The increase rate of MPOD was significantly higher in subjects with body mass index (BMI) less than 25 kg/m2 (n = 13) compared to those of 25 kg/m2 and higher (n = 3). SC levels increased significantly by week 4 and continued to increase until week 16 . All subjects completed the study without any serious adverse events. These results demonstrated the effectiveness of a high dose lutein/zeaxanthin supplement for MPOD volume and SC levels without serious adverse events.The effect of a high dose lutein/zeaxanthin supplement on macular pigment optical density (MPOD) and skin carotenoid (SC) levels in healthy subjects was investigated. This is a prospective, single-arm, open-label study. Subjects were 16 Japanese, age 26–57 years. Subjects took a supplement containing 20 mg/day of lutein, 4 mg/day of zeaxanthin, and other antioxidants  for 16 weeks. MPOD levels were measured by a two-wavelength autofluorescence imaging technique. SC levels were measured by reflection spectroscopy. Total volume of MPOD within 9° eccentricity significantly increased by week 8 and continued to increase until week 16 ( MP absorbs blue light and acts as a filter that may attenuate photochemical damage to the retina due to blue light exposure and potentially protects against light-induced oxidative damage in the retina by quenching oxygen radicals5. MP functions to improve contrast sensitivity and reduces night glare9. Some studies have reported that MP optical density (MPOD) levels in eyes with age-related macular degeneration (AMD) are significantly lower than those in normal, healthy eyes11. The light protection effect of MP is thought to prevent age-related macular degeneration (AMD)15, and our previous study on a Japanese population indicated that lower MPOD levels may be a risk factor for AMD progression16.The human macula contains yellow pigment, called macular pigment (MP), consisting of three carotenoids, lutein  -lutein), zeaxanthin  -zeaxanthin), and 17. These carotenoids protect skin against oxidation induced by sunlight exposure. Lutein and zeaxanthin have been reported to reduce lipid peroxidation and increase moisture in the skin18. The anti-oxidative effect of lutein also protects against UV-induced skin damage19. Regarding the subset of carotenoids found in the human macula, previous studies have reported a weak to moderate correlation between MPOD and skin carotenoid (SC) levels measured by resonance Raman spectroscopy (RRS)23.Carotenoids such as lycopene, alpha-. beta-, gamma-, delta-carotene, beta-cryptoxanthin, lutein, and zeaxanthin are contained in the epidermis, dermis, and subcutaneous fat25. A second clinical trial was conducted to investigate the effect of lutein/zeaxanthin instead of beta-carotene26, because several observational studies demonstrated that higher dietary intake of lutein/zeaxanthin was associated with a decreased risk of advanced AMD27. According to the AREDS2 study, a prophylactic effect of lutein/zeaxanthin-containing anti-oxidative supplements can be achieved at least for the lowest dietary intake of lutein and zeaxanthin quintile28. The formula recommended by AREDS2 is: vitamin C 500 mg, vitamin E 400 IU, lutein 10 mg, zeaxanthin 2 mg, zinc oxide 80 mg, and cupric oxide 2 mg. Based on this formula, several commercial products have been released in Japan, although the actual amount of each ingredient may be modified by the manufacturer. For example, commercial products in Japan contain less zinc than the AREDS formula since the maximum allowable amount of zinc in Japan is 30 mg per day, whereas the AREDS formula contains 65 mg of zinc (80 mg of zinc oxide).The Age-related Eye Disease Study (AREDS) Research Group conducted the first multi-center, randomized trial to verify the prophylactic effect of a supplement containing vitamin C, vitamin E, beta-carotene, and zinc, and demonstrated that this supplement formula reduced the 5-year risk of advanced AMD in persons at risk by 25%In this study, we investigated the change in MPOD and SC levels due to supplement intake of high doses of lutein/zeaxanthin in healthy subjects. This is the first study to show the effects of lutein and zeaxanthin supplementation with vitamin C, vitamin E, zinc, and copper on skin carotenoid levels.This is a prospective, single-arm, open-label study at a single institute . Thirty-six healthy volunteers were evaluated between June 2018 and May 2019, and twenty were excluded from enrollment due to incompatibility with the inclusion criteria . Baseline contrast sensitivity (C_AULCSF [the area under the log contrast sensitivity function]) was from 1.61 to 1.84, and glare disability (G_AULCSF) was from 0.85 to 1.49. Mean C_AULCSF at baseline, week 8, and week 16 were 1.74 ± 0.07, 1.76 ± 0.11 and 1.76 ± 0.08, respectively. Mean G_AULCSF at baseline, week 8, and week 16 were 1.25 ± 0.15, 1.26 ± 0.12, and 1.28 ± 0.13, respectively. No significant differences in C_AULCSF and G_AULCSF were observed at each time period for all subjects .Best corrected far and near decimal visual acuities at baseline were 1.2 and 1.0 in all subjects, and no change in visual acuity throughout the study period was observed in any subject. Mean retinal thickness at 1-mm diameter central area  measured by optical coherence tomography (OCT) of each subject at baseline was between 239–283 μm. Mean CRT values ± standard deviation (SD) for all subjects at baseline, week 4, week 8, week 12, and week 16 were 259.2 ± 10.5, 258.4 ± 11.4, 259.2 ± 12.3, 259.9 ± 13.0, and 259.1 ± 11.1 μm, respectively. No significant differences in CRT were observed at each time period for all subjects  were observed.MPOD levels of the study eye were measured using two different methods at baseline and 4, 8, 12, and 16 weeks after starting supplement intake. MPOD levels measured by HFP-MMII at baseline varied between subjects from 0.31–1.10 at 0.25° eccentricity and 0.27–0.63 at 0.5° eccentricity. Mean values at 0.25° and 0.5° eccentricities were 0.62 ± 0.20 and 0.49 ± 0.11, respectively. Mean baseline MPOD levels and mean MPOD levels obtained for all subjects at time points 4,8,12, and 16 weeks are shown in Fig. p = 0.801, 0.310, 0.205, 0.534, two-way factorial ANOVA). Total MPOV for each subject at baseline ranged from 4527 to 16535. Mean values at baseline, week 4, week 8, week 12 and week 16 were 12097 ± 3192, 12203 ± 3476, 12585 ± 3111, 13093 ± 3371, and 13408 ± 3521, respectively. Corresponding mean total MPOV levels obtained for all subjects at baseline and time points 4,8,12, and 16 weeks are shown in Fig. p < 0.0001, two-way factorial ANOVA, baseline/week 4, p = 0.641, baseline/week 8, p = 0.034; baseline/week12, p < 0.001; baseline/week 16, p < 0.001, post-hoc with LSD). The increase in total MPOV at week 16 for each subject  / total MPOV at baseline) ranged between 3–27%, with a mean of 11%.Local MPOD of each subject measured by two-wavelength autofluorescence imaging, AFI-SP  at 0.25°, 0.5°, 1°, and 2° eccentricities at baseline were 0.28–0.73, 0.19–0.64, 0.20–0.60, and 0.05–0.28, respectively. Mean values at 0.25°, 0.5°, 1°, and 2° eccentricities were 0.49 ± 0.12, 0.46 ± 0.12, 0.45 ± 0.10, and 0.19 ± 0.06, respectively. Corresponding mean MPOD levels obtained for all subjects at baseline and time points 4,8,12, and 16 weeks are shown in Fig. 2 (n = 13), and the other with BMI 25 kg/m2 and higher that is defined as obese in Japanese (n = 3), a significant difference in the increase of local MPOD at 0.25°, 1°, and 2° and total MPOV at week 16 was observed (Table A significant negative correlation between body mass index (BMI) at baseline and increase in local MPOD levels at week 16, excluding local MPOD at 0.5°, was observed Table . The cored Table . Percentp < 0.0001, two-way factorial ANOVA, baseline/week 4, p = 0.010; baseline/week 8, p < 0.0001; baseline/week12, p < 0.0001; baseline/week 16, p < 0.0001, post-hoc with LSD). Percentage increases in SC levels at week 16 of each subject except for one, (SC level at week 16 – SC level at baseline) / SC level at baseline) ranged between 16–114%, with a mean of 48%. For an exceptional subject, discussed in the discussion section who scored a noticeably low SC value at baseline, the increase in SC amounted to 616%. No significant correlation between BMI at baseline and the increase in SC levels at week 16 was observed . In addition, no significant difference in the increased SC levels at week 16 between subjects in the low and high BMI groups was observed .SC levels of each subject at baseline ranged from 37–483. Mean SC levels of all subjects at baseline, week 4, week 8, week 12, and week 16 were 277 ± 98, 337 ± 137, 380 ± 144, 402 ± 128, and 423 ± 172. The change in mean SC levels of all subjects is shown in Fig. No significant correlation between C_AULCSF at baseline and SC levels, local MPOD levels, or MPOD volume were observed Table . In addiNo significant correlation between SC levels and local MPOD levels or total MPOV at baseline were observed Table .Table 6CAll subjects completed the study without serious adverse events. Seven subjects reported changes in general condition for some days during the study period Table . No subjChanges in blood tests between baseline and week 16 are shown in Table All urine qualitative tests for pH, protein, glucose, urobilinogen, ketone body were negative for all subjects at baseline and week 16. Urine blood tests were positive for 6 female subjects at baseline, of which two were positive at week 16.2 compared to subjects with BMI 25 kg/m2 and more. All subjects completed the study without serious adverse events. These results demonstrated the effectiveness of the present supplement on the eye and skin.Mean total MPOV significantly increased at 8 weeks after the start of supplement intake and continued to increase until the end of supplement intake at week 16. Mean SC levels also increased at 4 weeks and continued to increase until week 16. A significantly higher increase in local MPODs and total MPOV at week 16 was observed in subjects with BMI less than 25 kg/m31. The value of 0.64 was chosen based on our previous study32. HFP-MM II was used for screening because it can be carried out without mydriasis. According to our previous study, MPOD hardly increased in myopic subjects in response to supplementation32. Consequently, subjects with myopia of −6.0D or higher were excluded as well.In this study, only those subjects were selected who had MPOD levels of 0.64 and lower at 0.5° eccentricity. The rationale for this selection is the avoidance of subjects with already saturated macular pigment, who would not be able to respond with a further increase upon supplementation35. Concerning the time at which a significant increase was observed, one study used a high dose meso-zeaxanthin supplement36 and reported a rapid increase of MPOD just two weeks later. In contrast, a relatively slow increase of MPOD (significant increase observed only at 12 weeks and after) was reported for a dietary investigation study with spinach and corn37. One study, using the same lutein product as in this study (20 mg lutein and 4 mg zeaxanthin) reported a significant increase at 8 weeks and after38, which is in agreement with this study. Concerning the increase in amount of MPOD level, previous studies reported it increases between 4–39%36. Mean increase of total MPOV at week 16 in this study was 11%. Speed and achievable percentage MPOD increases are