Domestic violence (DV) is a leading cause of homelessness for women, yet many DV agencies are just beginning to focus on helping clients stabilize their housing situations. The purpose of this study was to better understand the contexts and service needs of unstably housed and homeless DV survivors, to promote more efficient and successful service matching from DV agencies. We examined whether DV survivors could be grouped by particular features, histories, and contextual factors, and how these group differences impacted what they needed from DV agencies. The sample included 406 homeless and unstably housed DV survivors who had recently sought DV services. Latent class analysis supported the identification of four distinct classes: (1) highest disadvantages service seeker, (2) moderate disadvantages—criminal legal system service seeker, (3) moderate disadvantages service seeker, and (4) lower disadvantages service seeker. Additionally, we were able to profile each class, and test the types of services survivors in each class needed from agencies. Staff from each of the five agencies invited eligible clients to hear more about the research study. Eligibility criteria included (1) being a recent survivor of DV, (2) being homeless or at immediate risk of becoming homeless, (3) having sought services within the prior 3 weeks, and (4) speaking English or Spanish, or agreeing to participate with the assistance of an interpreter.Our research team spoke with 438 eligible survivors who indicated an interest in hearing more about the study. Of those, 406 were willing and eligible to participate in interviews (93%). Survivors are being interviewed five times over the course of 24 months by a highly trained interviewer, with interviews spaced every 6 months. Participants are paid $50 for each interview. All procedures were approved by Michigan State University's institutional review board.3.2The current study utilized the data collected at baseline, which includes demographics, historical data regarding abuse and homelessness, as well as information regarding survivors' contextual and service needs. The final sample of 406 participants consisted of predominantly cisgender female (97%) and heterosexual (86%) survivors of DV. Ages ranged from 19 to 62, with an average of 34.5 years old. Thirty‐five percent of survivors self‐identified as Non‐Hispanic White, and 65% reported an ethnic/racial minority: Hispanic/Latinx (35%), Black (19%), US Indigenous (12%), Asian (4%), and/or Middle Eastern (1%). Of survivors who reported an ethnic‐minority identity, 15% selected more than one race/ethnicity category, indicating multiracial or multiethno‐racial identities. Most survivors identified English as their primary language (80%). Immigrant survivors represented 18% of the sample. Participants' highest level of education varied considerably: 29% had not completed high school, 22% had a high school diploma/GED, 36% had some vocational training or had attended college classes, and 13% had either Associate's, Bachelor's, or Advanced degrees. Most study participants (73%) had a prior history of homelessness and the vast majority of the sample (87%) had stayed with family or friends at least once to avoid homelessness. For more detailed demographic data see Table 3.3Interviews averaged about 75 min and covered a wide variety of topics including demographics, employment status, well‐being, mental health, history of abuse, housing, income, schooling and child behavior, and service needs. The following measure descriptions are only those used for the current analysis. For several measures, we constructed measurement models to measure the constructs and outputted the factor scores as variables in the LCA models. The primary benefit of factor scores over raw sum or mean scores is that factor scores do not include measurement error and therefore provide an unbiased measure of the constructs. Additionally, in generating factor scores, we can relax the assumption that measurement items carry similar weights Brown, .3.43.4.1Participants reported their current housing location . Responses were recategorized to indicate participants who reported being homeless or not. Following the definition provided by the U.S. Department of Housing and Urban Development (HUD) HUD, , homeles3.4.2n = ~122) and a confirmatory factor analysis (CFA) with a validation sample (n = ~284) produced a 5‐factor model with good model fit . The five factors were (1) Housing barriers around finances , (2) Housing barriers around rental history , (3) Legal housing barriers , (4) Negative housing events , and (5) Housing barriers related to dependents . The α coefficient for the scale was 0.78 .Participants responded to questions about common barriers faced when seeking housing using a modified version of the 19‐item index by Gubits et al.   no moves, (1) one to two moves, (2) three to four moves, (3) five to six moves, (4) seven to eight moves, (5) more than 8 moves.3.4.4α for the full measure was 0.95 . Separately, to measure abuser's use of economic restriction and exploitation we used the Revised Scale of Economic Abuse .Experience of IPV through physical abuse, emotional abuse, sexual abuse, and stalking or harassment were measured using a modified version of the Composite Abuse Scale (CAS) .Participants responded to ten questions about their finances using the Adequacy of Financial Support scale, modified from Mowbray et al. . Items a3.4.7In a yes/no format, participants were asked if they held any employment in the past six months. We reverse coded this item for the analysis.3.4.8In a yes/no format, participants