly reduced the incidence rate of OIC compared with the control .A total of seven studies  that reported the incidence rate of OIC provided sufficient data for statistical pooling. The test for the heterogeneity among the studies showed significant heterogeneity , and as such, the random-effects model was used. The meta-analysis results showed in I2 = 0%; P=0.82; OR = 1.08; 95% CI: 1.00–1.16, Z = 1.84, P=0.07).Two studies  compared the effective rate of treating constipation between the TENS treatment group and the control group. The test for the heterogeneity among the studies showed significant heterogeneity , and as such, the random-effects model was used. The meta-analysis results are presented in I2 = 80%, P=0.03; OR = −1.91; 95% CI: −2.54 to −1.29, Z = 6.00, P < 0.01).Two studies  compared the quality of life scores between the TENS treatment group and the control group. The test for the heterogeneity among the studies showed significant heterogeneity (TENS was employed to ameliorate the adverse effects of chemotherapy, such as nausea, insomnia, cachexia, and pain, in patients with advanced cancer. Although it cannot be considered a substitute for opioids and other pharmacological interventions, it can support palliative care . CompareReportedly, 97% of patients with cancer and OIC experience moderate to severe constipation-related symptoms, despite the widespread application of laxatives . HoweverThe precise selection of points is paramount for the efficient employment of TENS in alleviating OIC or cancer-related discomfort. According to the comprehensive review of nine OIC prevention studies, the Tianshu acupoint was identified as the optimal point for selection, and a meta-analysis confirmed its efficacy in significantly reducing the incidence of OIC.Point selection is essential for TENS to treat OIC or cancer pain. The nine OIC prevention studies included in this review found that Tianshu acupoint was selected, and a meta-analysis showed that it could significantly reduce the incidence of OIC. There are few studies on TENS therapy or adjuvant therapy for OIC, and only 9 studies were searched in this study. The dearth of knowledge on the specific mechanisms of OIC, coupled with the numerous OIC cases, necessitates more in-depth and meticulous research in the future, such as stimulating different acupoints for the effect of comparative studies, different frequency stimulation effects of comparative studies, different types of cancer, and psychological interventions. Ideally, future studies should be randomized, double-blinded, and placebo-controlled to assess TENS' clinical efficacy and safety. However, this is an enormous challenge, as the blindness of TEAS treatment seems impossible, given that patients will eventually know whether they receive treatment. Nakano et al.  studied TENS may possess a mechanism of action akin to that of acupuncture. The mechanism of pain treatment via acupuncture centers around the activation of opioid receptors and neuropeptide genes . AcupuncChemotherapy patients often endure the pain caused by chemotherapy-induced adverse reactions, and due to the nature of their treatment, they commonly reside in their homes during the chemotherapy interval. Consequently, nurses are faced with the challenge of monitoring their condition and providing adequate care. The evolution of family rehabilitation and community health care as a means of continuing care has been slow, and nursing personnel generally lack a comprehension of the concept of continuing care. Given the remedial effects of acupuncture on analgesia, there has been a growing acceptance of acupuncture treatment. TENS, a new type of acupuncture, has a similar analgesic effect to acupuncture  but withSeveral limitations were present in this meta-analysis. Firstly, it is noteworthy that meta-analysis represents secondary research, and the outcome significantly relies on primary studies , inevitaNevertheless, this research conducted a comprehensive retrieval with a language limited to Chinese and English. Hence, it may lead to corresponding language bias, even though it is understood that accessibility is limited to databases and language ability. Fifthly, the lack of standardization is an issue. Currently, there is no standardized protocol for TENS treatment for OIC. The optimal frequency, intensity, and duration of treatment vary depending on the individual's response. Most studies on TENS have focused on treating pain rather than constipation. In conclusion, we must take the findings of this study into account.With the progress of technology, it is possible to individualize TENS therapy based on an individual's response. Especially, TENS is suitable for promotion in the community and home settings. In conclusion, TENS can potentially treat OIC, but the evidence of its efficacy is limited. Further research is essential to comprehend its mechanism better and establish the optimal therapeutic approach. TENS can be combined with other therapies to provide complete relief for OIC.