affected by various factors, such as the type of lutein , the amount of zeaxanthin and meso-zeaxanthin, the matrix of the formulation, and subject characteristics . When interpreting the results, it is important to consider the respective method used to measure MPOD and evaluated parameters such as local MPOD or MPOV. Therefore, comparison of these results with previous studies is difficult. However, the MPOD increase in this study was relatively slow and the percentage increase was moderate compared to previous studies. Possible reasons for this are as follows. The mean total MPOV at baseline of the subjects in this study was higher than in previous studies. Total MPOV at baseline in the study by G-Gomez was 5094, with a reference point at 7°, and in the study by Nolan, et al., it was 6593, with a reference point at 8° 39. Mean baseline total MPOV in this study was 12097, with a reference point at 9°. This value was converted to 8138 with a reference point at 7°, when we re-calculated MPOV with this reference point. While subjects with a relatively low MPOD levels were selected, a potentially still high MPOD at baseline might be a reason for the moderate increase. Other possible reasons are subject characteristics other than baseline MPOD and unknown interactions with other nutrients.A significant increase in MPOD levels measured by heterochromatic flicker photometry at four weeks and later has already been reported in many previous studies2 than in subjects with BMI 25 kg/m2 and higher . High BMI was reported to be a factor in low MPOD levels in previous studies40. Adipose tissue and the retina competed for lutein37. A higher amount of body fat provides a larger “sink” for lutein, which makes less lutein available for other tissues. The subject with the lowest BMI  may have some form of diet malabsorption.The ability of the supplement to increase MPOD was influenced by BMI in this study. The increase in total MPOV at week 16 was significantly higher in subjects with BMI less than 25 kg/mer Table . Interes41. From this, local MPOD levels could possibly vary between eyes, even in cases where the total amount of MP is the same. The local MPOD level at discrete eccentricities does not always reflect the total amount of MP at the macula. In contrast, total MPOV provides an overall description of MP across the macula. Total MPOV by AFI-SP was reported to be more appropriate to evaluate the effect of supplementation, and total MPOV could be the standard value to assess MP42.In this study, the effect of supplement intake was observed for total MPOV but not for local MPOD levels. The reason for this discrepancy is thought to be as follows. The MP distribution is not symmetrical and can be roughly divided into four major patterns23, the average SC level was 32% higher in subjects taking lutein supplements relative to non-supplementing subjects. The possibility to increase SC levels by beta-carotene, lycopene, and vegetable juice consumption was demonstrated by interventional studies46. However, no interventional study using lutein/zeaxanthin supplements has been performed to date. This study directly confirmed the effect of lutein/zeaxanthin supplementation on SC levels for the first time. It has been reported that lycopene and beta-carotene levels are predominant in skin, and the amount of lutein and zeaxanthin is much less than carotene47. However, a more recent study found a higher level, roughly 15%, amount of lutein and zeaxanthin in heel skin samples48, and the present results were consistent with this finding. Our previous study23 showed that BMI was a factor for a significant difference in SC levels, but in this study, no significant difference was observed. A possible reason for this discrepancy is the small number of subjects in this study.In our previous study53. Supplements induce a quick increase in serum lutein and zeaxanthin concentrations that reflect the increase in SC levels. In contrast, MP has been reported to accumulate gradually in the retina, so more time must elapse in order to detect a significant change. In other words, after taking supplements, SC levels increase first, while MP increases later.A significant increase in SC levels at week 4 was observed, while in contrast, a significant increase in MPOV was observed only at week 8. The reason for this time lag is considered to be as follows. SC levels are reported to reflect serum concentration of the carotenoidsp < 0.0001, two-way repeated ANOVA). The reason for the lack of significant improvement in visual functions and lack of significant correlation between contrast and/or glare sensitivity and MPOD levels/SC levels was considered to be due to good visual functions already present at baseline in healthy subjects.The SC value in one subject  and zeaxanthin intake of up to 0.75 mg/kg body weight are considered safeFrom the results of this study, the effectiveness of supplements containing 20 mg of lutein and 4 mg of zeaxanthin combined with co-antioxidants on MPOV and SC levels without any serious adverse event could be demonstrated in subjects with relatively low MPOD levels at baseline. Limitations of this study included its study design as a single arm without a control group and the small number of subjects. A lack of assessment of dietary intake of lutein and zeaxanthin during the study period was another shortcoming.32. In this study, mean MPOD was measured by the same method as the present study before and after intake of a 10 mg lutein supplement, with values of 0.62 and 0.72, respectively, with a standard deviation (SD) of 0.06. Increase was 16% which was comparable to that of other studies56. When α error is set at 0.05 and power at 0.8, the number of subjects with significant results in a comparative study was 14. Similarly, we set number of our subjects at 16. Self-selected recruitment of subjects was facilitated by intranet information of Seirei Hamamatsu General Hospital and by word of mouth. Measurements of far and near visual acuities and intraocular pressure, observation by slit-lamp biomicroscopy and fundus ophthalmoscopy, and OCT were performed before enrollment in order to assess the inclusion criteria. MPOD was measured using heterochromatic flicker photometry (HFP-MM II) with a reference point of 7° eccentricity, and subjects with a MPOD at 0.5° eccentricity of 0.64 or less were enrolled. Subjects with a MPOD greater than 0.64 were excluded. Details of the inclusion criteria are shown in Table Sample size was based on our previous studyThe study was approved by the institutional review board of Seirei Hamamatsu General Hospital (No.2965) and registered as No. UMIN000031870. All subjects provided a written informed consent form that complied with the tenets of the Declaration of Helsinki.Subjects were measured for far and near visual acuities using a decimal visual acuity test chart, and given a contrast and glare sensitivity test using a contrast glare-tester , at baseline, and 8 and 16 weeks after starting supplement intake. Contrast threshold values were assessed at six visual angles (sizes) of the target  under mesopic (10 candelas per square meter) and glare  conditions, and the area under the log contrast sensitivity function (AULCSF) was used to evaluate contrast sensitivity in the normal setting (C_AULCSF) and in the presence of glare light (G_AULCSF). OCT imaging was obtained at baseline and 4, 8, 12, and 16 weeks after starting supplement intake. Mean retinal thickness at 1-mm diameter central area  was obtained using SPECTRALIS software by volume scan with 20° × 15° in the 19 B-scan mode.58. Measurements are carried out with alternating blue and green laser light sources which are raster scanned over the retina for about 30 seconds. In contrast to earlier digital camera-based instruments that captured autofluorescence images with a single blue or green flash, AFI-SP uses a scanning laser technique that does not require pre-bleaching of photopigments. Optical densities at 0.25°, 0.5°, 1°, and 2°eccentricities , and total optical density volume within 9° eccentricity  were used for analyses. 9° eccentricity was set as a reference point. The local MPOD level is the average along a concentric circle at selected eccentricities, and total MPOV is the total of MPODs within 9° eccentricity. Total MPOV correlated to MPOD at each eccentricity and has been proposed as the preferred metric for the assessment of macular pigment42.MPOD levels of the study eye were measured using two different methods at baseline and 4, 8, 12, and 16 weeks after starting supplement intake. First, MPOD was measured by HFP-MM II without mydriasis. MPOD values at 0.25° and 0.5°eccentricities with a reference point of 7° eccentricity were evaluated. Then, the pupil was dilated with 2.5% phenylephrine hydrochloride and 1% tropicamide, and MPOD was measured by two-wavelength autofluorescence imaging, AFI-SP. Basic functionality and handling of this instrument have been previously described59. VEGGIE METER has been validated by comparing it to skin resonance Raman spectroscopy which has high specificity for carotenoid molecules60. Calibration was performed with the provided dark and white reference materials prior to daily skin measurements. Subjects placed their left middle finger into the device’s finger cradle and pressed their fingertip against the convex contact lens surface with the assistance of a spring-loaded lid. Slight pressure was applied to the fingertip to reduce blood perfusion of the measured tissue, which prevents highly blood with its high visible light absorbance from interfering with measurement of skin carotenoid levels. SC index was determined as the average of three consecutive measurements.Pressure-mediated reflection spectroscopy  was used to measure SC levels. Basic functions of this device have been previously describedCommercially available gelatin soft capsule supplements containing lutein/zeaxanthin  were used. The subjects orally took three capsules after a meal with water once a day for 16 weeks. Contents of three capsules were: lutein 20 mg (6.7 mg per capsule), zeaxanthin  4 mg (1.3 mg per capsule), vitamin C 408 mg, vitamin E 242.3 mg, zinc 30 mg, copper 1.5 mg. Lutein and zeaxanthin material used in this supplement was Lutemax 2020 . The carotenoids were suspended in a mixture of sunflower oil, safflower oil, beeswax, fatty acid ester, and glycerol ester. Soft capsules were made from porcine gelatin and glycerol. Table Subjects were asked about their general condition and past history of illness, and measurements of height and body weight were taken at baseline. Subjects were asked to record any change in general condition, details of any medicine taken (name and amount of the drug), and any changes in their lifestyle in the notebook every day. Fasting blood and urine tests were performed at baseline and after 16 weeks. Components of the tests are described in the results. All analyses were performed by SRL Co., Ltd .p < 0.05.Statistical analyses were performed by ORTHOMEDICO Inc.  using IBM SPSS Statistics version 23. Changes in numerical variables of each subject during the study period were analyzed by two-way factorial analysis of variance (ANOVA). Post-hoc analyses were performed by Fisher’s LSD or Dunnet’s test. Correlation between two numerical variables were analyzed by Pearson’s correlation coefficient test. Two average values of numerical variables were compared by t-test (two-sided). Average value was shown as the mean ± standard deviation. All statistical tests were two-sided; and significant difference was set at


