Lactobacillus plantarum CGMCC 23166 and Lacticaseibacillus rhamnosus CGMCC 18233 (1.5 × 105 cfu/g of fresh weight for each inoculant); and (CO) commercial lactic acid bacteria: L. plantarum (1 × 105 cfu/g of fresh weight). All mixtures were ensiled for 60 days. Data analysis was used as a completely randomized design with a 5-by-3 factorial arrangement of treatments. The results showed that with increasing alfalfa mixing ratio, dry matter, and crude protein increased, while neutral detergent fiber and acid detergent fiber decreased both before and after ensiling (p < 0.05), which was not influenced by fermentation. Inoculation with IN and CO decreased pH and increased the lactic acid content compared to CK (p < 0.05), especially in silages M7 and MF. The highest Shannon index (6.24) and Simpson index (0.93) were observed in the MF silage CK treatment (p < 0.05). The relative abundance of Lactiplantibacillus decreased with increasing alfalfa mixing ratio, while the abundance of Lactiplantibacillus was significantly higher in the IN-treated group than in other treatment groups (p < 0.05). A higher alfalfa mixing ratio improved the nutrient value, but also made fermentation more difficult. Inoculants improved the fermentation quality by increasing the abundance of Lactiplantibacillus. In conclusion, the groups M3 and M5 achieved the optimal balance of nutrients and fermentation. If a higher proportion of alfalfa needs to be used, it is recommended to use inoculants to ensure sufficient fermentation.Mixing grass with legumes before ensiling is beneficial for improving dry matter and crude protein yield, but additional information is needed to balance nutrient content and fermentation quality. In this study, the microbial community, fermentation characteristics, and nutrient content of Napier grass mixed with alfalfa at different proportions were assessed. Tested proportions included: 100:0 (M0), 70:30 (M3), 50:50 (M5), 30:70 (M7), and 0:100 (MF). Treatments included: (CK) sterilized deionized water; (IN) selected lactic acid bacteria:  Pennisetum purpureum Schum.) has been widely cultivated as ruminant feed in tropical and subtropical areas (Medicago sativa L.) is a high-quality forage legume with high protein content, which is generally not suitable for growing in humid and hot subtropical areas. However, with improved varieties and cultivation measures, it is being increasingly cultivated in subtropical areas.The increased demand for dairy products in many tropical and subtropical regions has highlighted the importance of the production and preservation of herbage . As a peal areas  because When these herbages are produced for hay, during harvest season, the climate in subtropical areas is usually too rainy and humid for drying so that dry matter (DM) is often lost. Therefore, in such areas, ensiling is a more suitable and efficient strategy to conserve nutrients in herbage. However, Napier grass commonly has high moisture and fiber but low crude protein contents, which can easily lead to butyric acid fermentation and also offers little nutritional value for silage production . It is aIn most studies on mixed silage, the grass component is either corn , sorghumThe objective of this study was to assess the effects of different legume and grass proportions and inoculants on nutritive value, fermentation characteristics, and microbial diversity of Napier grass and alfalfa mixed silage. The main hypothesis is that application of lactic acid bacteria (LAB) inoculants would result in higher silage quality than un-inoculated silage of Napier grass mixed with alfalfa at different ratios.Pennisetum americanum × P. purpureum) × P. purpureum Schum. cv. Guimu No. 1] and alfalfa (M. sativa L. cv. 6010) were grown on four plots within different blocks of an irrigated field at the National Grass Variety Regional Test Station, Xinjin, Chengdu, China . Napier grass was harvested when it reached the elongation stage at a height of 1.5–2 m, leaving a residual of 20–30 cm. Alfalfa were harvested by hand at full bloom in the third cutting, using a sickle and leaving a 5 cm stubble. After chopping to approximately 1–2 cm with a forage cutter , Napier grass and alfalfa were mixed at fresh weight ratios of 100:0, 70:30, 50:50, 30:70, and 0:100 . Groups of M0, M3, M5, M7, and MF were considered experimental units and treatments, which were applied in quadruplicate, were (1) sterilized deionized water (CK); (2) selected LAB: Lactobacillus plantarum CGMCC 23166 and Lacticaseibacillus rhamnosus CGMCC 18233 (1.5 × 105 cfu/g of fresh weight of each inoculant) (IN); and (3) commercial LAB: L. plantarum  (CO). To ensure the viability of inoculants and appropriate inoculation rates, lactic acid bacteria (LAB) were plated as described below, counted before inoculation of forages, and then stored as recommended to retain viability and prevent multiplication. Forage from each experimental unit was ensiled (1 kg of forage) in two vacuum-heat sealed nylon-polyethylene standard barrier bags . Bags were stored in a temperature-controlled room (25–30°C) for 60 days, so that four replicate bags per treatment per ensiling duration were obtained. Air was withdrawn from silos immediately before they were sealed with an external clamp vacuum pump .Napier grass . The pH and NH3-N (%TN) increased with increasing proportion of alfalfa. The pH of the CK silage was significantly higher than pH levels of IN- and CO-treated silage except for Group M0 (p < 0.05). In Group M0, there was no significant difference among treatments (p > 0.05). The highest pH of 4.69 was observed in MF without treatment (CK). A similar tendency was found in NH3-N (%TN), where MF without treatment (CK) had the highest NH3-N (%TN), which exceeded 10% (12.37%). M0 silage treated with IN and CO significantly decrease NH3-N (%TN) compared to CK. Proportions (p = 0.017) and inoculants (p = 0.023) had significant effects on the concentration of lactic acid (LA), while the interaction had an extremely significant effect on LA concentration (p = 0.002). IN-treated silages had higher concentrations of LA than CK-and CO-treated silages in every proportion expect Group M0. The lowest concentration of LA was observed in MF silage without treatment (CK). Proportion and inoculants had an extremely significant effect on concentration of acetic acid , while no significant effect was found in their interaction (p > 0.05). The acetic acid content of all treatments did not exceed 20 g/mg DM. Propionic acid was not detected in any of the silages. A small amount of butyric acid was detected in individual silages, but this was observed in all silages of the MF group .As shown in p < 0.01). Interaction with inoculants had extremely significant effects on DM and ash (p < 0.01), while inoculants had no significant effect on DM, CP, ash, NDF, and ADF (p > 0.05). DM, CP, ash, NDF, and ADF in silages showed similar trends with forage at different proportions. DM and CP increased with increasing alfalfa proportion, while NDF and ADF decreased. WSC decreased after ensiling, and inoculants had an extremely significant effect on WSC (p < 0.01), but proportion and their interaction had no significant effects (p > 0.05).p < 0.01), and the Simpson index of their interaction was extremely significantly different (p < 0.01). The highest Shannon index (6.24) was observed in MF silage without inoculants (p < 0.05). Inoculants and their interaction with proportion showed no significant difference in Chao1 (p > 0.05). Chao1 and Ace indexes were significantly different for proportion (p < 0.05).As shown in Lactiplantibacillus, Weissella, and Companilactobacillus were the most dominate bacterial genera across different proportions of mixed silage without inoculants . The three genera with the highest relative abundances were Lactiplantibacillus, Lacticaseibacillus, and Levilactobacillus in silages treated with IN . The genera Levilactobacillus and Lactiplantibacillus were significantly different (biomarker) in M0 silages treated with IN, while Lactiplantibacillus was the biomarker in M0 silages treated with CO  but was below 20% for Napier grass. This result is consistent with the research of While the CP content among mixtures was similar between pre-ensiled and ensiled mixtures, this was not the case for the NDF content. The NDF content was higher in pre-ensiled than in ensiled mixtures, which agrees with the results of Trifolium pratense L.), and kura clover have pH levels that range from 4.0 to 4.8 and are high in NH3-N (−1 DM) that could reduce the degree of pH decline, and affect both palatability of the silage and DM intake , and bacterial species with changing taxonomic statuses were described  can be found at: HG and HL conceptualization. HG methodology, software, validation, formal analysis, writing – original draft preparation, visualization, and project administration. HG, HL, LG, and SC investigation. SC resources. HG and YH data curation. HG, ZJ, WL, and XW writing – review and editing. QZ supervision. HG and QZ funding acquisition. All authors contributed to the article and approved the submitted version.This work was supported by Qinghai Provincial key research and development program (grant no. 2022-NK-130), the Southwest Minzu University Research Startup Funds (grant no. RQD2022032), the Fundamental Research Funds for the Central Universities (ZYN2022054), China Forage and Grass Research System (CARS-34), and Key Laboratory of Superior Forage Germplasm in the Qinghai-Tibetan Plateau (2020-ZJ-Y03).