were asked if they had a criminal charge that would show up in a background check.3.4.9In a yes/no format, participants were asked if they have a physical disability or disabling condition.3.4.10”) using a 5‐point Likert scale . For analysis, a mean scale score was created. Cronbach's α was 0.90 .The 6‐item Medical Outcomes Study Social Support Survey , two or more positive answers are considered an indication of abuse. Using these thresholds, we created dichotomous variables for indication of abuse (1) and no indication of abuse (0) for both drugs and alcohol.The widely used CAGE–AID (Adapted to Include Drugs) tool was used to assess substance misuse Ewing, . Respons3.53.5.1Participants provided a number of sociodemographic characteristics including race, ethnicity, education, parental status, and immigration status. For the purposes of this analysis, we recoded race to be a dichotomous variable where 1 signifies participants with one or more minority racial identity and 0 signifies single race White participants. For ethnicity, Hispanic/Latinx participants were coded as 1 and non‐Hispanic/Latinx participants as 0. Education was collapsed into two groups of participants who had completed high school or more schooling and those who completed less than a high school degree. For parental status, if a participant was caring for a child under the age of 18, they received a 1. For immigration status, participants with US citizenship were coded as 1.3.5.2Participants reported the number of times they had been homeless in their lifetime. Five or more times homeless was collapsed into one category. We also captured information about whether participants had been homeless before the age of 18 in a yes/no format.3.63.6.1Total Number of Needs variable (α = 0.70). We also conducted an EFA and CFA using these 14 items. The model fit the data well using a 4‐factor structure . The four factors were (1) vocational and transportation needs ; (2) financial and housing needs ; (3) child‐related needs ; and (4) specialized needs . Factor scores for each factor were calculated and used in subsequent analyses.Participants responded to 14 yes/no questions about the services they hoped to receive from the agency. These services were housing, employment, education, financial help, legal assistance, childcare, counseling, transportation, healthcare, issues for children (besides childcare), food, clothing, other material goods/services, and increasing social support. We created a sum score of these items for a 3.73.7.1We used LCA with a combination of categorical and continuous indicators to identify unobserved groups or classes of DV survivors who are similar based on participants' housing and financial status, abuse experience, mental health and disability status, substance misuse, criminal history, and level of social support.n = 6) on the LCA indicator or outcome variables, and these cases were removed using listwise deletion.Only 1.5% of cases had missing data  as the estimator in Mplus version 8.5 . The other 58% of participants were unstably housed: 24% were in homes they owned or were renting, 22% were staying with family and friends without paying rent, 9% were living with family and friends and paying part of the rent, and 3% were in transitional housing or a drug treatment program.Most study participants (73%) had a prior history of homelessness. Of those who had been homeless, the average cumulative amount of time spent homeless was just over 2 years. Almost a third of those with a history of homelessness had been homeless at least once before age 18. Seventeen percent of all participants had been in foster care. The vast majority of the sample (87%) had stayed with family or friends at least once to avoid homelessness.Over half of the participants had been employed (58%) at some point in the 6 months before participating in the study, but only 35% were employed at study entry. Of those who had lost their jobs in the prior 6 months, 70% reported it was due to the abuse they had experienced.M = 12.99, SD = 6.37) and moderate anxiety . With regard to post traumatic stress disorder (PTSD), a score of six on the TSQ signifies the presence of PTSD and the average score was just above this cutoff .Not surprisingly, participants had experienced a range of DV in the prior 6 months. Forms of abuse included emotional (96%), physical (93%), stalking/harassment (90%), economic (89%), and sexual (53%). On average, participants reported moderate depression  lower disadvantages service seeker. Lower disadvantages service seekers had the lowest scores on all class indicators. In contrast, participants assigned to the highest disadvantages service seeker class reported higher scores on all class indicators. Two distinct classes comprised the moderate disadvantage service seekers. Participants in these two classes had similar scores between the lower and highest disadvantage service seeker classes across almost all indicators, with three exceptions. What distinguished these two moderate classes were the scores on criminal legal system (CLS) variables . As a result, we labeled Class (2) moderate disadvantages CLS service seeker, and Class (3) moderate disadvantages service seeker. The moderate CLS class had the highest scores across all four classes on the three criminal‐legal focused variables. In addition, participants assigned to the moderate CLS class had slightly higher item response probability of having a physical disability than the highest disadvantages class.We labeled Class (1) moderate disadvantages service seeker class comprised the majority of participants . The lower