Bacillus cereus-contaminated red pepper powder was tested. A cocktail of three strains of B. cereus  was inoculated onto red pepper powder and then treated with MH (60 °C for 5–20 min) and DBD plasma (5–20 min). Treatment with MH and DBD plasma alone for 5–20 min resulted in reductions of 0.23–1.43 and 0.12–0.96 log CFU/g, respectively. Combined treatment with MH and DBD plasma was the most effective at reducing B. cereus counts on red pepper powder, and resulted in log-reductions of ≥6.0 log CFU/g. The largest synergistic values (4.24–4.42 log) against B. cereus in red pepper powder were obtained by the combination of 20 min MH and 5–15 min DBD plasma. The values of Hunter color ‘‘L’’, ‘‘a’’, and ‘‘b’’, were not significantly different from those of the untreated sample and that with the combination of MH (60 °C for 5–20 min) and DBD plasma (5–20 min). Also, no significant (p > 0.05) differences in pH values between samples were observed. Therefore, these results suggest that the combination of MH treatment and DBD plasma can be potentially utilized in the food industry to effectively inactivate B. cereus without incurring quality deterioration of red pepper powder.The synergistic efficacy of a combined treatment of mild heat (MH) and dielectric barrier discharge (DBD) plasma in  This spice is also commonly used as a cooking sauce for processed foods  [Bacillus cereus, respectively.Red pepper powder is an essential dietary spice in Korea, and the principle ingredient and determinant of the color, taste, and quality of traditional fermented d stews) . Becaused stews) . The used stews) , the conPlasma is a quasi-neutral ionized gas state composed of ions, free electrons, atoms, and molecules in their fundamental or excited states with a net neutral charge . Plasma Pasteurization, a relatively mild heat (MH) treatment in which food is heated to <100 °C, is commonly used in the food industry. It is also frequently applied as a critical control point in the hazard analysis critical control point (HACCP) system. Hurdle technology  can control the growth of spoilage and pathogenic microorganisms in foods, thus extending the shelf-life of foods . UV-C irEscherichia coli and Salmonella. Moreover, this combined approach does not cause quality deterioration of powdered red pepper. Choi et al. [E. coli O157:H7 and Staphylococcus aureus, following a radio frequency thermal treatment and plasma treatment combination, resulted in 2 log CFU/g reductions in the microbial counts proportional with increasing treatment cycles. To date, a few studies have researched combinations of non-thermal and thermal treatments on reducing foodborne pathogens in pepper powders. Cheon et al.  reportedi et al.  reportedB. cereus in red pepper powder.There is a need to examine the potential synergistic effects of combined treatment with MH and DBD plasma for the decontamination of red pepper powder. The present study was therefore undertaken to determine the synergistic effects of a combined treatment with MH (60 °C for 5–20 min) and DBD plasma (5–20 min) on the reduction of B. cereus  were tested. A stock culture (108 CFU/mL) was maintained at −80 °C in tryptic soy broth  containing 30% glycerol. Bacteria were cultured on tryptic soy agar  plates at 37 °C for 24 h. Afterwards, a single colony was inoculated into TSB and grown at 37 °C for 12 h with shaking at 150 × g.Three strains of × g for 10 min at 4 °C, and washed three times with 0.85% sterile saline water. The final pellets were resuspended in 10 mL of 0.85% sterile saline water, corresponding to approximately 107–108 CFU/mL. Suspended pellets from each of the three B. cereus strains were combined into a mixed culture cocktail at a final concentration of approximately 107 CFU/mL for use in this study.Each strain was cultured in 5 mL of TSB at 37 °C for 24 h, harvested by centrifugation at 5400 6–107 CFU/g.Commercially available dried red pepper powders were purchased at a traditional market . Red pepper powder samples were autoclaved for 15 min at 121 °C before inoculation to remove preexisting microorganisms. For inoculation, 1 mL of the culture cocktail was added to 25 g of samples in 500 mL glass beakers, and then mixed with a sterilized stainless-steel spoon for 5 min to ensure uniform distribution. After mixing, samples were dried for 1 h inside a clean bench (25 ± 1 °C) with the fan running. The concentration of final samples was 10To pasteurize using MH treatment, the sterilized petri dish containing 25 g of red pepper powder was sealed with parafilm  to prevent water vapors from going into the sample. Samples were treated at 60 °C in a water bath for 5, 10, 15, and 20 min, and then immediately cooled in an ice water bath for 5 min to stop further thermal inactivation. 2) was also screen printed to 100 µm in polylactic acid. A metal mesh grid was attached on the rear side of the glass and used as a grounded electrode. Gas flow can be guided to the mesh surface by a polylactic acid cover via a gas injection hole. DBD plasma was generated on the rear glass surface between the glass and metal mesh grid using a nitrogen flow rate of 1.5 L per minute. The DBD plasma, under a driving frequency 43 kHz, showed voltage and current characteristics with low discharge voltage of approximately 1 kV and discharge peak current 40 mA, respectively. The minimum discharge voltage for plasma production by DBD plasma devices used in this experiment was 1.1 kV. The optical emission profile was measured 3 mm from the mesh surface with a 10 s integration time, using a spectrometer . 2 SPS (second positive system) emission (300–400 nm) with the wavelength. The device was turned on at least 10 min before the start of the experiment, and the surface of the red pepper powder previously inoculated with B. cereus was treated with DBD plasma for 5, 10, 15, and 20 min in a sterile petri dish (35 × 15 mm). A distance of 3 mm was maintained between the plasma-emitting electrode and the sample during treatment. Fiveplicate samples of 5 g of red pepper powder were treated with DBD plasma. The DBD plasma device  was supplied by Plasma Biomedicine Institute  and was described by Ryu et al. . The silA is the reduction from combined mild heating and DBD plasma disinfection, B is the reduction from MH treatment disinfection alone, and C is the reduction from DBD plasma disinfection alone. On the basis of this equation, synergistic and antagonistic reduction effects are indicated as plus values and minus values, respectively.To estimate any synergistic effect on bacterial inactivation, the inactivation values of combined MH and DBD plasma were compared with those of MH or DBD plasma alone. The combination was conducted by applying MH as a first disinfectant and DBD plasma as a second disinfectant, because MH may have weakened or destroyed the cell membranes of bacteria, causing them to be more susceptible to the new physical disinfectants, such as DBD plasma. The disinfection efficacy after different treatments was determined by measuring microbial reduction. The synergistic reduction effect values of combined MH and DBD plasma were calculated using the following equation:B. cereus, a treated red powder sample (25 g) was transferred into a sterile stomacher bag  containing 225 mL of 0.85% sterile saline water, and then homogenized in a stomacher  for 2 min based on Korean Food Code [B. cereus. All plates were incubated at 37 °C for 48 h before counting.For the enumeration of ood Code . After hIn order to characterize any potential changes in the quality of red pepper powder after combined treatment with MH and DBD, color and pH factors were assessed. All treated samples were stored in a clean bench for 1 h to allow for equilibration to room temperature. Subsamples of powdered red peppers were selected from three random locations.After treatment with MH and DBD plasma, the colors of red pepper powders were measured using a color difference meter , which was calibrated with the original value from a standard plate . “L” , “a” , and “b”  values were measured, and the mean of the three measurements was recorded for each sample.To measure pH, 100 mL of distilled water was added to 1 g of red pepper powder, stirred at room temperature for 5 min, and filtered using Whatman paper . The supernatant was measured three times using a pH meter .p < 0.05).Data are presented as the mean of three determinations ± standard deviation. One-way analysis of variance (ANOVA) was performed using the SPSS software system. Bacteria enumeration presented as log CFU/g reductions (treated vs. pretreated), color, and pH values were analyzed with the Duncan’s multiple range test to identify any potential differences among mean values. Statistical significance was tested at the 5% probability level  reduced—by 0.23, 0.93, 1.16, and 1.43 log CFU/g, respectively. B. cereus counts were also significantly (p < 0.05) reduced by 0.12, 0.28, 0.61, and 0.96 log CFU/g after treatment with DBD plasma alone for 5, 10, 15, and 20 min, respectively. Treatment with DBD plasma resulted in a decrease of 0.96 log CFU/g after the 20 min maximum treatment, while MH treatment for 10 min resulted in a decrease of 0.93 log CFU/g. These results indicate that B. cereus reduction was primarily dependent on MH treatment rather than DBD plasma. To characterize the combined treatment effect of MH and DBD plasma on termined . After 5B. cereus counts in contaminated red pepper powder were reduced by 0.33–6.43 log CFU/g. The initial concentration of B. cereus inoculated on red pepper powder was measured as 7.14 ± 0.10 log CFU/g. This combined treatment led to decreases of more than 1 log CFU/g in most combinations, except for 5 min MH + 5 min DBD plasma (0.33 log CFU/g), and 5 min MH + 10 min DBD plasma (0.42 log CFU/g). As the MH treatment time and DBD plasma treatment time increased, the reduction effect was greater. Synergistic effects were greater among these combination treatments . Also, the maximum reduction of B. cereus was 6.43 log CFU/g after treatment with a combination of 20 min MH and 20 min DBD plasma. The results of these experiments demonstrate that DBD plasma used in our standard conditions led to a greater reduction in B. cereus compared with each individual treatment. After combined treatment with MH and DBD plasma, B. cereus in contaminated red pepper powder. Among them, synergistic effects were observed for most combination treatments, except for 5 min MH + 5 min, 5 min MH + 10 min DBD plasma, 10 min MH + 5 min DBD plasma, and 10 min MH + 10 min DBD plasma. Unfortunately, antagonistic effects did appear in certain combinations, including 5 min MH + 5 min DBD plasma (–0.22 reduction) and 5 min MH + 10 min DBD plasm (–0.28 reduction). Additionally, the maximum synergistic reduction values of greater than 4 log CFU/g (99.99%) were achieved when samples were treated with MH for 20 min and DBD plasma for 5 min, 10 min, or 15 min. p > 0.05) different from those of non-treated samples. Also, there were no significant (p > 0.05) differences in pH values among the treated samples , ‘‘a’’ (redness), and ‘‘b’’ (yellowness) values were measured on the red pepper powder . Hunter  samples .B. cereus is a soil bacterium [B. cereus is regarded as a food