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To explore the prevalence, outcome and perinatal risks of neonatal hypoxemic respiratory failure (NRF) in a survey of all livebirths from a regional network of perinatal-neonatal care during the transition period after 5-year universal health insurance implemented in China.Clinical data of all neonatal respiratory morbidities in Huai’an were retrospectively collected in the regional perinatal network database of all livebirths as vital statistics in 2015. NRF was defined as hypoxemia requiring continuous positive airway pressure (CPAP) and/or mechanical ventilation (MV) for at least 24 h. Mortality risks of antenatal and perinatal morbidities, major respiratory therapies and complications were analyzed by multivariable logistic regression model.There were 788 NRF cases identified in 9.9% (7960) hospitalized, or 13.3‰ (59056) livebirths, in which 6.7% received intensive care and 93.0% critical care. The major underlying morbidities were respiratory distress syndrome  and pneumonia/sepsis (35.3%), treated mainly by CPAP, MV and surfactant. Significantly improved outcomes by surfactant in RDS were in patients with birthweight (BW) < 1500 g or gestational age (GA) < 32 weeks. The overall mortality rate in NRF was 18.4% whereas for those of BW < 1000 g and GA < 28 weeks, 70% and 54%, respectively. The multivariable regression analysis showed the highest odds for NRF death among meconium aspiration syndrome, congenital anomalies, BW < 1500 g and necrotizing enterocolitis, whereas born in level III hospitals, cesarean delivery, CPAP and MV were associated with markedly reduced death odds.The salient findings with associated risk estimates reflected efficiency of respiratory support as critical care in a prefectural regional network infrastructure for annual livebirths in 5.6 million inhabitants. It implicated the representativeness of contemporaneous perinatal-neonatal care standard at medium to medium-high level, in one/fourth of the population of China, aiming at saving more life of very critical and preterm infants for better survival.The online version contains supplementary material available at 10.1186/s12887-022-03603-9. In the past decade, the development of maternal-infant healthcare and modern perinatal-neonatal medicine has been in transition with universal health insurance implemented in China . Almost Huai’an is such a city/region with 5.6 million inhabitants in 2015. Its gross domestic production , GDP per capita (9000 USD), and average disposable income (3300 USD) ranked 65th–70th, as medium or medium-high in ascending order, in all regional cities of the country . For neoThe standard of neonatal critical care involves resuscitation at birth, transportation, prompt admission, life sign monitoring, catheterization, and respiratory support with advanced ventilation strategies and medications , 13–15. For this issue, on the basis of the whole regional birth population survey in Huai’an in 2015 , we retrThe study design was on the assumption that the 2015 birth datafile provided comprehensive information regarding fetal deaths/stillbirths, livebirths, preterm births, in-hospital patients as well as maternal and perinatal morbidities, and overall perinatal and neonatal survival data , 9–12. NData of maternal and perinatal morbidities, as well as neonatal outcomes were included, with the diagnostic definitions consistent with previous studies –12. The For the description of the clinical characteristics of NRF patients by maturity status, the gestational age (GA) was stratified into: GA, < 28 weeks (extreme preterm), 28–31 weeks (very preterm), 32–33 weeks (moderate preterm), 34–36 weeks (late preterm), 37–38 weeks (early term), 39–41 weeks , ≥42 weeks (post-term); and birthweight (BW): < 1000 g (extremely low BW), 1000–1499 g (very low BW), 1500–2499 g (low BW), 2500–3999 g , ≥4000 g. GA < 37 weeks and BW < 2500 g were deemed as preterm and low BW (LBW), respectively.P) < 0.10 were further analyzed by multivariable models with backward stepwise selection. The crude and adjusted odds ratio (OR) and 95%CI of the identified variables, as well as the Hosmer-Lemeshow test for goodness of fit, were estimated. P < 0.05 was considered statistically significant.The statistical analysis was performed by software SPSS 23.0 . Continuous variables were presented as mean ± standard deviation (SD) or median [interquartile range (IQR)] or range. Categorical variables by GA or BW strata were presented as number and percentage (%) with comparisons by Chi-square test or Fisher’s exact test. Numbers needed to treat (NNT) was estimated by reciprocal (reverse ratio) of attributable risk difference of the survival rates for surfactant treatment. Mann-Whitney U test was applied for comparisons of continuous variables. Spearman rank correlation was used between SNAPPE-II in category of every 10-point increment and mortality rate, while Pearson correlation test was used for continuous variables. The prevalence or mortality rates and associated 95% confidence interval (CI) were estimated by a generalized linear Poisson regression model with empirical, robust standard errors but no explanatory variables , 29. Facn = 59,056), accounting for 9.9% total hospitalizations (n = 7960). As Table P < 0.001). Admission within 7 postnatal days (PND) accounted for 96.2% of total NRF, while 88.5% on PND 1. NRF required longer hospital stay days and higher costs compared to non-NRF. The overall CFR of NRF was 18.4% (n = 145), with the corresponding livebirth population-based mortality rate of 2.5‰ . For deaths in NRF, contributing to 86.3% of total in-hospital deaths (n = 168), 65.6% were within 7 PND, 93.1% within 28 PND, and 55.9% as withhold/withdrawal from critical care.There were 788 NRF cases, with corresponding prevalence of 13.3 and 95%CI of 12.4–14.3 per 1000 livebirth (The main underlying morbidities of NRF were RDS (36.4%), pneumonia/sepsis (35.3%), TRIN 13.6%), CA 10.2%), MAS (1.6%) and IVH (2.9%), with corresponding CFR of each morbidity in NRF patients as 21.6%, 10.1%, 10.3%, 45.0%, 46.2% and 4.3%, respectively. In those extremely (BW < 1000 g or GA < 28 weeks) and very (BW < 1500 g or GA < 32 weeks) premature patients, RDS was diagnosed in approximately 100% and 70% with CFR of 50–70% and 40%, which contributed to 100% and 85% of NRF deaths, respectively .As Table P < 0.001). The costs of rescuing a NRF patient were about 20,000 CNY, equivalent to a local adult’s annual disposable income. The financial burden was much higher in those of extremely or very preterm/LBW, about 80,000 CNY or 50,000 CNY, respectively. Table The prevalence rates of CPAP, MV, surfactant and postnatal steroids use were 80.8%, 44.2%, 27.8% and 15.7%, respectively. In very premature patients, the utility rates of CPAP, MV and surfactant were nearly 90%, 50% and 60%, respectively (Table P < 0.001). In contrast, BW ≥4000 g, born in level III hospitals, cesarean delivery, CPAP and MV were associated with the reduction of death odds.The mortality odds evaluated by univariable logistic regression models Table  showed tThe results of prevalence and outcome of NRF in Huai’an in 2015 depicted the efficiency of respiratory care of the regional tertiary centers and associated facilities in the context of perinatal-neonatal care paradigm for pregnant morbidities with high risk of exposure to their offspring. The survival of critically ill newborns, especially very and extremely low GA and BW infants remained a big challenge, despite surfactant and non-invasive ventilation showing benefits in patients with RDS. By logistic regression analysis, the improved survival of NRF was associated with born in the tertiary hospital, cesarean delivery and respiratory support. It should reflect an integrated strategy for the prenatal, peripartum and early postnatal care. RDS, MAS and CA became the leading odds for increased NRF mortality, which indicates a shift of clinical priorities for reducing high death risk population under local perinatal-neonatal network system in transition. The study design, protocol and definition of NRF were similar to the previous multicenter studies in nation-wide, provincial or trans-provincial perspectives (mainly based on the tertiary NICU admission), which facilitated temporal and spatial comparisons regarding the overall and specific care efficiency.Based on the current study, we have shown a prevalence of 13.3‰ and mortality of 2.5‰ of NRF in the whole regional livebirths. Although the data were close to NRF in United States and Italy with prevalence of 18–22‰, and mortality of 2.0–3.2‰, in the mid-1990s, the CFR (18.4%) in our study was still higher than in those countries 11.1–14.6%), denoting development of the care system still lagged at least two decades behind , 31. The%, denotiCompared to those livebirths with very preterm or very LBW, the BW in reference range still accounted for 30–40% NRF in proportion, and contributed to nearly 50% of total deaths, despite that the prevalence of NRF in term livebirths was significantly low < 1%). For those term infants, the perinatal morbidities underlying NRF were associated with substantial proportion of congenital pneumonia and early onset sepsis as at-risk population from all the hospitalized. However, their occurrence as primary diagnosis in those NRF of very and extremely low GA or BW was low or none  , 22, 23 The region of Huai’an had been undergoing transition of the maternal-infant healthcare since 2010 with improvement in both care facility and the universal health insurance –12, 23, The limitation, regarding the data reliability, may include under- or over-diagnosis and treatment, overt and occult, of major and minor respiratory morbidities. In the study design and data process, we managed to scrutinize clinical records in the retrospective data collection. Although we adjusted diagnosis according to the study protocol to balance the authenticity of original data with the diagnostic criteria and definitions, variations of the quality of practice among different facilities still existed. It revealed a real-world practice with respiratory support taking most of the major perinatal and neonatal morbidity and mortality into account. Even so, some risk factors were not controlled well from the data analysis due to sample size with stratification in the multivariable logistic regression models. Interpretation of the results should be cautious. Next, the mortality of NRF still had substantially high proportion of withhold/withdrawal of critical care though the health insurance was implemented. There was no socioeconomic and sociopsychological element engaged in the risk estimation. Further studies should include these factors into estimation for exposure risks and outcome in the perinatal-neonatal care in transition.The salient findings revealed efficiency of neonatal critical care in the management of NRF by associated risk estimates delineating respiratory support and surfactant use among all the hospitalized patients from regional livebirths. It should enable a comprehension of current neonatal critical care status at sub-provincial region, and may be extrapolated to a large proportion of domestic population taking SES and transitional perinatal-neonatal care into account. It requires further studies to validate from different regions for those requiring critical care with adequate respiratory support and management, especially very and extremely preterm births, for better survival.Additional file 1. The definitions of primary diagnosis as underlying disease of neonatal respiratory failure, and the criteria of care level of neonatal intensive care unit.Additional file 2: Table S1. Primary diagnosis, intervention and outcome of NRF in GA strata.Additional file 3: Table S2. The univariable logistic regression of other perinatal factors not included in the multivariable regression model.