Illegal and/or unsustainable trade is a major obstacle to effective primate conservation. The wildlife trade in the European Union (EU) and the United Kingdom (UK) is significant, but for many species, such as primates, the trade is poorly understood and sparsely reported. All EU countries are Party to the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES); all primates are listed on Appendix I or II of CITES and are included on Annex A or B of Regulation (EC) No 338/97. We here combine data from several databases  and seizure reports, to provide a narrative of the trade in primates into and within Europe. The legal import of live primates (2002–2021) amounted to 218,000–238,000 individuals , with France, the UK, and Spain as the main importers and Mauritius, Vietnam, and China as the main exporters. Over 21,000 primate parts  were imported mainly from African countries, and UN Comtrade data suggests that ~ 600 tonnes of primate meat was imported mainly from Asia. The vast majority of live primates are either captive-born or captive-bred, and this proportion has increased over time. Reports of the illegal primate trade are far from complete, but the illegal trade of specific species or primate meat can have negative impacts of wild populations of already imperiled species. Stronger policies and more effective enforcement in consumer countries, such as the EU, would also aid in, and garner support for, better protecting primates in primate range states. TMacaca sylvanus, Encap The trade in primates as pets into Europe is also ongoing; for example, it is believed to have caused a decline of 80% in the wild population of Barbary macaques (M. fascicularis) with marmosets and tamarins being the next most commonly used species. For those primates that were used for the first time for scientific research in 2018, the majority were sourced from self-sustaining colonies (29%) or as second- or higher generation captive-bred (56%), and none was reported as sourced from the wild.Although throughout the EU and UK primates are used only in exceptional circumstances for laboratory experiments, where no alternative methods are possible and no other species may suffice for the purposes of the studies, studies on great apes are effectively banned. In 2018, 8583 primates were used for scientific purposes in the EU (European Commission Declaration of the European Parliament on Primates in Scientific Experiments was established in 2007 (EU Parliament The Commission Recommendation 2007/425/EC) recommends that EU member states develop inter-regional collaboration to combat illegal wildlife trade by building links with other regional and sub-regional initiatives (Nijman and Shepherd Colobus satanas), several langurs (Trachypithecus spp.), titi monkeys  and all tarsiers . As such, as a group, primates are well covered in terms of import and export regulations.All primate species are listed by the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES), either under Appendix II, meaning commercial trade is regulated, or in Appendix I, which generally precludes commercial trade. CITES is ratified by all EU member states and the UK, as well as by the European Union itself  for the period 2002–2021 (data from 2022 were not yet available).We downloaded data, in December 2022, on the import of primates to the EU and the UK from the CITES trade database  Act 2018, and will remain in force, without amendment, apart from corrections to make the EU legislation fully operable APHA .www.CITES.org). To avoid over-counting, we excluded specimens where it was specified that the import was in metric volume units. We restricted dead individuals to trophies, bodies, and skulls to avoid possible double-counting . To prevent double-counting, we checked all re-exports . Reported import and export figures did not always coincide; therefore, we crosschecked the numbers and included the largest reported numbers by comparing figures from importing and exporting countries. The CITES trade database is conservative in the taxonomy employed, and taxonomy is listed as it was at the time of reporting. We, therefore, where possible, refined the taxonomy of primate species listed based on current knowledge of distribution patterns.We established the number of imported live and dead primates, as well as the main source and destination areas, assessing the proportion of wild-caught vs captive-bred or captive-born individuals. Regarding specimens in the CITES database, it is possible to overestimate the number of individuals, as specimens are defined as any readily recognizable part or derivative of the animal , rhesus macaques , and green monkeys . Live primates, where purpose and source was recorded, were imported to the EU and the UK mainly for medical , commercial (28.67%), or scientific (22.84%) purposes, and the majority were sourced from populations bred or born in captivity (95.50%).The total number of live primates reported to the CITES trade database as having been imported into EU/UK countries over the 20 year period was 218,189 individuals. The main importers were France , UK , Spain , the Netherlands , and Germany . The main exporters were Mauritius , Vietnam , China , Barbados (5176), and the Philippines (3574). There was some trade within the EU and the UK, between UK and Spain , and between Hungary and the Netherlands (133). In all at least 139 identified primate species were imported into the EU and the UK. The main species were long-tailed macaques . There has been a steady decline in both the number of species and the number of countries that have imported live primates , Spain , and the UK . The main exporters were Mauritius , Vietnam , and China . The UN