disadvantages service seeker class comprised 23.3% of participants (n = 94). The highest disadvantages service seeker class compromised 22.8% of participants (n = 91). Finally, the smallest class was the moderate disadvantages CLS service seeker class, which comprised 18.7% of the sample (n = 73). Three indicators—housing barriers related to children, current PTSD symptomology, and alcohol abuse—were not adequate differentiators of class membership.As illustrated in Figure 4.3highest disadvantages service seeker class had greater history of homelessness , followed by the moderate CLS class , then the moderate disadvantages service seeker class , and finally, the lower disadvantages services seeker class . The differences among these groups were significant when comparing the highest disadvantages class to the moderate disadvantages class  and lower disadvantages class . There was no significant difference between the moderate CLS class and the highest disadvantage class  in history of homelessness. Individuals in both the moderate disadvantages class and the moderate CLS class had a significantly greater history of homelessness compared with the lower disadvantages class . Although it was not statistically significant, results suggest that non‐US citizens were less likely to be assigned to the moderate CLS disadvantage class when compared to all other classes.Our second research aim focused on understanding whether class compositions differed demographically or based on survivors' homelessness histories. Multinomial logistic regression results are presented in Table 4.4ower disadvantages service seeker class had a significantly fewer number of needs (M = 7.81) than all other classes. The highest disadvantages service seeker class wanted a significantly higher number of services than all other classes (M = 10.82), except the moderate disadvantage class (M =  9.88), which was not statistically significant. The moderate CLS disadvantage class (M  = 8.95) had significantly fewer needs than the moderate disadvantage class.Our final aim tested whether the four distinct classes of survivors could predict the number and types of resources and services that survivors seek out from DV agencies. These results are presented in Table highest disadvantages service seeker class had significantly higher scores in all four DV service provision categories compared with the lower disadvantages service seekers. Both moderate disadvantages service seeker classes had significantly higher scores than the lower disadvantages service seeker class in all domains. Across the two moderate disadvantages classes, the moderate CLS class needed significantly more services related to specialized needs  compared with the moderate disadvantages class.Second, we tested whether the types of resources and services could be predicted by the latent classes. Using the four factor scores: (1) vocational and transportation needs; (2) financial and housing needs; (3) child‐related needs; and (4) specialized service needs, we tested the equality of means across classes and were able to significantly predict the type of resources and services survivors in each class needed from the agency. Survivors in the 5The results of this study complement several others in emphasizing the importance of matching interventions and services to the unique needs of individuals seeking help , highlighting that even DV survivors with fewer disadvantages still require significant assistance to obtain safe and stable housing. Furthermore, this finding points to the importance of strong collaborations between DV agencies and other community resources to best support the needs of survivors and their families, suggesting that it is critical for advocates to be knowledgeable of other supportive services and resources available in their communities. This corroborates other findings that suggest that connecting survivors to the multiple services they need may be essential for survivors' housing stability, particularly those with legal barriers , they may impact survivors' ability to obtain and maintain safe and stable housing.The types of disadvantages measured in this study support and advance what we know about common housing barriers facing DV survivors (Adams et al., moderate CLS disadvantages class members were more likely to have legal‐related disadvantages, including having a criminal history, drug use, and other legal‐ related housing barriers. Housing scholars have consistently found evidence that possessing a criminal history exacerbates the process of obtaining safe and stable housing and employment (Barile et al., The moderate CLS class were also significantly more likely to report needing specialized services from DV agencies. In this study, specialized services were operationalized as services other than the “typical” advocacy services provided at DV agencies. This included counseling, legal assistance, health care, and social support. This finding has important implications for the allocation of DV service and advocacy funding to support navigation of legal and physical and mental health systems. In addition, providing space and resources to bolster social support is something that DV service providers try to do when resources allow, and these findings reinforce recommendations to promote ongoing counseling or social support groups, for example (Guyon‐Harris et al., In addition to requiring a high number of services from agencies, participants assigned to the moderate CLS disadvantages, the highest disadvantages, and the moderate disadvantages classes were more likely to report the presence of a physical disability