Consumption of anxiolytics reported did not vary significantly between the 3 groups (p = 0.330). In conclusion, patients managed with AS for localized prostate cancer do not report more anxiety or depressive symptoms than patients managed with curative treatment, encouraging the extended use of active surveillance.Active surveillance (AS) is a standard treatment option for low risk localized prostate cancer. However, the risk of anxiety and depression compared to other curative strategies, namely radical prostatectomy (RP) and radiotherapy (RT), is controversial. This study consisted in a French representative sample of 4174 5-years cancer survivors. Self-reported data, including quality-of-life assessment, were prospectively collected through telephone interviews. Among the 447 survivors with PC, we selected 292 patients with localized prostate cancer, T1–T2 stage, Gleason score ≤ 7 and we compared anxiety and depressive symptoms according to treatment strategy. Among patients on AS, 14.9% received curative treatment during the 5 years of follow-up. Anxiety was reported in 34.3% of cases in the AS group versus 28.6% in the RP group and 31.6% in the RT group ( The patients may experience feelings of anxiety and distress while living with ‘‘untreated’’ cancer. The establishment of close monitoring with regular PSA testing, digital rectal examination, prostate MRI and biopsies as an integral part of AS could exacerbate perceptions of threat and therefore cause concern10. Yet, the management of this anxiety therefore seems essential in order to allow better patient adherence to this treatment modality12. Few studies have focused on anxiety and depressive symptoms experienced by men undergoing AS for prostate cancer.In patients with PC managed by AS, intolerance of uncertainty is a predisposing trait for anxiety marked by the tendency to perceive uncertainty as threateningThe aim of our study was to assess the long-term impact of active surveillance on the risk of anxiety and depression compared to other curative strategies, namely radical prostatectomy (RP) and radiotherapy (RT).13.The French VICAN5 survey was a multicenter national French prospective cohort carried out in 2015–2016 among cancer survivors, 5 years after their diagnosis of cancer. The study was approved by the national ethics committee and all patients signed an informed consent. The study methodology and data collection procedure has been detailed elsewhere14.Three types of data were collected. (1) A patient questionnaire administered by phone, which included data on living conditions, Health-related Quality of Life (HR-QOL), anxiety and depression. (2) Medical and clinical data collected from healthcare teams who initiated the cancer treatment. (3) Medico-administrative data using the national health insurance database (SNIIRAM) which recovers all on their healthcare consumption since diagnosis n = 447). We selected patients with localized prostate cancer, stage T1–T2, Gleason score ≤ 7, treated with radical prostatectomy (RP), radiotherapy (RT) or AS, who responded to the 5-year survey (VICAN5). Patients with recurrence requiring salvage therapy were excluded. Patients receiving more than 6 months of concomitant or sequential hormone therapy were excluded. A total of 292 men met the eligibility criteria , a validated patient-reported instrument. To create binary measures, Anxious/depressed participants were identified as those having an anxiety/depression score above 1016.The consumption of anxiolytics at 5 years of the diagnosis was assessed using the national health insurance database (SNIIRAM). HR-QOL was measured using the French version of the SF12 which allow to build two health scores, the Physical Component Summary (PCS) and the Mental Component Summary (MCS)Chi-squared tests, Fisher exact tests, student’s t-tests were used in descriptive analyzes, depending on the type of variables. To identify the factors associated with anxiety and depression, univariate and multivariate analyzes using binary logistic regressions were performed. A sensitivity analysis (adjusting for age and treatment received) was performed by excluding patients who received delayed curative treatment after initial AS. All these analyses were performed in the STATA software program, version 17.0 .The VICAN cohort study has been approved by the Institute of Public Health , by the French Commission on Individual Data Protection and Public Liberties  and by the Comité Consultatif sur le Traitement de l'Information en Matière de Recherche dans le Domaine de la Santé . The VICAN study therefore has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. All participants gave their informed consent.Among the 292 patients with localized prostate cancer, T1–T2 stage, Gleason score ≤ 7, participants underwent RP alone in 57.5% of cases, RT in 19.5%, while 23% of participants had AS. Among patients on AS, 14.9% received curative treatment during the 5 years after diagnosis.p = 0.034), a higher WHO Performance Status score (p = 0.003) and a lower clinical stage (p = 0.018) compared to the curative treatment groups. In the RT group, we observed significantly more elderly patients (p < 0.001), a greater number of inactive (p = 0.023), a significantly higher WHO Performance Status score (p = 0.002) and a higher proportion of clinical stage T2 (p = 0.023), compared to AS or RP group.The baseline characteristics of our population are presented in Table p = 0.400). Consumption of anxiolytics reported did not vary significantly between the 3 groups (p = 0.330). The results are presented in Table Among patients managed with AS, 34.3% 23/67) reported anxiety, compared to 28.6% (48/168) in the RP group, and 31.6% (18/57) in the RT group, with no significant difference (3/67 repop = 0.770). The results are presented in Table Among patients managed with AS, 14.9% (10/67) reported depressive symptoms, compared to 10.7% (18/168) in the RP group, and 22.8% (13/57) in the RT group, with no significant difference (p = 0.002) and anxiety (p = 0.044)  Table .Table 3Fp < 0.001 and p < 0.001 respectively), a decreased physical HR-QOL (p < 0.001 and p = 0.017 respectively), and reported fatigue (p < 0.001 and p < 0.001 respectively).There was a significant association between depression/anxiety and a decreased mental HR-QOL  , distress was ascertained using the Distress Thermometer and Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9). No difference in prevalence rates of depression, anxiety, and distress over time was noted , with < 5% of patients exhibiting moderate or high levels of depression or anxiety in both groups18. Van den Bergh et al. reported that patients with low-risk PC who chose AS showed low anxiety and distress from the time of diagnosis up to 9 months. Significant decreases were seen between 2.4 and 9.2 months after diagnosis in mean scores of general anxiety (STAI-6) (p = 0.016), prostate cancer-specific anxiety (MAX-PC), fear of progression subscale (p = 0.005), and self-estimated disease progression risk (p = 0.049)19. Men with prostate cancer on AS exhibit low general and illness-specific anxieties, relayed by Jake Anderson et al. A high percentage of men had low levels of general state anxiety as measured by the HADS-A (86%) and trait anxiety as measured by the STAI-T (77%). For illness-specific anxieties, 87% of men reported low levels of prostate cancer-related anxiety and 92% reported low levels of fear of recurrence20. In a study conducted by Marzouk et al., men undergoing active surveillance did present a moderate risk of cancer specific anxiety, which was 29% risk of reporting cancer specific anxiety within the first year. Moreover, anxiety significantly decreased with time21.In our study, we showed that men with prostate cancer on AS, 5 years after their diagnosis of cancer, didn’t present an increased risk of anxiety or depression compared to patients treated by RP or RT, which is also reflected by the absence of overconsumption of anxiolytics. These results are consistent with those of the previously published ProtecT study, which assessed anxiety and depression using the Hospital Anxiety and Depression Scale (HADS)22. Other risk factors as neurotic personality score seemed to be an important determinant of anxiety and distress in men on AS23. In our study, we identified new factors significantly associated with anxiety and depression in patients with localized prostate cancer, in particular a financial situation perceived as critical or difficult. Less surprisingly, the other parameters of HR-QOL, namely mental or physical HR-QOL and reported fatigue, were also associated with anxiety and depression.In the patients on AS, some risk factors of anxiety and depression have been identified in the literature. Greater intolerance of uncertainty and moderate/severe urinary symptoms have been described as risk factors in patients on AS, as shown by Tan et al.Strengths of our study are the prospective, population-based and nationwide design, which facilitates generalizability. Moreover, we ensure long-term follow-up with a larger sample at 5 years, and a high questionnaire response rate which increased the precision and internal validity. Finally, the evaluation of the consumption of anxiolytics is an interesting parameter that has not been usually evaluated previously.Several limitations of the present study require discussion. First, the active surveillance protocol was not standardized, as it was left to the discretion of the urologist, assuming regular PSA monitoring and repeat biopsies according to national guidelines. Similarly, the criteria for treatment choice were not detailed. These limitations are inherent in the design of the VICAN observational survey. A second limitation is that this research used self-report measures by phone, which may limit the objectivity of participant responses and induce a risk of information bias. In the end, the distribution of patients in each group is unequal, without randomization, which can induce a patient selection bias. Although the overall response rate is quite high in this survey (43% of patients with prostate cancer at diagnosis), we do not know if the response rate was similar across the different treatment groups (AS versus other), especially for patients presenting with symptoms of depression or anxiety, and this could induce a nonresponse bias.Patients managed by AS for localized prostate cancer do not report more anxiety or depression than patients managed by curative treatment, encouraging the extended use of AS for patients with low-risk localized prostate cancer.Supplementary Information 1.Supplementary Information 2.