poisoning bacterium that can occasionally be an opportunistic human pathogen [B. cereus can survive harsh environments, including normal cooking temperatures. Herbs and spices are the main source of spore-forming bacteria like Bacillus spp. And Clostridium spp. in food products , which can provide good conditions for the growth of these microorganisms. B. cereus has also been shown to cause food poisoning in consumers [B. cereus was considered as the main pathogenic microorganism detected in red pepper powder [acterium  and is cacterium . Additiopathogen . B. cereonsumers . It was r powder ,17,18. RVarious methods, such as UV irradiation, chlorine dioxide treatment, infrared treatment, radiation, and electron beam irradiation, have been used to reduce microorganism contamination of red pepper powder ,20. AlthE. coli Ol57:H7 decreased from 5.98 log CFU/g to 4.16 log CFU/g after treatment at 60 °C for 5 min (1.82 log CFU/g decrease). The results of this study are in line with the findings of Koseki et al. [E. coli O157:H7 and Salmonella by 2.73 and 2.81 log CFU/g, respectively. Such MH treatments are also capable of inactivating microbial spores and many enzymes and toxins present in foods. Generally, MH treatment can kill microbes by altering their cell membranes and denaturing proteins [Many studies on the inactivation of pathogenic bacteria in vegetables by MH treatment have been conducted. Son et al.  reportedi et al. . They reproteins . These rE. coli, S. Typhimurium, and L. monocytogenes on cheese slices treated with plasma for 5 min (approximately 5 log CFU/g) were decreased by 1.75, 1.97, and 1.65 log CFU/g, respectively. Deng et al. [E. coli counts on almond samples. This decrease is high compared with the present results; however, it is considered to be caused by differences in the voltage and frequency of the plasma. Similar to the results presented here, Won et al. [E.coli on onion powders inoculated with E. coli O157:H7 treated with atmospheric plasma for 5, 10, 15, and 20 min were inhibited by 0.4, 0.8, 0.9, and 1.4 log CFU/g, respectively. We may speculate that compared to our study, the reductions in E. coli O157:H7 was greatly influenced by food type; as the moisture in food increased, the efficiency of the plasma against bacteria on the food increased. Muhammad et al. [S. aureus for 1 min, the counts of this bacteria were reduced by roughly 1.7 log CFU/g.In the food processing industry, cold plasma treatment represents an innovative technology, especially since it has been proven to be effective against foodborne pathogens with relatively little effect on food nutritional value . Yong etg et al.  observedn et al.  determind et al.  observedd et al.  noted thE. coli and Salmonella enterica when treated with UV-C light at mild temperature. Simultaneously treatment with sanitizers, UV-irradiation and MH was shown to be more effective than either treatment alone or when applied sequentially. Ha and Ha [E. coli O157:H7 was reduced from about 8.28 log CFU/mL to undetectable levels following exposure to the combined treatment of plasma-activated water and 60 °C (approximately 8 log CFU/mL reduction). Kim et al. [B. cereus spores decreased from 6.0 log CFU/g to 3.4 log CFU/g after exposure to microwave-combined cold plasma for 20 min (2.60 log CFU/g decrease). Seong et al. [E. coli O157:H7, S. Typhimurium, and L. monocytogenes on fresh lettuce were reduced by 1.55, 2.39, and 2.45 log CFU/g, respectively, following combined treatment with cold plasma and UV-C. The combinations of MH treatment and DBD plasma with other food preservation technologies not only allow the optimization of microbial inactivation, but also effectively maintain the nutritional and sensory attributes of food products during storage [There are a variety of active species in the activated plasma . Cold plasma for the inactivation of microorganisms is mainly associated with the reactive species generated, particularly reactive nitrogen species (RNS) and reactive oxygen species (ROS) . Rupturia and Ha  reporteda and Ha  reportedm et al.  reportedg et al.  reported storage . To evaluate the suitability of this combined decontamination approach, quality properties of red pepper powder were measured. The results from the Hunter color and pH value assessments demonstrated the potential for combined treatment with MH and DBD plasma, as bacterial decontamination approach did not noticeably alter the color properties of red pepper powder. According to Li et al. , here waB. cereus compared with MH treatment alone. Also, in our antagonism results (−0.22 ± 0.6 and −0.28 ± 0.7), the average results are shown to be antagonistic. However, because of the wide range of standard deviations, it is difficult to determine accurately by either antagonism or synergism. Moreover, this combined approach does not lead to a deterioration in the quality of red pepper powder. Thus, this combined treatment can be utilized as an alternative to conventional decontaminating interventions . Combining treatment with MH and DBD plasma is more effective at inactivating B. cereus counts in contaminated red pepper powder were significantly (p < 0.05) reduced as treatment times with MH and DBD plasma increased. Reduction values for combined treatment with MH and DBD plasma against B. cereus in red pepper powder were 0.12 to 6.43 log CFU/mL, respectively. The largest synergistic reduction values (4.24–4.42 log CFU/mL) of B. cereus in red pepper powder were obtained by a combination of 20 min MH and 5~15 min DBD plasma. In addition, it appears that the degree of microbial reduction can be affected by many factors . Hunter color ‘‘L’’, ‘‘a’’, and ‘‘b’’ values of the combination-treated samples were not significantly (p > 0.05) different from those of non-treated samples. Also, there were no significant (p > 0.05) differences in pH value. This combined treatment approach did not result in any deterioration in the quality of red pepper powder. The results of this study reveal that the reductions of >6-log CFU for B. cereus in red pepper powder were accomplished by a combination of 20 min MH and 5–15 min DBD plasma. These results suggest that combined treatment with MH and DBD plasma is a potentially a novel method to improve the microbial safety of dried spices, including red pepper powder.The current combined MH and DBD plasma is cost-effective  compared to other possible treatment processes. It was specifically noted here that a combined treatment of red pepper powder with MH and DBD plasma was more effective compared with treatment with MH or DBD alone.


Ascaris eggs is expanded with additional literature data. The information is of value to designers and operators of sanitation equipment who have Ascaris inactivation as an objective.A time–temperature plot presenting the inactivation of  Ascaris sp.  is associated with the infectious diseases that burden approximately one-third of the world’s population Bardosh . Access Ascaris eggs are inactivated within a few minutes, but may survive more than a year at 40°C . Previous studies indicate that above 60_C k Naidoo  defines Ascaris suum eggs were procured and exposed to 60°C, 65°C, 70°C, 75°C and 80°C for 5, 10, 15, 30 and 45 seconds, and 1, 2, 3 and 4 minutes, respective to each temperature. Eggs were pipetted into plastic test tubes containing water, which had been preheated to the test temperature. Two samples (triplicated) were treated at each temperature/time combination and processed by either i) washing directly onto a 20 μmsieve , or ii) transferred into a beaker containing iced water  and then washed onto the sieve. Eggs were immediately analysed via light microscopy, washed back into the test tube, and incubated for 28 days to determine whether further development occurred.Details of the experimental procedure and presentation of results can be found elsewhere Naidoo . MethodoAt 4-second exposure time, treatment at 80°C was sufficient, with <11% viable eggs recovered pre-incubation and <1% viable eggs recovered post-incubation. Eggs that appeared undeveloped but globular  did not develop further during incubation, indicating successful inactivation. Lower temperatures required longer exposure times , and from a visual examination of egg morphology the die-off mechanism appeared different.et al.  looked at lime and quick lime concentrations. Pecson & Nelson (et al. (Data included are briefly discussed. Maya et al.  conclude, et al. , Berggre (et al. , Trimmer (et al. , Katakam (et al.  and Seam (et al.  are incl (et al.  included (et al.  included& Nelson  included (et al.  presenteet al. (et al. equation predicts inactivation of 0.1 sec at 80°C, while controlling exposure time in the laboratory is challenging at 1.0 sec. Below 45°C a new relationship may be appropriate.In examining the plot, the trend appears consistent with the Vinnerås et al.  equationet al. (A. lumbricoides egg die-off over 181 days with average temperatures from 19 to 32°C and variables such as lime, rice husks and aeration. Berendes et al. (et al. (et al. (et al. (Several studies are informative for practitioners but not presented in et al.  monitores et al.  studied  (et al.  develope (et al.  presente (et al.  discusse (et al. . Some da (et al. .Ascaris eggs. At 75°C and 70°C treatment may also be effective, but exposure time should be increased to achieve the same level of inactivation.Based on data from the current study, 4–5 seconds of exposure at 80°C appears sufficient to inactivate


To investigate the optimal dose of dexmedetomidine to maintain hemodynamic stability, prevent of cough and minimize postoperative pain for patients undergoing laparoscopic cholecystectomy.1, D2, D3 and NS groups, and dexmedetomidine 0.4, 0.6, 0.8μg/kg and normal saline were administrated respectively. Patients’ heart rate, systolic blood pressure and diastolic blood pressure were measured at T1-T7. The incidence of cough was recorded. Other parameters were noted, the time of spontaneous respiratory recovery and extubation, visual analogue scale scores and dosage of tramadol.One hundred twenty patients were randomly divided into D2 and D3 groups has smaller fluctuations at T2–3 and T7 compared with NS and D1 groups (P < 0.05). The incidence of cough was lower in D2 and D3 groups than NS group (P < 0.05). The visual analogue scale scores and tramadol dosage of D2 and D3 groups were lower than NS group (P < 0.05). The time of spontaneous respiratory recovery and extubation in D3 group was longer than that in D1 and D2 groups (P < 0.05).The heart rate, systolic blood pressure and diastolic blood pressure of DIntravenous infusion of 0.6μg/kg dexmedetomidine before induction can maintain hemodynamic stability, decrease cough during emergence, relieve postoperative pain of patients undergoing laparoscopic cholecystectomy.ChiCTR1900024801, registered at the Chinese Clinical Trial Registry, principal investigator: Qin Ye, date of registration: July 28, 2019. Patients with general anesthesia are often accompanied with adverse reactions, such as cough, agitation, hypertension and tachycardia, and the incidence of cough is up to 82.5% . The couThis study was approved by the Ethics Committee of the Affiliated Hospital of North Sichuan Medical College (2019ER(R)071–01) and registered at the Chinese Clinical Trial Registry . All the participants for this prospective, randomized, double-blind, single center clinical trial