Comtrade database indicates a considerable within-EU trade with, for instance, relatively large numbers traded between France and Spain , the Netherlands and Italy , and Spain and Germany . The total declared monetary value of the live primate trade (including re-exports) over the two decades, when corrected for inflation, amounted to US$ 869 million.Papio spp., 7228 individuals) and vervets ; trophies were mainly of the same two species, Papio spp. (7487) and Chlorocebus spp. (1261); whilst most of the bodies were marmosets  and baboons (167). The main importers were Germany , Spain , and Denmark . The main exporters were South Africa , Namibia , and Brazil . For the primate parts where purpose and source was recorded, skulls, trophies, and bodies were imported to the EU and the UK mainly as hunting trophies  or for scientific (12.53%) or commercial (11.96%) purposes. The majority were sourced from wild populations (96.29%) of which 43.03% were imported as trophies, mainly from South Africa  and Namibia (2786).The CITES trade database contains records of 21,060 primate items  over the 20-year period. The skulls were mainly from baboons , Taiwan (132 tonnes), and China (31 tonnes). The total monetary value of the primate meat in trade over the two decades, when corrected for inflation, amounted to US$ 3.11 million.While the numbers between the CITES trade database and the UN Comtrade database showed quite some discrepancies for individual countries, overall, there is a good degree of concordance at the EU level Fig. .Fig. 3CoConcerning seizure of illegally traded primates, using the TRAFFIC WiTIS database and media reports, 58 seizures were recorded. Most seizures were reported in the UK (27 reports), France (6), Spain (5), and the Netherlands (4), but there were also reports from Germany, Sweden, Belgium, Italy, Poland, Greece, Hungary, Ireland, and Portugal. Regarding the number of individual primates seized, German authorities reportedly seized 569 primates, followed by the UK which has seized more than 76 primates, and Spain (33). Often reports of seizures did not report actual numbers, so these are minimum esitmates.Many of the seizures were made within country, not when entering a country, and the origin was not always reported. For the seizure reports on primates being illegally brought into the EU and the UK over the past 20 years where the origins were included, the majority arrived from Africa, with 22 seizures involving more than 45 individual primates. Most of these seizures involved dead primates or parts of primates (61%), and mainly coming from Cameroon and Madagascar. From Asia, all of the primates seized were dead/parts, and mainly from Indonesia (55%).Pan troglodytes), one gorilla (Gorilla spp.), and one just reported as great ape). Other primates that were illegally traded as parts/meat/dead were langurs (Trachypitchecus spp.), grivets (Chlorocebus aethiops), other macaque species, orangutans (Pongo spp.), and red colobus (Piliocolobus spp.). The most commonly seized live primate was marmosets , followed by Barbary macaques (3), capuchins , gibbons , pygmy loris  and ring-tailed lemur . Five guenon species were seized (Cercopithecus spp.), live and dead, but it was not indicated how many of each.In 19 of the primate seizure reports, the species was not identified or reported. Out of the remaining 39 seizure reports, the species with the highest demand on the illegal market were long-tailed macaques. This was due to a seizure from the United States to Germany for scientific purposes and involved 572 individual macaques. The second most seized primates were baboons, with 13 individuals, of which all were seized as skulls or parts. African great apes were seized on four occasions, all dead/parts , the outcome of the incident was that the primates were simply confiscated. In eight incidents, the person(s) got a prison sentence, with the imprisonment length ranging from 3 to 66 months (both extremes in the UK). Four of these prison sentences were in the UK, and the others in Greece, France, Spain, and the Netherlands, and all between 2013 and 2021. In seven incidents the person(s) got a fine, sometimes in addition to imprisonment (reported in four incidents), and the fines ranged between US$ 316 and US$ 244,453. The lower fine was given in Sweden and the highest in Spain. All reported fines were between 2013 and 2021.The EU, the UK included, is considered one of the major hubs in terms of wildlife trade, being the top global importer of wildlife and their derivatives by monetary value and ranking as the third-largest wildlife trade hub in the world in terms of consumption and transit (Engler and Parry-Jones Cercopithecus ascanius) and De Brazza’s monkey (C. neglectus), were identified in Brussels . Monitoring the trade in pet primates is vital to reduce the risk of zoonosis. Primates act as reservoirs for a fifth of the diseases that affect humans, and their close phylogenetic relationship to humans amplifies the risk of transmission (Wolfe et al. We did not record many seizures of illegally imported primates into countries such as Poland, but it has been found that primates are among the most traded groups of wildlife in the Polish online trade Paquel . This waProsecution information was not always reported, so we were unable to measure prosecution rates. However, our findings indicate that punishments are seldom handed out, and if so, the fines or imprisonment lengths tend to be minimal.The clandestine nature of the illegal wildlife trade, and insufficient resources at EU boarders, as well as loopholes in enforcement policies and law penalties, makes the exact quantities of trade hard to measure (Wyatt and Cao