P < 0.05). Neuropathic Pain Symptom Inventory clusters burning , tingling  and evoked by cold  occurred more frequently in central post-stroke pain. Hyperpathia, thermal and mechanical allodynia also occurred more commonly in this group (P < 0.001), which also presented higher levels of deafferentation (P < 0.012) with more asymmetric cold and warm detection thresholds compared with controls. In particular, cold hypoesthesia  odds ratio (OR) was 12 (95% CI: 3.8–41.6) for neuropathic pain. Additionally, cold detection threshold/warm detection threshold ratio correlated with the presence of neuropathic pain . Correlations were found between specific neuropathic pain symptom clusters and quantitative sensory testing: paroxysmal pain with cold  and heat pain thresholds , burning pain with mechanical detection  and mechanical pain thresholds , evoked pain with mechanical pain threshold . Logistic regression showed that the combination of cold hypoesthesia on quantitative sensory testing, the Neuropathic Pain Symptom Inventory, and the allodynia intensity on bedside examination explained 77% of the occurrence of neuropathic pain. These findings provide insights into the clinical-psychophysics relationships in central post-stroke pain and may assist more precise distinction of neuropathic from non-neuropathic post-stroke pain in clinical practice and in future trials.Central post-stroke pain affects up to 12% of stroke survivors and is notoriously refractory to treatment. However, stroke patients often suffer from other types of pain of non-neuropathic nature  and no head-to-head comparison of their respective clinical and somatosensory profiles has been performed so far. We compared 39 patients with definite central neuropathic post-stroke pain with two matched control groups: 32 patients with exclusively non-neuropathic pain developed after stroke and 31 stroke patients not complaining of pain. Patients underwent deep phenotyping via a comprehensive assessment including clinical exam, questionnaires and quantitative sensory testing to dissect central post-stroke pain from chronic pain in general and stroke. While central post-stroke pain was mostly located in the face and limbs, non-neuropathic pain was predominantly axial and located in neck, shoulders and knees ( Dissection of distinct post-stroke pain syndromes evidenced that the neuropathic pain inventory, the presence of cold thermal deficit and the finding of allodynia on bedside examination, explained 77% of the occurrence of neuropathic central post-stroke pain, a new finding that has clear diagnostic potential.  Although significant insights have been gained from neuroimaging,12–18 neurophysiology,19–23 basic studies24–28 and psychophysics,29–39 currently no efforts have been made to integrate a comprehensive clinical characterization of these patients with the concomitant abnormalities of the somatosensory system in a controlled fashion that includes PSP of non-neuropathic origin, by far the most common PSP subtype.Along with motor, language and coordination deficits, stroke may also lead to pain in up to 50% of individuals.40 So, efforts to define the optimal method to classify patients based on symptoms profile, bedside examination and quantitative sensory testing (QST)41 have been made in an attempt not only to diagnose neuropathic pain itself, but also to stratify patients who are more likely to respond to specific therapeutic interventions.41–47 By doing so, one expects to replace the current treatment strategies proposing to treat all patients similarly, which has provided relatively poor symptomatic control.49 For this aim, studies exploring the relationship between symptoms and somatosensory loss and gain of function are required. To date, studies exploring symptom-psychophysics relationships have included mainly patients with peripheral neuropathic pain,50 while symptom-psychophysics correlations in CPSP remain less common, often without standardized symptom characterization51 and with either no control groups or one composed of patients without chronic pain. In order to dissect CPSP from PSP in general, we have compared a sample of CPSP patients with non-neuropathic PSP patients and with stroke patients without chronic pain matched for sex, age and stroke location. We have evaluated stroke characteristics, neuropathic pain symptoms, bedside examination and static and dynamic QST across groups to provide a deep phenotyping of CPSP and describe potential symptom-QST correlations specific to CPSP that could be used in the future in preventive or therapeutic trials.Additionally, sensory abnormalities in neuropathic pain reflect altered mechanisms of nociceptive processing, and neuropathic pain mechanisms are thought to be diverse within a single disease aetiology.11 The present study aimed to compare pain characteristics and sensory profile of CPSPs with two control groups: (i) patients with non-neuropathic PSP (PSP-Non) and (ii) stroke patients without chronic pain (No-Pain). The three groups were matched according to sex, age and stroke area.This was a controlled cross-sectional study, part of the Central Pain Initiative Project focused on the assessment and treatment of central neuropathic pain.52Data collection took place at the Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP). It was approved by the Institution’s Ethics Review Board (No. 690.455). All patients were volunteers and informed about the procedures and provided written informed consent before inclusion in the study. No financial compensation was offered for study participation. Neuroimaging findings form part of these patients have been reported elsewhere.53; (ii) occurrence of de novo pain attributed to a central lesion due to stroke; (iii) pain characteristics not compatible with other aetiologies of pain .5According to clinical evaluation and imaging information, two neurologists trained in pain management and one neuroradiologist  classified each patient’s pain syndrome. All cases were confirmed by a board (D.C.d.A. and M.J.T.), and only patients with consensual pain classifications were included. All participants had suffered an ischaemic or haemorrhagic stroke at least 3 months before the evaluation was confirmed by imaging (CT or MRI). Exclusion criteria were major cognitive or language impairments that would compromise filling in questionnaires or sensory examination . Also, p54CPSP patients were compared with two control groups: (i) PSP that was non-neuropathic in nature (PSP-Non) and (ii) No-Pain. These groups were recruited from the cerebrovascular diseases outpatient clinic from the Department of Neurology, University of São Paulo. They were matched according to sex, age and stroke location .before the stroke was an exclusion criterion for the PSP-Non group.5Post-stroke painful symptoms present most of the days for longer than 3 months with a clear non-neuropathic aetiology , in the absence of concomitant neuropathic pain according to the IASP/NeuPSIG grading system. The presence of chronic pain Included patients without chronic pain before or after stroke, and no episode of acute pain (e.g. episodic headaches) within the 7 days preceding the clinical evaluation.Participants were assessed in a single visit. They underwent a clinical evaluation, which included an analysis of current symptoms and limitations, and physical examination focused on sensory musculoskeletal systems. Sociodemographic information, medical comorbidity status and medication use were registered. Concomitantly, functional scores, questionnaires to evaluate pain, incapacity, mood and catastrophism, were also filled out as detailed below.The subsequent scales were employed to assess functional status:56: Quantifies the level of independence, varies from 0 to 100 .Barthel index57: Seven-point scale for functional outcome after stroke anchored at 0 = asymptomatic and 6 = death.Modified Rankin scale (mRS)58: Assesses disability, limitations for social activities and work, the severity of pain, and the interference with sleep, related to arm, shoulder and hand symptoms 61: It is composed of two factors: (i) functional status component (maximum score of 90) and (ii) psychosocial component (maximum score of 60). The total PDQ score consists of the sum of all items .Pain Disability Questionnaire (PDQ)The following questionnaires were used to assess pain in the CPSP and PSP-Non groups:62 Sensory, affective, evaluative and total descriptors are obtained by counting the words chosen by the patient.63Short-form McGill Pain Questionnaire (SF-MPQ): It has pain descriptors divided into three dimensions: sensory (eight items), affective (five items) and evaluative (two items).65Brief Pain Inventory: Measures pain intensity ; and interference scores .67Douleur Neuropathique Questionnaire-4 (DN-4): A screening test for neuropathic pain composed of ten items. It ranges from 0 to 10 and is positive when ≥4.69 Recently, a new cluster has been proposed, classifying patients into three groups according to an artificial intelligence algorithm applied to the scores of each of the items: pinpointed, deep and provoked pain.41 Cut-off point of NPSI total score differentiating neuropathic from non-neuropathic pain was assessed through receiver operating characteristic (ROC) curve analysis.Neuropathic Pain Symptoms Inventory (NPSI): A qualitative and quantitative inventory of different neuropathic pain descriptors that enables the evaluation of different phenotypes through discrimination and quantification of five distinct clinically relevant dimensions of neuropathic pain: burning  spontaneous pain, pressing (deep) spontaneous pain, paroxysmal pain, evoked pain and paresthesia/dysesthesia. Its total score ranges from 0 to 100, and each dimension’s score ranges from 0 to 10 with higher scores indicating more intense symptoms.70The Short Form 12-Health Status Questionnaire (SF-12): Measures health-related quality of life and is composed of 12 items that generate two scores related to physical health (PCS) and mental health (MCS). Each score ranges from 0 to 100; the higher the score, the greater the health-related quality of life.72Hospital Anxiety and Depression Scale: Evaluates symptoms of anxiety and depression; higher scores mean more severe symptoms. Scores of eight for anxiety and nine for depression were used as cut-off values.73The Pain Catastrophization Scale: Assesses catastrophic thoughts or feelings accompanying the experience of pain. This scale consists of 13 items on a Likert scale. The total scale score ranges from 0 to 52; higher scores represent greater catastrophic thinking.74 It was classified into three categories—absent, low to moderate (m-AS 1 or 2 in at least one limb) and moderate to severe (m-AS score above 2 in at least one limb).75 Muscle strength was measured according to the Medical Research Council (MRC) scoring system. Motor impairment degree was grouped into four severity grades—Grade 0 , Grade 1 (MRC = 4 in at least one limb), Grade 2 (MRC = 2 or 3 in at least one limb) and Grade 3 (MRC = 01 or 1 in at least one limb).76 Myofascial trigger points (TP) were evaluated bilaterally in standardized regions, including temporal, masseter, scalene, trapezius, pectoralis major, levator scapulae, rhomboid, supraspinatus, biceps brachii, triceps brachii, wrist and finger extensors, first dorsal interosseous, quadratus lumborum, gluteus maximus, piriformis, vastus lateralis and gastrocnemius muscles.77 Briefly, TP were looked for with 4 kg/cm2 of pressure, using the thumb (just enough to blanch the examiner’s nailbed).78 Active TP were considered to be present when digital pressure evoked pain in a corresponding referred pain pattern and resembled at least 50% of the patients’ clinical pain.80Spasticity in the upper and lower limbs was quantified according to the modified (m-) Ashworth spasticity scale (AS), in which higher values indicate more severe spasticity.79 Hyperpathia was assessed with a pin: patients were asked to quantify the evoked pain during examination using the numeric rating scale  after one stimulus and after a train of 10 stimuli delivered at 1 Hz.81 Allodynia intensity (NRS) differentiating neuropathic from non-neuropathic pain patients was assessed through ROC curve analysis.The sensory assessment employed standardized bedside examination, including the evaluation of superficial touch and allodynia with a piece of cotton wool, cold sensitivity and cold allodynia with a metal rod at room temperature, and mechanical pain sensitivity by light prick with a pin. Regions of the face, trunk, arms and legs were tested, comparing them with the contralateral side and proximal and distal body regions.82 PSP-Non and No-Pain groups were tested over the area of most severe motor/sensory abnormalities  and its respective asymptomatic mirror area. If the patient presented bilateral symptoms, the worse area was tested, and the contralateral mirror area was used as the control side. In all areas, the following QST parameters were tested according to previously described techniques: briefly, cold detection threshold (CDT), warm detection threshold (WDT), mechanical detection threshold (MDT), vibration detection threshold (VDT), cold pain threshold (CPT), heat pain threshold (HPT), mechanical pain threshold (MPT) and the numerical pain rating scale for suprathreshold cold (STCP), suprathreshold heat pain (STHP), suprathreshold mechanical pain (STMP) and wind up ratio (WUR) were evaluated. The tests were assessed by the method of limits.83CPSP patients underwent a static QST battery to assess sensory findings at the site of the most severe neuropathic pain area (pain area) and the corresponding contralateral site (mirror area).Results were analysed in three outputs according to specific research questions:84–86), and a QST index of asymmetry was obtained to assess differences between groups so that threshold or hyperalgesia indices for each QST parameter were calculated according to the formula: value from the test area/value from the mirror area.Side-to-side differences: Comparisons were made within-subjects  was calculated and considered abnormal if it was above or below the following lower and upper cut-off values for: CDT (0.41–2.42), WDT (0.42–2.39), MDT (0.38–2.62), MPT (0.4–2.53), WUR (0.52–1.94).87 For CPT and HPT, the difference between results from test and mirror areas (test area–mirror area) was calculated and considered abnormal if it was above or below the following lower and upper cut-off values: CPT (−10.3 to 10.3°C) and for HPT (−4.2 to 4.2°C).87 For VDT, STCP, STHP and STMP, abnormal values were considered for indices below 0.4 or above 2.5.Single-patient classification: Single QST results from each parameter were classified as normal or abnormal according to Rolke 85 a ‘thermal ratio’ was created consisting of CDT pain area × WDT mirror/CDT mirror × WDT pain area. This CDT/WDT thermal ratio is analogous to the ‘sensory limen’83 or the sensitivity index proposed by Jensen et al.88 and used by Vestergaard et al.84. It was intended to illustrate unbalance between cold and WDTs .Thermal limen assessment: Since warm and CDTs were the sensory modalities reported to be more starkly altered in CPSP,91 Furthermore, the deep pressure hyperalgesia [i.e. the intensity of the pain (0–10 NRS)] generated by a three second-stimulation at the PPT + 2 kg/cm2 was also measured for each muscle site.92Pressure pain threshold (PPT) was assessed with an algometer  in patients with chronic pain in the same muscles tested in the myofascial pain investigation, as described above. The rubber tip of the algometer was vertically positioned on the point to be examined. The pressure was increased at ∼1 kg/s continuously until the subject reported the triggering of pain or discomfort. The lowest pressure value-generating pain at each point was considered as the PPT.94 CPM was reported as the evoked pain intensity difference between the conditioned and unconditioned test stimuli.Dynamic QST was assessed by conditioned pain modulation (CPM) and was evaluated by measuring the pain intensity of a stimulus (test-stimulus—suprathreshold heat pain stimulus over the thigh not affected by stroke) which was then repeated after a painful tonic stimulus .χ2 test and Fisher’s exact test were used to compare the nominal and ordinal qualitative variables between groups. OR and 95% confidence intervals (CIs) were calculated to assess the relations between neuropathic pain and somatosensory abnormalities assessed through physical examination and QST. Spearman coefficients were used to assess the correlation between variables found to be significantly different. Correlations with a correlation coefficient ≥ ± 0.4 were included in logistic regression analyses. Basic assumptions including independence of errors, linearity in the logit for continuous variables, absence of multicollinearity and lack of strongly influential outliers were checked before the test. The study size was estimated based on the proportion of the most prominent finding on QST in CPSP  according to one of the largest studies to date.86 This was a convenience sample with 31 patients in the smallest group allowing to detect a difference in proportion around 23% between chronic pain groups with a power of 80% and a Type I error set at 5% bilaterally. The estimated sample size was also in line with the CPSP sample size of previous studies.95–98 The level of significance considered was 5%. Since it was an exploratory study, adjusting for multiple testing was not mandatory. However, we opted to evaluate the subgroup analysis with a pairwise correction to distill the more robust findings that could be inputed into the regression model,99 so Bonferroni correction for multiple testing was performed when indicated.Categorical variables were represented by frequencies, percentages and absolute numbers. Quantitative variables were tested for normal distribution using Kolmogorov–Smirnoff tests and Q–Q plots and histograms. The Kruskal–Wallis test was employed for comparisons of non-parametric quantitative variables between the three groups. The Mann–Whitney test was applied for comparisons of non-parametric quantitative variables between two groups, and the Bonferroni correction was used for multiple comparisons. The The data that support the findings of this study are available on request from the corresponding author.P = 0.28). Male patients made up 64.7% of the total sample, and most medical comorbidities were similar between groups , 32 patients had chronic pain of non-neuropathic origin with onset post-stroke–(PSP-Non group) and 31 were pain-free (No-Pain) . The mean groups .The stroke location , the time elapsed since stroke (47.7 ± 44.3 months), the type of event  and the number of lesions (20.6% had more than one) were distributed similarly in the three groups, with no significant differences among them .P = 0.949). CPSP pain was mainly located in the face, upper and lower limbs (n = 31) considered their pain as continuous compared with 40.6% in the PSP-Non group (n = 13), P = 0.001. Pain in the PSP-Non pain group was mainly axially located: in the neck, shoulders and knees (P < 0.001). The spatial distribution pattern of pain areas in this subgroup of PSP-Non patients was similar to the rest of the PSP-Non group (n = 22), chronic headache (more than 15 days per month for 3 months), 12.5% (n = 4) and headache associated with musculoskeletal pain 18.8% (n = 6) of this group.The mean duration of pain was 47.3 (±47.2) months without difference between groups  and affective dimensions of pain  , tingling  and pain evoked by cold stimulus . PSP-Non patients never described their pain as tingling or as electric shocks. The pain descriptors were clustered in the five distinct dimensions of neuropathic pain, and the burning  spontaneous pain dimension corresponded to the highest scores in the CPSP. All scores, except the pressing (deep) spontaneous pain, were significantly higher in the CPSP group compared with the PSP-Non    4 and 5 PSP-Non . Similary of 28% .P = 0.013. The mRS followed the same trend, with a higher concentration in mRS 3 and 5 in the CPSP , P = 0.013. Comparisons between groups evidenced a difference when comparing CPSP versus No-Pain for the Barthel index (P = 0.004) and the mRS (P = 0.005)—Quality of life, mood and catastrophism ratings were worse in patients with chronic pain (both CPSP and PSP-Non) compared with No-Pain . The BarP < 0.001. Pairwise comparisons confirmed differences between all pairs. A similar trend was observed for the PDQ  for both types]  than in PSP-Non  and in No-Pain , P = 0.001  and PSP-Non (62.5%) than in No-Pain (35.5%),  = 0.001 .n = 21) versus 25% (n = 8) PSP-Non and 9.7% (n = 3) P < 0.001, and motor weakness was present in 70.3% (n = 26) of CPSP, 75% (n = 24) PSP-Non and 54.8% (n = 17) No-Pain P = 0.030, evidencing a tendency of higher impairment in CPSP versus No-Pain (n = 24), whereas they were present in 13.2% (n = 5) of the CPSP group, P < 0.001 (Spasticity was present in 53.8% CPSP ( No-Pain . Active  < 0.001 .Side-to-side differences were measured via the affected area versus mirror area and QST index of asymmetry. CPSP had higher CDT and WDT asymmetry than PSP-Non (P < 0.001 and P = 0.003) and No-Pain , indicating a higher degree of sensory deafferentation. Conversely, mechanical hyperalgesia (STHP) was higher in the PSP-Non group than in CPSP (P = 0.007). All QST findings are reported in Single-patient classification: CPSP presented higher percentages of loss of function for spinothalamic tract (STT)  and for dorsal column lemniscal-dependent inputs, VDT and MDT  when compared with the PSP-Non and No-Pain groups . Additionally, there was a correlation between this CDT/WDT thermal ratio limen and the presence of neuropathic pain  and also with pain intensity .P = 0.047), with patients with chronic pain (CPSP and PSP-Non) showing lower values, meaning a defective CPM, but these findings did not persist after multiple comparisons adjustments (P = 0.947) though CPSP had lower PPT in all muscles tested compared with PSP-Non and No-Pain  and HPT ;Paroxysmal pain and CPT  and MPT .Burning pain and MDT  and STMP .Evoked pain and MPT (There was no correlation between the other two clusters (pressing pain and paresthesia/dysesthesia) and QST modalities .