conducted signed the written informed consents and performed at the Affiliated Hospital of North Sichuan Medical College. All procedures adhered to the applicable CONSORT guidelines , dexmedetomidine 0.4 μg/kg group (D1 group), dexmedetomidine 0.6 μg/kg group (D2 group) and dexmedetomidine 0.8 μg/kg group (D3 group). The anaesthesia nurse completed the drug preparation and gave it to the anesthesiologist in this study. After the experiment, the anesthesiologist showed the data back to the statistician. Patients, the anesthesiologist and the statistician did not know the grouping, meanwhile anesthesia nurse did not participate in anesthesia management, postoperative follow-up and data analysis.2 < body mass index (BMI) < 28 kg/m2 and ASA physical classification status of I–II, were enrolled from July 2019 to November 2019.One hundred twenty consecutive patients scheduled for elective LC, aged 18–60 years and with 18.5 kg/mpatients with a history of PONV, motion sickness, gastroparesis, bradycardia, atrioventricular block and severe cardiac dysfunction, diabetes, hypertension, coronary heart disease, liver and kidney function seriously damaged, chronic pain, upper respiratory tract infection, asthma, smoking, allergic to dexmedetomidine. Withdrawal criteria: conversion to open surgery, the operation time over 90 min, massive hemorrhage during surgery, patients refusing to participate.2), electrocardiography (ECG), end-tidal carbon dioxide (ETCO2) and bispectral index (BIS) were monitored. D1, D2 and D3 groups were provided with 10 ml dexmedetomidine containing 4, 6 and 8μg/ml respectively, and the NS group was provided with 10 ml normal saline. Dexmedetomidine or normal saline 0.1 ml/kg was continuously intravenously injected for 10 min and followed by anesthesia induction. The induction of general anesthesia was administrated by intravenous midazolam 0.03 mg/kg, propofol 1.5–2 mg/kg, sufentanil 0.4 μg/kg and rocuronium 0.6 mg/kg. Then tracheal intubation was performed, followed by mechanically controlled ventilation. The pure oxygen flow was 2 L/min, the tidal volume was 8 ml/kg, the respiratory rate was 14 times/min and the inhalation/exhalation ratio was 1:2. Respiratory parameters adjusted according to ETCO2 maintained at 35–45 mmHg and SpO2 remained above 98%. Intraoperative anesthesia was maintained by sevoflurane and BIS values were remained at 40–60. After induction of anaesthesia for 40 min, 0.2μg/kg sufentanil and 0.2 mg/kg rocuronium were added. Analgesics and muscle relaxant were discontinued 30 min before the end of surgery and inhalation of sevoflurane was discontinued 10 min before. Body temperature of the patients was maintained at about 36 °C during the operation. During surgery, all patients were placed in the position of head upward 30°, left inclination 15°, and abdominal pressure maintained at 12 mmHg. After surgery, the patients met the indications of extubation , and then the catheter was extracted and transferred to the post-anesthesia care unit (PACU). When the blood pressure decrease was greater than 20% of the base value or SBP decreased to 80 mmHg, ephedrine was given 6-10 mg immediately. When the increase of blood pressure was greater than 20% of the base value or the blood pressure was up to 160/95 mmHg, urapidil 5–10 mg was administrated. When the HR was less than 50 beats per minute, atropine 0.3–0.5 mg was given each time. When the HR was greater than 110 beats per minute, esmolol 10 mg was given. When PONV required medication, ondansetron 4 mg was administrated per time. And when the VAS ≥4, tramadol 2 mg/kg was given.Before surgery, all patients fasted for solid food for 12 h and clear liquids for 4 h, with intramuscular injection of phenobarbital sodium 0.1 g and scopolamine butylbromide 20 mg 30 min in advance. After entering the operating room, the peripheral vein was opened and 10 ml/kg/h lactated ringer solution was administered intravenously. HR, systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse oximetry , 1 min before intubation (T2), being intubated (T3), 5 min after intubation (T4), establishing pneumoperitoneum (T5), 5 min after establishing pneumoperitoneum (T6), being extubated (T7) and 5 min (T8) and 20 min T9) after extubation. To record the incidence of hypotension and bradycardia during the operation, operation time (from cutting skin to dressing), anesthesia time , spontaneous respiratory recovery time  and extubation time . To assess and record the occurrence and severity of cough during recovery period  [ after exk groups. Where pA and pB represent the proportions in two of the k groups. We will compute the required sample size for each of the τ comparisons, and total sample size needed is the largest of these. In the formula below, n represents the sample size in any one of these τ comparisons. This calculator uses the following formulas to compute sample size:A Previous study has shown that the incidence of cough is 66.7% during the tracheal extubation period in the CON group. We hypothesized that dexmedetomidine infusion before induction could reduce the incidence of cough during emergence by 50%. In more general terms, we may have Twenty-five patients are required in each group (a power of 80% and α of 0.05). To ensure sufficient sample size, 33 patients were needed for each group.X2 test or Fisher’s exact test. P-value < 0.05 was considered to statistically significant.Statistical analysis was performed by using SPSS 23.0 statistical software. Continuous variables with normal distribution were expressed as mean ± standard deviation . Compared with NS group, the time of spontaneous respiratory recovery and extubation in the D1, D2 and D3 groups were prolonged more significantly (P < 0.05). As for comparison among D1, D2 and D3 groups, it was in the D3 group that the time was prolonged more significantly (P < 0.05), as shown in Table There were no significant differences in gender, age, BMI, operation time and anesthesia time among the four groups (P < 0.05), as shown in Fig. P < 0.05). Compared with NS group, SBP and DBP decreased at T7 in D2 group and decreased at T2–3 and T7 in D3 group (P < 0.05), as shown in Figs. At T1, there were no differences in HR, SBP, DBP among all groups. Compared with T1, HR decreased at T2, T5 in all groups. Besides HR also decreased at T4, T6 in NS group and decreased at T4 in D1 and D2 groups. HR increased at T3 and T7 in NS and D1 groups, while it increased at T7 in D2 group(P<0.05). Compared with NS group, HR decreased at T4 in D1 group, decreased at T2–4, T7 in D2 group and T2–3, T7–9 in D3 group  and the incidence of moderate cough . Both the total incidence of cough and the incidence of moderate cough were lower in D1 group than that in NS group, but the differences were not statistically significant , as shown in Table Compared with NS group, it was significantly lower in DP < 0.05). At t2–6, it was lower in D2 and D3 groups than that in D1 group (P < 0.05). There were no differences between D2 and D3 groups (P > 0.05), as shown in Table At t1–6, the VAS was lower in D2 and D3 groups than that in NS group , as shown in Table The dosage of tramadol in D1, D2 and D3 groups were 53.33, 50.00, 46.67 and 40.00% respectively, with no statistically significant differences among the four groups (P > 0.05). At t4, the incidence of PONV in D2 and D3 groups was significantly lower than that in NS group . There were no differences between D2 and D3 groups (P > 0.05), as shown in Table The incidence of PONV in NS, DP > 0.05), as shown in Table There were no statistically significant differences in the incidence of adverse reactions among the groups (This study found that intravenous infusion of dexmedetomidine 0.6μg/kg and 0.8μg/kg before induction could reduce the stress response during intubation, pneumoperitoneal and extubation in patients undergoing LC, maintain intraoperative hemodynamics more stable, reduce the incidence and severity of cough during extubation, relieve postoperative pain, and decrease both the postoperative analgesic requirements and the incidence of PONV. However, when dexmedetomidine 0.8μg/kg administrated, it delayed the time of spontaneous respiratory recovery and extubation, and significantly increased the incidence of bradycardia. That shows dexmedetomidine 0.6μg/kg may be the optimal dose administered before induction for patients undergoing LC.Intubation, pneumoperitoneum and extubation during general anesthesia are all harmful stimulus, which can cause a strong stress response. This can lead to increasing the concentration of catecholamines such as epinephrine and norepinephrine in the blood and make the HR and blood pressure elevate , which c2 adrenergic receptor agonist that can produce sedative and anti-anxiety effects through receptors in the locus coeruleus without respiratory depression [Cough during the recovery period of general anesthesia is a more concerned problem, mainly caused by the stimulation of endotracheal tube, secretions and volatile anesthetics, which not only brings unpleasant feelings to patients, but also accompanies with complications such as laryngospasm, circulation fluctuation, arrhythmia, wound dehiscence and bleeding. Many drugs such as propofol, ketamine, remifentanil and lidocaine have been used to reduce the cough reflex during extubation –4. Dexmepression , 17. Morpression . Howeverpression , 7 foundpression . This shpression –7. This Although the trauma of LC is small, postoperative pain is still the main reason that affects postoperative recovery and prolongs hospital stay. Previous studies have shown that dexmedetomidine could effectively relieve postoperative pain and improve the quality of postoperative recovery , 18. BecPrevious studies  have shoThis study showed that the spontaneous respiratory recovery time and extubation time increased more significantly in the experimental groups compared with NS group. The dexmedetomidine 0.8μg/kg group had the greatest effect on the spontaneous breathing time and extubation time, which was similar to previous studies , 15, 17.There are several limitations in our study. First, intraoperative hemodynamic changes informed the grouping, which might influence the assessment of cough. Second, the sample size was calculated according to the incidence of cough during recovery period, so further study was needed to determine if there was statistical significance among other observation indicators. Third, the dosages of anesthetics and analgesics during the operation was not counted in this study, so the effects of different doses of dexmedetomidine on the dosages of anesthetics and analgesics in operation were unclear. Fourth, the dosage of tramadol in D2 and D3 groups was significantly lower than that in NS and D1 groups. That maybe effect the incidence of nausea and vomiting. In future studies on the effect of dexmedetomidine on postoperative nausea and vomiting, this interference factor should be avoided.The administration of 0.6μg/kg dexmedetomidine before anesthesia induction can attenuate the stress response during intubation, pneumoperitoneum and extubation, maintain the hemodynamics more stable, reduce the incidence and severity of cough during emergence period, relieve postoperative pain, decrease postoperative adverse reactions such as PONV, shoulder pain, sleepiness and agitation, and have less effect on the spontaneous breathing time and extubation time.