compared with the lower disadvantages class. Barile and colleague's LCA examining pathways to homelessness similarly found that individuals with physical disabilities reported higher needs and differential barriers to accessing services, particularly around transportation (Barile et al., Another key difference between the classes was the presence of a physical disability. Individuals in the highest disadvantage groups most likely to report this behavior. This finding corroborates other studies evidencing a link between DV victimization and substance abuse. For example, a national survey found that DV victims were significantly more likely to actively use cannabis, cocaine, and opioid use, or experience problems related to these substances than those who had not experienced DV (Smith et al., Class membership also differed by level of drug misuse and abuse, with those in the lower disadvantages also reported having higher levels of social support, and vice versa with the highest disadvantage class (Liang et al., In line with prior research on the importance of social connection, participants in the class noting 5.1before receiving services. We are aware that service need is not a time invariant variable and are interested in exploring how service needs change over time for these classes of DV survivors. However, the data for subsequent timepoints are still being collected. Moving forward, we hope to build on this analysis to look at whether the classes found in this study change over time and the extent to which different survivors' needs are met.Findings need to be considered in light of study limitations. As with any exploratory analysis, there is always a possibility that relevant themes may have been misinterpreted, overlooked, or over emphasized. First, we may have unintentionally excluded variables that should have been considered for the LCA model. Given the litany of factors that could influence DV service needs, we relied on theory and a statistical variable selection process to determine which variables to include in the model. As such, several of the variables included in this analysis are factor scores. Although this allowed us to include a wider variety of topics in the LCA model, we simultaneously lost information about individual items. Nonetheless, we remain confident in the classes observed and the rigorous methods applied to our variable selection process. Additionally, these data are cross sectional baseline data and therefore represent participants who have not yet received services from the agency. Thus, this study is limited by only relying on reports of what participants needed The generalizability of findings may be impacted by a number of factors. All of the study participants were not only DV survivors but also unstably housed or homeless at the start of the study. Most identified as heterosexual and cisgender. While the sample was heterogeneous in terms of race and ethnicity, it was primarily Latinx, African American or White, and more studies are needed with a higher number of Native American and Asian American participants. Finally, this study was conducted in the Pacific Northwest, and may reflect some contexts and service needs specific to that geographic area.5.2There are several important implications to glean from this study for both policy and practice. This study joins a growing evidence base demonstrating the utility of identifying distinct groups of service seekers who may subsequently require different services (e.g., Barile et al., Uncovering evidence for multiple types of service seekers also has important implications for the types and level of services DV agencies provide. For example, advocates may be able to assess whether a client needs a “light touch” of service provision as opposed to a high‐needs client that requires a heavier dose of service provision, and adapt their caseloads accordingly. Furthermore, having a concrete understanding of the various experiences, contextual realities, and potential housing barriers of unstably housed survivors could significantly help advocates prioritize their efforts accordingly. This holistic understanding may provide advocates with the necessary insight to adequately tailor services to effectively respond to survivors' individual needs.Nevertheless, DV advocates working on the front lines might find evidence of higher, moderate, and lower need classes of survivors unsurprising, as advocates see a diversity of survivors and their stories each day. Advocates may already be able to determine survivor needs at intake but are limited by the resources available to adequately address survivor needs. As such, these findings might be best disseminated to policy makers and institutions that fund such DV services to account for extra training, staff, resources, and funding time required to provide adequate support around housing for multiply disadvantaged DV survivors. Additionally, these findings speak to the importance of community mobilizing and collaborations across agencies on the front lines. With the ever‐shifting landscape of housing equity in the United States, we urgently need collaborative synergy across communities in efforts to safely house disadvantaged community members.5.3This study aimed to gain a broader understanding of the range of contextual factors influencing the service needs of homeless and unstably housed DV survivors. Overall, findings from this analysis elucidate the diversity in housing needs and barriers faced by DV survivors as well as highlight critical aspects of providing adequate and survivor‐centered services when working with unstably housed and homeless DV survivors. The results further reveal important implications for the ways in which DV agencies can promote efficient service matching. Finally, findings add to the burgeoning literature around attending to the multitude of factors that influence homelessness prevention for DV survivors.The authors declare that there are no conflict of interests.