χ²(3) = 85.1, P < 0.001] and explained 77% (Nagelkerke R2) of the variance in CPSP. Of the variables, all were statistically significant: cold hypoesthesia OR = 8.1, 95% CI = 1.6–42.5; NPSI OR = 1.1, 95% CI = 1.0–1.1; NRS allodynia OR = 2.1, 95% CI = 1.3–3.7.We performed a binomial logistic regression including variables found to be different between groups from pain descriptors (NPSI), from clinical bedside examination , and from QST (CDT in painful side versus mirror area < 41%) and the likelihood these patients would have been classified as being from the CPSP group. The model was statistically significant  and explained 69% (Nagelkerke R2) of the variance in CPSP. Of the variables, all were statistically significant: cold hypoesthesia OR = 7.4, 95% CI 1.3–43.6; NPSI OR = 11.3, 95% CI 2.4–53.4; allodynia OR = 36.9, 95% CI 3.7–370.6.Employing dichotomous variables on the model NPSI (≥20) and NRS allodynia (≥2), the model was statistically significant  have suggested that continuous ongoing pain would be related to injuries affecting small fibres, while paroxysmal pain would be related to lesions to myelinated large fibres.116 However, even in these reports, these distinctions are not unequivocal: in patients with multiple sclerosis, about a third of those with pain due to Lhermitte sign’s (shock-like triggered though the neck-dorsum by neck flexion) had normal SEPs, while SEPs were abnormal in about a third of those presenting with ongoing extremity pain.117 Importantly, most hypothesis linking myelinated fibre lesions leading to abnormal discharges and paroxysmal pain relies on an otherwise normal second/third order wide-dynamic range neurons that would receive high-frequency discharges conveyed by injured myelinated fibres  and would then divert them into nociceptive pathways, where discharges would eventually be perceived as painful. In central neuropathic pain, 2nd or 3rd order sensory neurons are frequently included within the lesion area, thus potentially altering the central processing of thermo-nociceptive inputs. It must also be kept in mind that correlations found here and elsewhere do not imply causality, and may be due to an undetermined mediating cofactor between paroxysms and thermal thresholds abnormalities such as the severity of lesion.This was the first description of neuropathic symptom cluster profiles and their relationships with QST in CPSP compared with PSP pain of non-neuropathic nature. Four out of the five original neuropathic pain symptom clusters were more common in CPSP, except for deep spontaneous pain. In CPSP, burning  spontaneous pain was the symptom cluster with the highest scores, followed by paresthesia/dysesthesia and evoked pain.121 This has led to the imbalance theory,122 postulating that CPSP would occur due to residual lemniscal inputs arriving in the absence of STT information in higher-order neurons. Our results are in line with such a view, since QST-based thermal cold hypoesthesia carried the highest OR for CPSP (=12.0), and that CPSP patients had more widespread sensory abnormalities. However, classic QST batteries offer a relatively limited assessment of lemniscal function and one cannot refute that concomitant lemniscal abnormalities were not present in our samples.Previous studies on central neuropathic pain have reported that patients had altered spinothalamic-dependent abnormalities, while lemniscal pathways could be either intact or affected.87), explained 77% of the occurrence of neuropathic pain. Interestingly, this model comprises the basic steps in the clinical diagnosis of neuropathic pain: use of pain descriptors, presence of abnormal sensory gain on bedside examination and the determination of STT-related deficits (CDT). This may potentially be useful information in the distinction between neuropathic from non-neuropathic PSP and may help better design interventional trials in the future.Most clinically relevant results came from the logistic regression. The association of pain NPSI score, presence of allodynia on bedside examination and CDT abnormalities on QST , to bias related to slower reaction time in stroke patients, or to maladaptive plasticity after stroke. The fact is that these reports highlight the need to have control groups with pain and stroke in order to account for these abnormalities ipsilateral to the stroke side.It has been proposed that, compared with healthy volunteers-based normative data,In summary, we reported, in a double-controlled study, that CPSP was associated with thermal detection deficits, allodynia, hyperpathia, on bedside assessment, and several of the symptom clusters of CPSP were correlated to discrete QST parameters. Also, we showed that a combination of neuropathic pain symptoms, the presence of cold detection deficits and allodynia explain a large proportion of the occurrence of CPSP. These findings will have diagnostic utility and may help better design personalized treatments based clinical and QST findings for CPSP in the near future.fcac090_Supplementary_DataClick here for additional data file.


Bowel perforation is a relatively rare presentation of abdominal tuberculosis, whose diagnosis is challenging but fundamental to minimize morbidity and mortality. Laparoscopy is considered an effective modality for diagnosis, but its role in surgical treatment is still not established. We reported the first worldwide case of totally laparoscopic treatment of intestinal tuberculosis complicated with bowel perforation.A 30-year-old man with a history of weight loss, preceded by 2 years of nonproductive cough, was admitted to the Infectious Disease Department with a presumed diagnosis of tuberculosis. A microbiological culture test confirmed the diagnosis, and the patient undertook quadruple antituberculous therapy. During hospitalization, he presented sudden abdominal pain, fever, and vomit. An abdominal CT scan showed small bowel perforation with granulomatous reaction. Laparoscopy was performed and revealed a 2 cm perforation on the medium ileum. Small bowel resection and totally intracorporeal side-to-side anastomosis were performed. No complication occurred until a clinical follow-up of 2 months.In consideration of the increasing incidence of intestinal TB in both underdeveloped and Western countries, the diagnosis of this pathology should be taken into account in high-risk patients. Probably, the diagnostic challenges and emergency settings of intestinal TB with perforation and peritonitis, together with the lack of standardized guidelines regarding surgical management, make the use of laparoscopy apparently arduous, but the known advantages of laparoscopy and its technical feasibility should make it a conceivable option for the treatment of complicated cases. Mycobacterium tuberculosis, a member of the M. tuberculosis complex. It is a major global health concern since more than 1.7 billion people (approximately 22% of the world population) are estimated to be infected with M. tuberculosis (Tuberculosis (TB) is an infectious disease caused by rculosis  has led TB is a multisystem disease that primarily affects the lungs [referred to as pulmonary TB (PTB)]; however, it can affect any organ of the body wherein it is termed extrapulmonary TB (EPTB) . AccordiAbdominal involvement can occur during primary infection or following secondary reactivation. For instance, extrapulmonary tuberculosis, such as appendicular tuberculosis (ATB) and thyroid tuberculosis, has been described even in the primary form without any evidence of the disease elsewhere , 14.M. tuberculosis in peritoneal fluid, a biopsy specimen of an involved site, obtained through laparoscopy   –29. On mt (NAAT) , 20, 30.t (NAAT) , 22, 29.A 30-year-old man of Chinese origin was admitted to the Infectious Diseases Department of our University Hospital with a 2 month history of progressively weight loss, preceded by 2 years of nonproductive cough. No other diseases are known in the patient’s past history. Unfortunately, linguistic barriers made communication with the patient difficult, and no further information regarding his history, including family and psychosocial history, could be obtained.On admission, the patient was cachectic (BMI 16.5) and had a high respiratory rate (RR 34/min), fever (body temperature 38.5 °C), and nonproductive cough with thoracic pain. Sars-Cov-2 nasopharyngeal swab test resulted negative. Microbiological tests for HIV and hepatitis viruses resulted negative.In 3/µl. An abdominal CT scan showed small bowel perforation with granulomatous reaction compatible with intestinal tuberculosis . Imaging evaluation through thoracic and abdominal contrast-enhanced CT scanning showed multiple areas of consolidation with cavitation (maximum diameter 35 mm) and mediastinal lymphadenopathy . The blorculosis With a preoperative clinical and radiological diagnosis of small bowel perforation secondary to likely intestinal tuberculosis, written informed consent for emergency surgery was obtained. Surgery was performed by a young surgeon. Regarding the surgical approach, despite marked distension of the stomach and small bowel with multiple air-fluid levels, laparoscopy was considered a conceivable option. The patient was positioned supine with both arms tucked. The surgeon and camera operator were located on the patient's left side. A urinary catheter was placed. Pneumoperitoneum was induced through an open trans-umbilical technique with the placement of a 12 mm optical trocar . Other tEnterococcus faecium and Streptococcus gordonii; therefore, intravenous antibiotic therapy with meropenem (1 g every 8 h) and quadruple antituberculous treatment  were administered. No complications occurred until a clinical follow-up of 2 months. The pathological macroscopic examination showed that the ileum wall was widely thickened with a stenotic tract covered by fibrinous exudate and brownish-gray color; two areas of perforation were found, one of 2 × 1.2 cm and one of 3 × 1 cm , and on the first postoperative day (POD), the patient was successfully extubated and oral feeding was started. On the fifth POD, we transferred the patient to the Infectious Disease Department. Peritoneal fluid culture found 3 × 1 cm . The his3 × 1 cm . Vascula3 × 1 cm .Although rare, there is an increasing incidence of abdominal tuberculosis in developed countries. The diagnosis of this disease continues to pose significant challenges, but early recognition is fundamental to minimize morbidity and mortality . The tre