School‐age children frequently consume snacks. However, most of the snacks they consume are of low nutritional quality. The objective of this study was to develop a nutrient‐rich and acceptable extruded bean‐based snack, which could contribute to improved nutrient intake, especially for school‐age children. Snack formulations developed from Roba1 beans, maize, orange‐fleshed sweet potato, and amaranth mixtures, and processed in a twin‐screw extruder, were evaluated and optimized for nutritional, textural and sensory properties. High proportion of beans in the formulation was associated with high protein, iron, zinc, and dietary fiber content. An optimal formulation , containing 20.38 g, 4.12 g, 4.83 mg, and 1.51 mg per 100 g, of protein, dietary fiber, iron, and zinc, respectively, was obtained. The snacks were crunchy and moderately acceptable with average sensory scores of 6 on a 9‐point hedonic scale, and hardness 26.6 N. Nutrient contribution 43, 19, and 12% for protein, iron, and zinc, respectively, to children aged 6 to 8 years; and 24, 19, and 7.6%, respectively, to children aged 9 to 12 years from a 40 g serving was estimated from the snack. The results demonstrate the potential of using extrusion to produce nutrient enriched value‐added food products from blends of iron‐rich beans and common staples. Nutrient‐rich extruded composite snack formulations were processed from common beans, maize, orange‐fleshed sweet potato, and amaranth and evaluated. An optimal composite snack with acceptable taste, texture, and high potential nutrient contribution in terms of protein, iron, and zinc (to children) was identified. The beans were included as the main source of protein, iron, and zinc. Beans also contain high levels of lysine compared with maize USDA, . Dry amaRoba1 beans were sorted to remove any foreign matter , washed with clean potable water, and dried in a hot air oven  to 8%–10% moisture content. OFSP was washed with clean potable water, peeled, thinly sliced , and oven‐dried . The beans, maize, amaranth, and OFSP were separately milled into flour using a commercial mill , to pass through a 1.5 mm sieve.2.2Bean‐based snacks were prepared from beans, maize, OFSP, and amaranth flour. In total, 20 formulations were generated using mixture design using Design–Expert software , five of which were replicates. A formulation that could provide the highest protein, iron, zinc, and dietary fiber content and suitably contribute to the recommended daily intakes for children aged 6–12 years , outer screw diameter (D), and length to diameter of extruder were 6 mm, 124 mm, 27 mm, 41 mm, and 18:1, respectively. Cylindrical shaped extrudates  were obtained.Snack samples were processed using a Twin Screw extruder (Model DP 70‐III) at barrel temperatures 60/120/142°C for the feed, internal barrel and die temperatures, respectively, and feed moisture 15% as determined in previous works  to final moisture content of 6%, and flavored . The snacks were double‐layer packaged in high‐density polythene (gauge 30 microns) to prevent moisture and air entry, and stored (at 25–28°C) until further analysis.2.42.4.1Nutrient composition data for the different formulations were computed using a Nutrisurvey programming tool Erhardt, , based o2.4.2Y) was calculated using Equation X was the pH after 10 min.Protein digestibility was determined using the multi‐enzyme (trypsin‐chymotrypsin‐papain) technique  required to break the extruded samples, while crunchiness/crispiness was estimated from the energy required to puncture the extrudate (N.mm), equivalent to the average area under the force deformation curve  was measured using a Stable Microsystems Texture Analyzer (Model TA.XT‐Plus 42095) by compression with a cylindrical probe of 6 mm diameter (SMS P/6) following methods used earlier  aged 18–30 years. Laboratory panelists were students of food science and technology. Prior to evaluation, panelists signed consent forms for voluntary participation. A 9‐point hedonic judgement scale was used for score, where 1 was “2.4.5dislike very much” and 5 “like very much”  were presented for consumer evaluation by school children. A panel of 112 children aged 8–12 years (who could easily read and understand the questionnaire) evaluated the snacks for taste and texture against a 5‐point pictorial hedonic scale, where 1 indicated “Guinard, . Forms o2.5n mathematical functions existed: fkk=1,2,3,…,n.Mixture design with numeric optimization  was used for experimental design and analysis , adjusted R2 values, and derived model p‐values. The criterion for optimizing formulations was based on numerically maximizing, minimizing, or targeting parameters for each response variable  depending on the perceived need for obtaining desirable snacks. Optimization of ingredient levels was done by selecting responses, on the basis that they had direct effect on the nutritional quality and acceptability of the snack formulation as shown by their respective regression (R2) values. Optimal formulations for production of a snack with high protein, iron, dietary fiber, and zinc content as well as a soft crunchy texture were identified.The goodness‐of‐fit of the models was evaluated using the significance of lack‐of‐fit, correlation coefficients (33.1p < .05) on the protein, dietary fiber, iron, and zinc content of the snack extrudates. Coefficients of determination  implied that 99% of the changes in protein, 92% for dietary fiber, 92% changes of iron, and 98% zinc content among the formulations were attributable to ingredients. High proportion of OFSP and maize content in the formulation resulted in increasing total carbohydrates content  on the protein digestibility of extrudates. Thus changes within the physicochemical components and other factors in extrusion may explain the changes in extrudate protein digestibility.Extruded formulations containing beans, maize, OFSP, and amaranth produced snacks with higher protein digestibility  of the composite bean snack extrudates Table  were obs3.43.4.1Sensory characteristics are key determinants of the acceptability of food among consumers , implying that variation in these attributes was partly dependent on other factors. None of the formulations scored lower than 5, a score considered the lower limit of acceptability  of extrudate yielded an optimal formulation with global desirability index of 0.97. A desirability index of 0.97 for a snack formulation containing 82% beans in total ingredients and providing 20.4 g protein and 4.8 mg iron for every 100 g of snack with 5.7 average taste score possibly suggests adequacy in nutritional value and acceptability (Table p < .05), which could be attributed to error and nutrient losses during the preprocessing of ingredients. In addition, it is likely that the nutrient composition values in databases used were relatively high compared with the raw material composition. The taste and flavor scores of the optimal bean‐based snack  for children aged 4–12 years , iron, and zinc content in the snack when compared to extruded plain corn snacks. Thus, ingredient complementation can strategically be applied in the development of extruded bean‐based food products to boost nutritional quality and sensory acceptability.The authors declare no conflict of interest.


Onopordum acanthium essential oil and its major constituents as environment friendly herbicides was investigated. In total 29, 25, and 18 compounds were identified from flower, leaf, and stem oils, representing 94.77%, 80.02%, and 90.74% of the total oil, respectively. Flower and stem oils were found to be rich in n-alkanes, which accounted for 57.33% in flower oil, and 82.33% in stem oil. Flower oil exerted potent inhibitory activity on both receiver species, Amaranthus retroflexus and Poa annua, which nearly completely suppressed seed germination at 5 mg/mL, and β-eudesmol is the most likely responsible compound for its phytotoxicity; in comparison, leaf and stem oils exhibited much weaker inhibitory activity on A. retroflexus, and stimulatory effect on P. annua when tested concentration was below 2.5 mg/mL. Alkanes in the oils were found to exert relatively weak plant growth regulatory activity. This report is the first on the chemical profile and phytotoxic action of O. acanthium oil as well as the phytotoxicity of β-eudesmol.The potential of utilizing  Onopordum (Asteraceae) comprises 50 species that distribute in continental Europe and central and southwest of Asia1. Among them, O. acanthium L., also known as Scotch thistle, is a biennial species, and height of mature plants can reach up to 3 m. Flowering plants have white lanate stems that are ridged with spiny-margined wings; the plant bears purple flowers, the inflorescence is a panicle that bears capitula2. This plant is a competitive species against forage plants, and its flowering stalks form a barrier to livestock movement, which makes this plant an agricultural pest in the U.S., Canada, and other countries2. In China, O. acanthium can be found frequently as a dominant species distributing in the Tianshan mountains and the Junggar basin of Xinjiang province, which is known as the arid or semi-arid region located in northwest China5.The genus O. acanthium has been extensively used to treat cancers, inflammatory disorders, cardiovascular, and urogenital diseases13 For instance, Cardiodoron, a medicinal product made by O. acanthium, is well-tolerated for treatment of functional cardiovascular that shows positive effects in medical practice11. Phytochemical studies revealed that it might produce allelochemicals with phytotoxic activities, such as flavonoids and sesquiterpene lactones, which could attribute to its widespread over several continents14. Flower of O. acanthium is widely used as a coagulating agent in cheesemaking industry, and its young shoots as well as its first year roots are used in salads16. The oil obtained from O. acanthium can be used as a renewable fuel and chemical feedstock, and there are quite a few reports on the yield and chemical composition such as fatty acid composition, tocopherol, and mineral contents of its oil20.Worldwide, 25. So far there is no report on the chemical constituents of O. acanthium essential oil. The objectives of the current study include: (i) determination of the chemical profile of the essential oils obtained from different plant organs of O. acanthium; (ii) evaluation of the phytotoxic activity of O. acanthium essential oils and the major components.Essential oils are a group of special natural substances known for biological activities such as antimicrobial, herbicidal, antioxidant, anti-inflammatory activities, and so onO. acanthium using hydrodistillation method. The phytochemical profiles of the essential oils obtained from different plant organs were analyzed via GC/MS, and the results were presented in Table n-alkanes (mainly C22–C29), such as tricosane, tetracosane, pentacosane, hexacosane, heptacosane, octacosane, nonacosane, etc., especially in flowers and stems, which accounted for 57.33% in the flower oil, and 82.33% in the stem oil. The major components of flower, leaf and stem oils differed significantly: pentacosane (12.41%), hexacosane (10.44%), β-eudesmol (10.10%), heptacosane (8.67%), tetracosane (8.43%), and tricosane (5.36%) were dominant in flower oil; leaf oil contain 1-Hexanol (14.88%), 3-Hexen-1-ol, (E)- (13.53%), 2-Hexen-1-ol, (E)- (12.18%), 2-Hexenal, (E)- (6.93%), nonanal (9.74%); on the other hand, stem oil was rich in nonacosane (16.44%), nonacosane, 2-methyl- (15.54%), hentriacontane (15.05%), and dotriacontane (13.73%).Essential oils were extracted from fresh flowers, leaves, and stems of A. retroflexus, with flower oil being the most potent oil, suppressing root elongation by 12.92% and 14.25% at 0.25 and 0.5 mg/mL. When the concentration of flower oil was increased to 1 mg/mL, the inhibitory effect was enhanced markedly, reaching 54.3% compared with the control. The suppressive effect was enhanced to 75.49% by 2.5 mg/mL oil, meanwhile 5 mg/mL flower oil almost completely killed the seedlings (99.60%).Flower, leaf, and stem oils (concentration tested ranged from 0.25–5 mg/mL) all exhibited significant plant growth regulatory activity against both receiver species Figs. , 5. The A. retroflexus, the strength was much weaker. Root length decreased to 6.89–33.66% of control when treated with leaf oil ranging from 0.25–5 mg/mL, and 9.15–26.28% with stem oil. It was obvious that strength of the oils’ phytotoxicity was much weaker compared with the commercial herbicide glyphosate, which reduced root length by 71.22%, 78.75%, 91.94%, 95.66% and 96.20% at 0.25, 0.5, 1, 2, and 5 mg/mL, respectively. Shoot development of A. retroflexus responded to the oils in a similar way, however both leaf and stem oils promoted shoot length by 3.91% and 5.91%, respectively  when the applied concentration was between 0.25–0.5 mg/mL, and the strongest inhibitory effect (13.12%) was observed when the mixture of different alkanes were mixed at 5 mg/mL , oxygenated long-chain hydrocarbons (31.5–33.8%), and oxygenated monoterpenes (14.4–6.6%), with palmitic acid being the most abundant constituent (25.5–28.7%)26. As of non-volatile compounds, phytochemical study revealed the presence of flavonoids such as apigenin, luteolin, scutellarein, coumarins such as aesculin and aesculetin, sesquiterpene lactones including derivatives of elemane, germacrane, eudesmane, and guaiane1. Watanabe et al. (2014) suspected that allelopathy might facilitate the invasion success of O. acanthium, therefore bioassay-guided isolation procedure was applied using wheat seeds as test species to investigate the chemicals in the leaves, which was extracted with different solvents; the CH2Cl2 extract showed the most potent phytotoxic activity, which was then further purified to yield 4 compounds, i.e. two flavonoids, pectolarigenin (1) and scutellarein 4′-methyl ether (2), and two sesquiterpene lactones, elemanolide 11(13)-dehydromelitensin b-hydroxyisobutyrate (3) and acanthiolide (4), among which they found compound 3 (IC50 = 1.794 × 10–4 M) strongly inhibited the growth of wheat coleoptiles and compound 1 (IC50 = 1.263 × 10−3 M) showed an intermediate effect14. To the best of knowledge, this is the first study on the chemical profile and phytotoxicity of this plant’s essential oil. Altogether 60 compounds from flower, leaf and stem oils of O. acanthium were identified, which were found to be rich in higher n-alkanes.Our study is the only report so far on the chemical composition and phytotoxicity of Asphodelus aestivus flower essential oil, which was abundant in hexadecanoic acid (35.6%), pentacosane (17.4%), tricosane (13.4%), heptacosane (8.4%), heneicosane (4.5%), tetracosane (3.0%), and hexacosane (2.0). Polatoğlu et al. also identified nonacosane (16.18 ± 0.13%) and heptacosane (14.91 ± 0.17%) from the flower oil of Arabis purpurea Poech oil; it is interesting that similar to the current study, this oil was also obtained from the flowers of the donor plant27.Alkanes are important industrial chemicals and energy resources that can be found rich in petroleum and natural gas. Although a number of plant species are found to produce essential oils containing alkanes as constituents, the amount is usually relatively low, except a single report on the chemical profile of Centaurea raphanina, and 6.1% of C. spruneri28; other reports include that Hemizonia fitchii oil contained 1.7% alkanes (C25–C29)29, and 0.9% in Sigesbeckia jorullensis oil30. Compared with published studies, alkanes (C22–C29) including tricosane, tetracosane, pentacosane, hexacosane, heptacosane, octacosane, nonacosane accounted for 57.33% in flower oil, and 82.33% in stem oil, indicating the potential value of utilizing O. acanthium as a natural source to produce alkanes for industrial uses. It is noteworthy to mention that O. acanthium is a widespread species with high biomass that can adapt to various environmental conditions including arid and barren habitats, which makes it practical to be cultivated in large scale for industrial purpose.Besides, alkanes have been reported to be present in essential oils extracted from other Asteraceae plants. For instance, alkanes (C11-C27) accounted for 4.12% of the total mass of the essential oil of A. retroflexus was 2.96 and 3.79 times of leaf and stem oils, and on P. annua was 8.29 and 101.88 times of leaf and stem oils, respectively. Further experiment revealed that β-eudesmol (10.10%), which was a dominant compound in flower oil but not detected in leaf and stem oils, was most likely responsible for the potent phytotoxic activity of flower oil by comparing the strength of β-eudesmol and flower oil. β-eudesmol was found to possess antiangiogenic, antimutagenic, anticancer, antioxidant activity and so on, however there is no report on its phytotoxicity36.This study indicated that flower oil possessed much stronger inhibitory effect compared with leaf and stem oils: the inhibition rate of flower oil on root growth of Drimys winteri oil (7.27%), and in the drupe essential oil of Citharexylum spinosum as the most abundant component (33.1%) and other species; in some cases, essential oils containing β-eudesmol were reported to exert phytotoxic activity, such as Geranium wilfordii root oil (4.18% β-eudesmol), Helichrysum italicum essential oil (1.4% β-eudesmol), Achillea wilhelmsii essential oil (2.7% β-eudesmol), and Rhynchosia minima , however it is difficult to ascribe the activity to certain constituent (s), especially considering the fact that in most cases β-eudesmol was not even the major components in the oils with phytotoxic activity. It is noteworthy to mention that the current report is the first on the phytotoxicity of β-eudesmol39.β-Eudesmol has been previously reported to be abundant in 42.Essential oils produced by various plant species are found to possess a number of biological activities including phytotoxic activity. As a matter of fact, not only essential oils but also their constituent such as thymol, β-myrcene, limonene, camphor, eucalyptol, geraniol, α- and β-pinene, borneol, etc. have been reported to play roles as plant growth regulatory agents44. The potent inhibitory activity of the flower oil and its major component, β-eudesmol, indicated their potential value of being further explored as environment friendly herbicide; meanwhile, the fact that the aboveground plant parts of O. acanthium can release volatile compounds into the surroundings support the hypothesis proposed by Watanabe that allelopathy might contribute to the widespread of this species46.Besides, there are successful examples of utilizing essential oil or oil constituents as commercial herbicides. For example, the herbicide cinmethylin is the derivative of 1,4-cineole, which is a natural phytotoxin that can be found in the volatile oils of many plant species; clove oil is used as the major component in the commercial herbicide Burnout II O. acanthium were harvested in Changji city, Xinjiang province, China, in July 2018 . Specimens were authenticated and identified by Dr. Wenjun Li, and a voucher specimen (XJBI018326) was deposited at the herbarium of Xinjiang Institute of Ecology and Geography, Chinese Academy of Sciences. Plant materials were separated into flowers, leaves, and stems for further process.Aboveground plant parts of O. acanthium (200 g were used for each plant organ) were laid out in the flask containing water and the unit is carried to boiling for 4 h. The mixture of water–oil was produced in the flask then condensed in the condenser, where the oils were harvested. The same procedure was repeated until enough oils were obtained for GC/MS analysis and the phytotoxic activity assay. The essential oils were dried over anhydrous Na2SO4 and stored at 4 °C for the following GC/MS analysis and bioassay experiments.Essential oils were obtained by performing traditional boiling hydrodistillation procedure. Fresh flowers, leaves, and stems of O. acanthium oil using a 7890A/5975C GC–MS system with an automatic injector  equipped with FID and a DB-5MS 5% Phenyl Methyl Silox column . The experimental conditions were programmed as follows: Helium (carrier gas) at a flow rate of 1 mL/min; the temperature of the oven was first maintained at 60 °C for 5 min, then programmed from 60 to 280 °C at a rate of 3 °C/min; injector and detector temperature: 280 °C; sample injection volume: 0.1 µL ; split ratio: 50:1; mass spectra were taken at 70 eV with mass range from m/z 40–800 amu. Identification of essential oil constituents was achieved based on comparison of their mass spectra and retention indices  with the National Institute of Standards and Technology (NIST 14) library database and a home-made library obtained from genuine compounds, as well as those given in the published literature25. Relative amounts of individual constituents were calculated based on GC peak areas without using correction factors.GC/MS was performed to determine the chemical constituents of O. acanthium essential oils obtained from different plant parts along with the oil’s major components were investigated by performing bioassays against Amaranthus retroflexus L. (dicot) and Poa annua L. (monocot) using glyphosate  being the positive control; these 2 species were chosen because they can be found growing alongside O. acanthium in the same habitat. The essential oils’ major constituents including tricosane, tetracosane, pentacosane, hexacosane, heptacosane, octacosane, nonacosane, and β-eudesmol were purchased from Alfa Aesar® ; purity of all compounds were 98%. Seeds of receiver species were surface sterilized with 2% sodium hypochlorite before use. The oils and the major components were first dissolved in DMSO  and then diluted with distilled water containing Tween 80  to give solutions at 0.25, 0.5, 1, 2.5, and 5 mg/mL for the assay (a preliminary experiment was conducted and results demonstrated that DMSO and Tween 80 at such concentrations did not affect seedling growth of A. retroflexus and P. annua significantly). Each petri dish (φ 5 cm) received 2 mL solutions (controls received 2 mL of distilled H2O containing 0.1% DMSO and 0.02% Tween 80) and 10 sterilized seeds of receiver species. Petri dishes were sealed with parafilm and kept in a growth cabinet at 25 °C with a 12-h photoperiod. A. retroflexus and P. annua seedlings were measured after 5 days and 7 days of incubation, respectively, due to relative slow development of P. annua seedlings. Three replicates were performed for the assays (n = 30)46.Strength of phytotoxicity of p < 0.05) was applied to determine the significance of phytotoxicity triggered by the O. acanthium essential oils and the major components, followed by analysis using Fisher’s LSD test (p < 0.05). Experimental results were statistically analyzed using SPSS 13.0 software package and presented as means of 3 replicates ± standard error.ANOVA (O. acanthium essential oil, and on the phytotoxicity of β-eudesmol, which is speculated to be the responsible compound of flower oil, indicating their potential of being further explored as bioherbicides; flower oil and stem oil were found to be rich in n-alkanes, implying that O. acanthium has the potential to be further explored as a natural source to produce alkanes for industrial purpose.The current study is the first report on the chemical profile and phytotoxicity of


The differential diagnosis for neutropenia is large and includes, drug effect, viral infections, sepsis, immune, hypersplenism, and bone marrow disorder. The presence of an autoimmune disorder and large granular lymphocytosis should prompt assessment for immunophenotyping and in select cases a bone marrow biopsy to rule out LGL‐leukemia. The differential diagnosis for neutropenia is large and includes, drug effect, viral infections, sepsis, immune, hypersplenism, and bone marrow disorder. The presence of an autoimmune disorder and large granular lymphocytosis should prompt assessment for immunophenotyping and in select cases a bone marrow biopsy to rule out LGL‐leukemia. A 63‐year‐old male patient with progressive lymphocytosis and cytopenias is described. At presentation, he complained of an upper respiratory tract infection and infrequent oral ulcers. His CBC showed a hemoglobin at 106 g/L, neutrophils at 0.9 × 10E9/L, and lymphocytes at 16.2 × 10E9/L. The peripheral blood film showed lymphocytosis with LGL morphology (Figure,None declared.HMR is the case pathologist, took all the photographs, prepared the manuscript, and diagnosed the case. There are no other authors on this submission.