After 3 hours, 24 hours, 3 days, and 7 days of drug administration, the modified Neurological Severity Score tests were performed. The ultrastructure of the brain and hippocampus was observed by electron microscopy. Real-time quantitative polymerase chain reaction (PCR), western blotting, and immunohistochemistry were used to detect Nogo receptor (NgR) expression in the hippocampus and cerebral cortex, and Nogo–NgR expression in CA/CPR model. Neurological deficits in the model group were severe at 3 hours, 24 hours, 3 days, and 7 days after the recovery of natural circulation, whereas the neurological deficits in CWM, antagonist, and Shenfu group were relatively mild. The ultrastructure of neuronal cells in Shenfu group had relatively complete cell membranes and more vesicles than those in the model group. The results of PCR and western blotting showed lower messenger ribonucleic acid and protein expression of NgR in Shenfu group than the model group and CWM group. Immunohistochemical examination indicated a reduction of Nogo–NgR expression in Shenfu group and antagonist group. Our results suggested that Shenfu injection reduced brain injury by attenuating Nogo–NgR signaling pathway and promoting axonal regeneration.The effect of Shenfu injection on brain injury after cardiac arrest (CA) and cardiopulmonary resuscitation (CPR) along with the underlying mechanism of axonal regeneration was explored. CA/CPR model in rats was established for subsequent experiments. A total of 160 rats were randomly divided into sham group, model group, conventional western medicine (CWM) group, Shenfu group, and antagonist group ( Cardiac arrest (CA) is one of the leading causes of mortality worldwide, with approximately 375,000–700,000 cases each year in Europe  and an eCerebral ischemia–reperfusion injury is often present during CA/CPR process. Neurons in the central nervous system usually do not regenerate after damage due to the presence of proteins in mature oligodendrocytes . Nogo prShenfu injection is an extract of red aconite, which has been widely used in the treatment of many heart-related diseases, such as cardiogenic shock, coronary heart disease, acute myocardial infarction, and myocarditis . ZF wangWe speculated that the effect of Shenfu injection on axonal regeneration may be associated with the Nogo/NgR signaling pathway. In this study, the CA/CPR rat models were established to investigate the protective effect of Shenfu on brain injury and to explore whether the mechanism of axonal regeneration is involved in Nogo/NgR signaling pathways.A total of 160 adult male Sprague–Dawley rats (weighing 300–350 g) were purchased from Shanghai Xipuer Bikai Experimental Animal Co., Ltd., Shanghai, China. After one week of acclimatization, all animals were housed in the specific-pathogen-free rooms under a standard light environment (12 hours light–dark cycle) at the temperature of 23 ± 2°C. Rats were given free access to normal standard chow diet and water. This study was conducted in strict accordance with The International Guidelines for Care and Use of Laboratory Animals. The experimental protocols were approved by the Ethics Committee of The First Affiliated Hospital of Guangxi University of Traditional Chinese Medicine, Nanning, China. All procedures were performed under sufficient anesthesia and analgesia to minimize the suffering of animals.n = 32 per group); (1) sham group: exposed body but not operated on plus the administration of 1 mL normal saline intraperitoneally; (2) model group: rats with CA received CPR and injected intraperitoneally with 1 mL normal saline after return of spontaneous circulation (ROSC); (3) conventional western medicine (CWM) group: the rats with CA received CPR and CWM treatment of epinephrine, dopamine, and mild hypothermia after ROSC; (4) Shenfu group: the CA rats received Shenfu injection  immediately after ROSC; (5) antagonist group: rats with CA received CPR and NogoA antagonists (10 mg/kg) immediately after ROSC. Each group was then categorized into 4 subgroups (n = 8 per subgroup) according to the different time period of drug administration as follows: 3 hours, 24 hours, 3 days, and 7 days.Rats were randomly divided into 5 groups  was placed in the airway for end-tidal PCO2 monitoring. The ventilation rate and the tidal volume were controlled to maintain normocapnia (35–45 mmHg) of rats. Arterial blood gases were also analyzed by ABL90 Blood Gas Analyzer  Co., Ltd., Shanghai, China) to confirm baseline ventilation.All rats were fasted overnight and had only free access to water before the operation. The rats were anesthetized through intraperitoneal injection ketamine (50 mg/kg) and xylazine (10 mg/kg) and placed supine on the operation table. The left femoral artery and vein were isolated for cannulation. A catheter was inserted into the left femoral vein and connected to a microinfusion pump  to inject normal saline (2 mL/hour) continuously. An F24 catheter  was inserted from the left femoral artery to the thoracic aorta and connected to the animal electrocardiogram monitor  through a transducer  to check arterial blood pressure and heart rate. After completion of the above processes, endotracheal intubation was carried out, and rats were connected to a volume-controlled ventilator  at the tidal volume of 15 mL/kg, FiOThe CA rat models were successfully established using asphyxiation combined with intravenous potassium chloride solution . Rats wiAfter 5 minutes of CA on rats, CPR was performed with chest compressions (160–200 beats/minutes) by an experienced CPR technician in the laboratory. Meanwhile, the rats were ventilated by a small animal ventilator with a respiratory rate of 80 beats/minutes, a tidal volume of 2.5 mL, and 100% pure oxygen. After that, epinephrine (0.01 mg/kg) and atropine (0.01 mg/kg) were injected into the femoral vein. If necessary, the rats were taken an additional dose of epinephrine every 3 minutes until ROSC was achieved. ROSC was defined as a regular cardiac rhythm with the mean aortic pressure greater than 60 mmHg for at least 10 minutes .After administration drugs at different time points, rats were sacrificed by cervical dislocation after being treated with ketamine (50 mg/kg) and xylazine (10 mg/kg). Cerebral tissue samples of rats were collected for real-time quantitative polymerase chain reaction , western blotting, and immunohistochemistry, whereas the hippocampus were taken for electron microscopy examination and RT-qPCR. All the brain samples were frozen and stored in liquid nitrogen at −80°C.The modified Neurological Severity Score (mNSS) test was applied to evaluate the neurofunctional behavior of rats at the corresponding time points of drug administration , 13, whiμm, followed by fixation with 2.5% glutaraldehyde and 1% osmic acid. The tissues were then dehydrated through an ethyl alcohol–acetone gradient and embedded in Epon812. Tissues were sectioned as 60 nm by an Ultra-thin microtome  and stained by uranyl acetate and lead citrate. After that, the ultrastructure changes of hippocampus tissues were observed under a transmission electron microscope .A portion of hippocampus tissues was taken and cut into 1 Total RNA was extracted by TRIzol  following the manufacturer's instructions. The extracted RNAs were transformed into complementary DNA (cDNA) through a Reverse Transcription Reagent Kit . After that, cDNA was amplified by the Real-Time PCR detection system for observation.  with the following primer sequences: NgR , Nogo , and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) . GAPDH was used as loading control.Brain samples were rinsed with phosphate buffered saline (PBS) and lysed by radio-immunoprecipitation assay lysis buffer containing protease inhibitors and phosphatase inhibitors. The solutions were centrifuged to collect the supernatant, followed by extracting protein according to the manufacturer's protocol. Proteins were then separated by 10% sodium dodecyl sulfate-polyacrylamide gel electrophoresis and transferred to polyvinylidene fluoride membranes. The membranes were blocked in 5% non-fat milk in Tris-buffered saline/Tween-20  for 1 hour and incubated with 1 : 200 diluted Rabbit Anti-Nogo  and anti-NgR polyclonal antibody  overnight at 4°C. Subsequently, the membranes were placed at room temperature for 1 hour with goat anti-rabbit secondary antibody  conjugated to horseradish peroxidase. An enhanced Chemiluminescence Detection System  was carried out to detect the protein bands by a Geliance 600 Imaging System (PerkinElmer Instruments (Shanghai) Co., Ltd., Shanghai, China) with a cooled 12-bit camera. Proteins were finally quantified by densitometry.NgR monoclonal antibodies were purchased from Santa Cruz Biotechnology. All procedures were following the manufacturer guidelines. Cells from brain with brown granular in cytoplasm or nucleus were considered as Nogo or NgR positive cells under light microscopy, whereas 0.01 mmol/L PBS instead of primary antibody was added into negative control. No immunological reactions were observed in the negative control. Non-overlapping areas of the cortex and hippocampus from 4 serial slices in each rat were randomly selected under a 40-fold microscope, and the parts stained brown in each field of view were observed.P < 0.05 was considered statistically significant.Statistical analysis was performed with SPSS 20.0 software. Continuous variables were presented as the means ± standard deviation (SD). Comparisons between groups were done with one-way analysis of variance (one-way ANOVA) with Bonferroni post-hoc tests. P < 0.01). Compared with CWM group, the mNSS of antagonist group and Shenfu group at different time periods were lower, with no significant difference. There were also no significant differences in mNSS between the antagonist group and the Shenfu group.The higher the mNSS, the severer the neurological dysfunction in rats. The results of sham group showed no neurological deficits at 3 hours, 24 hours, 3 days, and 7 days after ROSC, whereas the degree of neurological impairment in model group was much severer than CWM group, antagonist group, and Shenfu group . In addiAs shown in The messenger ribonucleic acid (mRNA) expressions of Nogo and NgR in the hippocampus and cortex at 3 hours, 24 hours, 3 days, and 7 days after ROSC were demonstrated in P < 0.001), whereas Nogo and NgR expression in Shenfu group were obviously lower than that in CWM group  and reduces apoptosis of nerve cells after hypoxia and ischemia in newborn mice [Shenfu injection contains the main active ingredients ginsenosides and aconitine. In clinical practice, Shenfu injection is not only used to treat coronary heart disease  but alsoorn mice . SimilarNumerous studies have shown that Nogo/NgR pathway plays a significant part in plasticity, axonal regeneration, and axonal repair. Wei-Ping Xiao et al.  have claIt has been reported in previous study that Shenfu injection might show anti-inflammatory or anti-oxidative effects on myocardial ischemia–reperfusion injury, sepsis, and acute lung injury in rats –23. NogoTaken together, this study was the first one to report the effect of Shenfu injection on rats with CA and discussed the role of Nogo/NgR signaling pathway in promoting axonal regeneration. Our study provided a theoretical basis for the application of Shenfu injection in brain injury after CA; however, the efficacy of Shenfu injection still needs to be further studied.In conclusion, Shenfu injection effectively protects the brain from CA by alleviating the damage to hippocampal tissues and cerebral cortex tissues and regulating Nogo/NgR signaling pathway for axonal regeneration.