Obesity has become increasingly prevalent worldwide and is a risk factor for many malignancies. We studied the correlation between body mass index (BMI) and the incidence of acute promyelocytic leukemia (APL), non‐APL acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), and control hospitalized patients without leukemia in the same community.Multicenter, retrospective analysis of 71 196 patients: APL (n = 200), AML (n = 437), ALL (n = 103), nonleukemia hospitalized (n = 70 456) admitted to University of Maryland and Johns Hopkins Cancer Centers, and University of Maryland Medical Center.2) than those with AML (28.3 and 27.1 kg/m2), ALL (29.3 and 27.7 kg/m2), and others (29.3 and 27.7 kg/m2) (P < .001). Log‐transformed BMI multivariable models demonstrated that APL patients had a significantly higher adjusted mean BMI by 3.7 kg/m2 (P < .001) or approximately 10% (P < .01) compared to the other groups, when controlled for sex, race, and age.Patients with APL had a significantly higher unadjusted mean and median BMI (32.5 and 30.3 kg/mThis study confirms that when controlled for sex, age, and race there is an independent association of higher BMI among patients with APL compared to patients with ALL, AML, and hospitalized individuals without leukemia in the same community. In addiP < .001) and mortality  of leukemia in adults among all subtypes including acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), chronic myeloid leukemia (CML), and chronic lymphocytic leukemia (CLL)  37–68 years), and 35 744 (50.2%) were male. Median BMI was 27.7 kg/m3.22, P < .001) and median  BMI than those with AML (28.3 and 27.1 kg/m2), ALL (29.3 and 27.7 kg/m2), and all‐comers (29.3 and 27.7 kg/m2)  , and 3.15 kg/m2 higher BMI compared to patients without acute leukemia diagnoses . Compared to all groups, patients with APL had a 3.7 kg/m2 higher BMI adjusted for age, gender, and race .We used multivariable linear regression to estimate the difference in BMI between the subgroups adjusted for gender, age, and race. Patients diagnosed with APL had a 3.0 kg/mP = .003). Similarly, patients diagnosed with APL had a higher adjusted BMI compared to patients diagnosed with AML  and patients without acute leukemia diagnoses   alone versus t with additional abnormality, CNS involvement at diagnosis, and relapse status  and specific baseline characteristics (dependent variables). None of the univariable models showed statistically significant associations of higher BMI with the examined characteristics including risk status based on Sanz score or Breccia, WBC and platelet counts at diagnosis, 42 higher mean and median values, respectively, in APL patients. Results of this study confirm that when controlled for sex, age, and race, there is an independent association of higher BMI with APL compared with ALL, AML, and other diagnoses.The purpose of this study was to assess the association between elevated BMI and the diagnosis of APL when compared to the non‐APL acute leukemias and nonleukemic population in the same community. BMI of APL patients was significantly higher than those of patients with ALL, AML, and other diagnoses, with 3.2–4.2 and 2.6–3.2 kg/mThe data in the current literature on the association of body fat and leukemias are somewhat conflicting, and with this project we tried to clarify this more. Our observation aligns with previous literature describing higher BMI in APL patients compared to AML patients, with BMI of AML patients being similar to that of the general population averages , 10, 11.2 [2 found in hospitalized patients in our study.It has been demonstrated that among the US population, there is a higher proportion of obesity among those 40 years and older compared with those 20–39 years old, with the greatest proportion of obese individuals among non‐Hispanic African Americans [2 , which iThe reason for the relationship between obesity and APL is unclear. Chronically increased insulin levels have been associated with cancers of breast, colon, pancreas, and endometrium , 25, 26.In conclusion, we highlight that there is an independent association of higher BMI in patients with APL compared to patients with ALL, AML, and control nonleukemic patients admitted to the hospital in the same community. On the basis of our findings, supported by the prior literature reports, we suggest adding APL to the list of the cancers that are associated with overweight and obesity.The authors declare that there is no conflict of interest.Sarah M. Kashanian contributed to the conception and design of the study, collected and interpreted the data, and wrote the first draft of the typescript. Andrew Y. Li contributed to the conception and design of the study, collected and interpreted the data, and participated in editing and critically reviewing the typescript. Moaath Mustafa Ali contributed in editing and critically reviewing the typescript as well as performing statistical analyses. Gabriel Ghiaur, Vu H. Duong, Maria R. Baer, Noa G. Holtzman, and Firas El Chaer provided critical review and assisted in editing the typescript. Mark E. Sutherland, Ciera L. Patzke, Jonathan Cornu, Alison Duffy, Bryan C. Hambley, Kyle Zacholski, Amy E. Dezern, Ivana Gojo, Kelly J. Norsworthy, Mark J. Levis, B. Douglas Smith, and Mohammad Imran assisted with acquisition of study data. Ashkan Emadi conceived the idea, conceptualized the hypotheses, and designed and supervised all areas of the study. All the authors provided critical feedback, edited, and approved the typescript.


Prompt dental service utilisation (DSU) is needed for the prevention and treatment of oral diseases, and it is therefore important to determine the facilitators and barriers of DSU. There is, however, scarce information available on DSU in Sudan. Therefore, this study aimed to investigate the prevalence and associated factors of DSU in a general population-based survey among 18–69 year-old persons in Sudan.Cross-sectional nationally representative data of 7,722 18–69 year-old persons (36 years median age) from the 2016 Sudan Stepwise approach to surveillance (STEPS) survey were analysed. Using questionnaire, anthropometric and biochemical measures, predisposing, enabling and health and lifestyle factors of DSU were assessed. Multinomial logistic regression was conducted to estimate the predictors of DSU .p < 0.001), urban residence (p < 0.001), screened for blood pressure (p < 0.001), raised total cholesterol (p < 0.05), poor SROH (p < 0.001), pain in teeth or mouth (p < 0.001), and not working because of teeth or mouth (p < 0.01) were positively and not knowing their household income (p < 0.01), high physical activity (p < 0.05), and having 20 or more teeth (p < 0.001), were negatively associated with both > 12 months and past 12 months DSU. Higher household income (p < 0.001), overweight/obesity (p < 0.05), using tooth paste (p < 0.001), and difficulty chewing (p < 0.001), were positively, and male sex (p < 0.01), and teeth cleaning twice or more times a day (p < 0.05), were negatively associated with > 12 months or past 12 months DSU.About two-thirds of the participants (64.6%) had never DSU, 22.0% had more than 12-month DSU, and 13.4% had past 12- month DSU. Among those who had ever DSU, the main reason for the last DSU was pain or trouble with teeth, gums, or mouth (66.9%), treatment or follow-up treatment 22.3%, and routine check-up treatment 5.0%. In adjusted multinomial logistic regression analysis, higher education (More than one in ten participants had past 12 months DSU and several factors were detected which could be targeted in intervention activities. Study findings suggest to improve oral health awareness, in particular stressing the relevance of regular dental check-ups, by using different modalities of oral health promotion. Oral diseases pose a major health burden globally causing pain, discomfort, disfigurement and even death, and are increasing in low- and middle-income countries . “The maSudan has a population of 45.5 million people, life expectancy at birth is 66.5 years, 35.3% live in urban areas, 60.7% can read and write, and there are 0.26 physicians per 1,000 population . People According to data from the World Health Survey , adults In a review including studies from 28 countries found a global mean “proportion of individuals regularly/preventively utilizing dental services was 54%.” . In specPredisposing factors of DSU include female sex –15, 19, Health and lifestyle factors of DSU include better general health status , having The sample included 7722 adults  that participated in the cross-sectional 2016 Sudan Stepwise approach to surveillance (STEPS) Survey , 28. STEA nationally representative population-based sample was selected using a multistage sampling approach. The 2016 Sudan STEPS survey was conducted from February to December 2016. The study response rate was 88%; further details and data can be accessed , 28.All methods were performed in accordance with the relevant guidelines and regulations.All methods were carried out in accordance with the Declaration of Helsinki.The study protocol was approved by the “national Ethical Committee at the Federal Ministry of Health, Sudan” , 28. InfSample size calculation. In a systematic review and meta-analysis the mean past 12 month DSU was 21.4% [as 21.4% . Based oThe study used the STEPS Survey questionnaire  residence status, (2) health care workers advised to “quit using tobacco or don’t start” in the past three years, (3) ever had blood pressure measured by a health care worker? (4) ever had blood sugar measured? and (5) ever had cholesterol (fat levels in blood) measured) [easured) .2 overweight and ≥ 30 kg/m2 obesity”) [Using WHO STEPS standard methodology , diabetebesity”) .Oral health-related behaviours were sourced from two items: 1) “How often do you clean your teeth?” (“1 = never to 7 = twice or more a day”), and 2) “Do you use toothpaste?” [hpaste?” Other health behaviours included past and current tobacco smoking, current smokeless tobacco use, daily fruit and vegetable intake [e intake , and hige intake SROH was sourced from two items, 1) “How would you describe the state of your teeth, and 2) How would you describe the state of your gums?” [r gums?”  Poor SROr gums?” .Oral health impact (OHI) was sourced from three items, “Difficulty in chewing foods in the past 12 months?” embarrassment about the appearance of teeth in the past 12 months, and “Days not at work because of teeth or mouth?” (“Yes/No”) [Yes/No”) .Physical symptoms were sourced from the item, “During the past 12 months, did your teeth or mouth cause any pain or discomfort?” (“Yes/No”) [Yes/No”) .Self-reported number of teeth was measured with the question “How many natural teeth do you have?” Response options were: no natural teeth, 1–9, 10–19 and ≥ 20 teeth [20 teeth .p < 0.05 was seen as significant.Statistical procedures were conducted with STATA software version 15.0 , taking into account the multistage sampling design and weighting of the data . MultinoIn all, 7,722 persons  were included in the study sample, 35.1% were males and 64.9% were females, 51.5% had a household income (≤ 1000 Sudanese pounds), and 33.8% could not read and write. The majority (62.9%) of the participants lived in rural locations, 8.5% had been advised not to smoke, 39.0% had ever their blood pressure, 14.6% glucose, and 5.2% their cholesterol measured. Regarding health and lifestyle factors, 28.3% of the sample had overweight/obesity, 5.9% had diabetes, 13.7% raised total cholesterol, and 31.5% hypertension. In terms of health behaviour.63.2% cleaned their teeth twice or more times a day, 97.5% used toothpaste, 9.6% were currently using smoking tobacco, 7.9% smokeless tobacco use, 5.3% had five or more fruit and vegetable servings a day, and 55.1% had high physicl activity. In terms of need factors, 20.2% had poor SROH, 23.1% had pain in teeth or mouth, 10.8% had less than 20 teeth, 17.5% experienced difficulty in chewing foods in the past 12 months, 3.5% were embarrassed about the appearance of their teeth in the past 12 months, and 6.1% were not at work because of teeth or mouth in the past 12 months. About two-thirds of the participants (64.6%) had never DSU, 22.0% had more than 12-month DSU, and 13.4% had past 12- month DSU , treatment or follow-up treatment 22.3%, and routine check-up treatment 5.0%  was higher than in Beijing 11.3%) , but low.3% , but.4% was hIn terms of predisposing factors, DSU increased with age, higher education, higher income, and among women. Similar results were found in some previous studies , 19–23. Regarding enabling factors, this study showed that urban residence and previous health screening  increased the odds for DSU. One possible way of increasing DSU is the integration of oral health into the prevention and control of non-commuicable diseases within the framework of enhanced primary health care, such as blood pressure or glucose screening, in Sudan .In terms of health factors and consistent with some studies , this stRegarding perceived need factors, consistent with a number of previous research studies , 22, 25,The identification of determinants and potential barriers of DSU in the general population in Sudan has dental public health implications. Oral health promotion activities can be targeted at identified barriers of DSU. New and current activities should be reinforced for the active inclusion of groups with less access to DSU, including younger age groups and rural residents, those with lower education, those who have never screened for blood pressure, those not using tooth paste, and those not experiencing poor oral health. Study findings suggest to improve oral health awareness, in particular stressing the relevance of regular dental check-ups, by using different modalities of oral health promotion .The study limitations included that this investigation was limited due to the self-report of data and the cross-sectional survey design. An additional limitation was that some relevant variables for DSU, such as oral examination, medical insurance coverage, oral health literacy, unmet treatment needs, and supportive family structure were not assessed in the 2016 Sudan STEPS survey, and should be incorporated in the future.This investigation showed among a nationally representative population of 18 to 69 years in Sudan that more than one in ten participants had past 12 months DSU. Several associated factors for > 12 months and/or past 12 months DSU were identified, including female sex, higher education, higher household income, urban residence, screening for blood pressure, raised total cholesterol, overweight/obesity, tooth cleaning less than twice a day, using tooth paste, having less than 20 teeth, difficulty chewing, poor SROH, pain in teeth or mouth, and not working because of teeth or mouth, which can be targeted in improving DSU. Moreover, oral health promotion should stress the importance of preventive DSU.Additional file 1.