This systematic review and dose–response meta-analysis of published randomized controlled trials (RCTs) was conducted to determine the effectiveness of camelina oil supplementation (COS) on lipid profiles and glycemic indices.Relevant RCTs were selected by searching the ISI Web of Science, PubMed, and Scopus databases up to July 1, 2022. RTCs with an intervention duration of less than 2 weeks, without a placebo group, and those that used COS in combination with another supplement were excluded. Weighted mean differences and 95% confidence intervals were pooled by applying a random-effects model, while validated methods examined sensitivity analyses, heterogeneity, and publication bias.Seven eligible RCTs, including 428 individuals, were selected. The pooled analysis revealed that COS significantly improved total cholesterol in studies lasting more than 8 weeks and utilizing dosages lower than 30 g/d compared to the placebo group. The results of fractional polynomial modeling indicated that there were nonlinear dose–response relations between the dose of COS and absolute mean differences in low-density cholesterol, high-density cholesterol, and total cholesterol, but not triglycerides. It appears that the greatest effect of COS oil occurs at the dosage of 20 g/day.The present meta-analysis indicates that COS may reduce cardiovascular disease risk by improving lipid profile markers. Based on the results of this study, COS at dosages lower than 30 g/d may be a beneficial nonpharmacological strategy for lipid control. Further RCTs with longer COS durations are warranted to expand on these results.The online version contains supplementary material available at 10.1186/s12944-022-01745-4. Camelina sativa), a lesser-known oil, is considered a good source of ALA compared to other edible oils; 36 to 40% of its fatty acid content is ALA, an n-3 fatty acid derived from plants [Prior research indicates that alpha-linolenic acid  can reduce the risk of cardiovascular disease (CVD) by improving blood lipids, blood pressure, and hemostatic factors, among others [m plants . Moreovem plants .Several randomized controlled trials (RCTs) were conducted to evaluate the efficacy of camelina oil on CVD-related markers, including lipid profile and glycemic parameters –12. ThesThe study’s protocol was registered in the International Prospective Register of Systematic Reviews Database CRD42021275655) and conducted according to the 2020 PRISMA guidelines . An expl275655 anTwo researchers screened the titles, abstracts, and full texts of relevant studies. All RCTs in humans  that evaluated the effect of COS on the lipid profile  and glycemic indices (FBS and FI) were selected. The exclusion criteria were as follows: (1) clinical trials with an intervention duration of less than 2 weeks, (2) clinical trials without a placebo group and those that were not randomized, (3) use of COS in combination with another supplement, (4) observational or animal studies, book section, editorial, conference paper, letter, short survey, notes and (4) those with insufficient data for the outcomes of interest.The main features of the included studies are reported in Table The Cochrane Collaboration tool  was applTo assess the effect size of the lipid and glycemic markers, the mean and standard deviation (SD) changes were extracted from the COS and placebo groups. Subgroup analyses relating to the study duration (≤ 8 weeks and > 8 weeks), sex , body mass , dosage (< 30 g/day and ≥ 30 g/day), participants’ baseline body mass index (≤ 25 and > 25) and mean age (≤ 55 and > 55 years) were carried out to identify potential sources of heterogeneity. For the random-effects model, the DerSimonian and Laird method was applied . Within-P < 0.100) and the I2 index. The potential nonlinear effects of COS dose (g/d) and study duration (week) were evaluated by applying fractional polynomial modeling [P < 0.05.×SDfinal . For trimodeling . Sensitimodeling . All staThe general certainty of evidence in randomized clinical trials was ranked utilizing the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group guidelines. According to the relevant evaluation criteria, the quality of evidence was ranked into four classes: high, moderate, low, and very low .n = 3), not presenting sufficient data (n = 2), and using Camelina oil in combination with other supplementations (n = 2) . The mean age of the participants ranged from 44.30 ± 4.38 to 66.6 ± 5.6 years. Trials were conducted in Finland [The seven eligible RCTs included 428 individuals (202 participants in the COS group and 226 in the control group) Table . The mea Finland –12, Iran Finland , Poland  Finland  and Fran Finland  and hype Finland , as well Finland , postmen Finland , and hyp Finland , 10, sun Finland , 11, a d(Table 2). As illustrated in Table 2, all studies were ranked low risk for random sequence generation and allocation concealment domains [Based on the results of the Cochrane risk of bias tools, all clinical trials were categorized as good quality (demonstrating a low risk of bias on ≥3 domains) –12  or FI  compared to the placebo group , HDL , TC  or TG  compared to the control group  (Table 4) in trials with more than 8 weeks in length and dosages of less than 30 g/d. The results of fractional polynomial modeling indicated that there were nonlinear dose–response relations between the dose of COS and absolute mean differences in LDL (P = 0.024), HDL (P = 0.003), and TC (P = 0.042) but not TG (P = 0.515) . According to Fig. P = 0.250), HDL (P = 0.532), TC (P = 0.276), and TG (P = 0.515) .Data analysis from six trials that evaluated the lipid profile showed that COS did not significantly change LDL  was not altered remarkably by removing each of the trials. This showed that the meta-analysis outcomes were stable and not sensitive to any of the seven trials.P = 0.970, Egger’s test), FI , LDL , HDL , TG , or TC  (Table 1). In addition, the funnel plots were symmetrical, which showed no clear publication bias among the included studies .The GRADE guidelines were utilized to assess the quality of evidence for the outcomes. The effects of LDL, HDL, TG, and TC were downgraded to a moderate level. Moreover, FBS and FI were categorized as very low quality Table .Table 5GThe current meta-analytic investigation assessed the effects of COS on lipid and glycemic profiles. Pooled data analysis did not show any effects of COS on lipid profile and glycemic indices compared with placebo intake. However, subgroup analysis showed that COS for more than 8 weeks and at a dose lower than 30 g/d could decrease TC. Furthermore, the results indicated that there were nonlinear dose–response relations between the dose of COS and absolute mean differences in LDL, HDL, and TC, but not TG. The greatest COS effect occurs at a dosage of 20 g/day.Camelina sativa L., also known as false flax, may have a beneficial effect on reducing CVD risk due to its high content of polyunsaturated fatty acids. Because omega-3 fatty acids are abundant in Camelina oil and contain 40–45% ALA, 15% linoleic acid (LA), and a low amount of saturated fatty acids (SFAs) (approximately 6%) [Recently, nutraceutical products have gained attention for reducing the risk of CVD. This is important, as data showed 18.6 million deaths due to CVD in 2019 alone . Camelintely 6%) , it is tFADS1 rs174550 compared to baseline values [The analysis revealed no effect of COS on FBG and FI. In line with these results, a study performed on participants with impaired glucose metabolism found that 12 weeks of COS intervention did not affect glycemic control . Anothere values . Additioe values . Conseque values . Anothere values . There ie values , 27. On e values . The bene values . Furthere values  demonstre values . Thus, iDyslipidemia is another risk factor for CVD that plays an important role in the initiation and progression of the disease. The pooled data analysis did not show a significant change in the lipid profile after COS compared to placebo. Karvonen et al.  conducteA recent meta-analysis revealed that olive oil intake led to a decrease in TG, TC and LDL-C, but its effects were lower than those of other vegetable oils, including omega-3-rich vegetable oils. However, prior research indicates that refined olive oil could not exert a beneficial effect on the lipid profile . This maThe main strength of the current study is that it is the first meta-analysis study that assessed the effects of COS as a nutraceutical component on indicators of CVD risk. A limitation of the present research is the small number of studies included in the analysis. This may have played a role in the lack of significant changes in some of the assessed parameters. It is essential that more studies be conducted in this field. Additionally, studies were performed in Iran and European countries. Further studies in other areas are needed to determine whether outcomes apply to other ethnic cohorts.The present meta-analysis showed that COS improved TC in studies lasting more than 8 weeks and dosages lower than 30 g/d. Decreases of 39 mg/dL in TC values can diminish all-cause and coronary heart disease-related mortalities by 24 and 25%, respectively . Thus, tAdditional file 1: Supplemental Table 1. Description of population, intervention, comparator and outcome (PICO).Additional file 2: Supplementary Table 2. Search strategies including the key terms and the queries for each database.Additional file 3: Supplemental Table 3. Reason for exclusion of retrieved articles.Additional file 4: Supplemental Fig. 1. Forest plot (A) and funnel plot (B) of effect of camelina oil supplementation on fasting blood glucose. Supplemental Fig. 2. Forest plot (A) and funnel plot (B) of effect of camelina oil supplementation on fasting insulin. Supplemental Fig. 3. Forest plot (A) and funnel plot (B) of effect of camelina oil supplementation on low-density cholesterol. Supplemental Fig. 4. Forest plot (A) and funnel plot (B) of effect of camelina oil supplementation on high-density cholesterol. Supplemental Fig. 5. Forest plot (A) and funnel plot (B) of effect of camelina oil supplementation on triglycerides. Supplemental Fig. 6. Forest plot (A) and funnel plot (B) of effect of camelina oil supplementation on total cholesterol.Additional file 5.