LEP (2548G>A) and LEPR (109 Lys>Arg and 223Gln>Arg) genes polymorphisms to the risk of breast cancer development. The study involved 209 women aged 59.6 ± 11 years diagnosed with breast cancer and 202 healthy women aged 57.8 ± 8.2 years, who were blood donors. Polymorphism were evaluated by PCR–RFLP reaction followed by the verification of part of the samples by sequencing. The results of the study confirmed obesity as a significant breast cancer development risk factor in Polish women. However, no significant association between the studied polymorphisms and breast cancer risk or severity of the neoplastic disease was found. Interestingly, it was shown that wild type 223Gln>Gln leptin receptor (LEPR) was statistically more common in women with human epidermal growth factor receptor 2 negative (HER2−) than human epidermal groth factor receptor 2 positive (HER2+) breast cancer and wild type form of 2548G>A LEP was more common in women with progesterone receptor positive (PR+) than progesterone receptor negative (PR−) breast cancer. Studied polymorphisms of the LEP and LEPR genes do not increase breast cancer risk in the population of Polish women. However, they can affect PR an HER receptors expression and thus the severity of the disease. Noteworthy, this interesting correlation is being reported for the first time and might constitute an essential contribution to the identification of molecular mechanisms of carcinogenesis.On a global scale, breast cancer is the most common type of cancer in women, and it is still a growing problem. Therefore, new prognostic or diagnostic markers are required that would facilitate the assessment of patients or provide more efficient therapy, respectively. In these studies, we analyzed the contribution of  LEP gene [LEPR gene [The increasing incidence of breast cancer in both women and men is significantly correlated with obesity . AdiposeLEP gene . BiologiEPR gene . The mosEPR gene . Leptin EPR gene . It is aEPR gene , 7.ERBB2) [Interestingly, a positive correlation was found between the leptin level and the incidence of breast cancer, which probably results from the proinflammatory, pro-angiogenic, and pro-carcinogenic activity of this protein. Both in vitro and in vivo studies have shown that leptin stimulates tumor growth and cell migration, thereby increasing the risk of distant metastasis , 9. LeptERBB2) . As a reERBB2) —to terazERBB2) . Leptin ERBB2) . An incrLEP and LEPR genes, which can be affected by polymorphisms [The increase in serum leptin concentration may be due to excess body fat or a decreased leptin receptor functioning/sensitivity. The production of leptin may also depend on the expression of the orphisms .LEP gene  and polymorphisms of the LEPR gene in position 326 (326A>G) which results in the conversion of lysine to arginine at position 109 of the leptin receptor  and position 668 (668A>G) resulting in the conversion of glutamine to arginine at position 223 , respectively [The most significant effect on the function of these proteins seems to be correlated with the polymorphisms in the position 2548G>A of the ectively .LEP polymorphic allele A (2548G>A) varies in different populations. This polymorphism is found in the gene promoter region, thus can regulate the binding of transcription factors and, consequently, contribute to the change in LEP gene expression and serum leptin levels [LEPR gene encoding the leptin receptor extracellular domain. Replacing amino acids in this part of the protein may interfere with the binding of leptin, which can lead to the lack of a biological effect and increased leptin concentration. The frequency of both polymorphic forms varies between populations [LEP and LEPR genes polymorphisms on the development of breast cancer in women from the Greater Poland region. Unfortunately, since these were just retrospective studies based on the assessment of already collected blood samples (with no plasma fraction), we could not evaluate the correlation between the leptin level and the LEP/LEPR genotypes.Noteworthy, the frequency of the n levels . The pren levels . The Lysulations –21. In sBased on the population data on the incidence of breast cancer among women from the Greater Poland region the sample size and power was calculated with calculator.net (α = 0.95).The control group consisted of 202 women in menopausal age (age 57.8 ± 8.2) who were blood donors at The Regional Center for Blood Donation and Blood Treatment in Poznań, Poland. Women were diagnosed as cancer-free.The health status of blood donors was assessed using: medical history including the age of the donor, past diseases, lifestyle, medicines and treatments; physical examination including body height and weight, body temperature measurement, blood pressure, and heart rate, and assessment of lymph nodes; laboratory blood tests including blood counts, total protein level, presence of HBs antigen, anti-HIV antibodies, anti-HCV antibodies, HCV RNA, HBV DNA, and HIV RNA.The study group consisted of 209 women aged 59.6 ± 11 hospitalized in the Department of Oncology, Poznan University of Medical Sciences. They were diagnosed with various types of breast cancer at various stages. The most common type of tumor (50.5%) was invasive ductal carcinoma (IDC).DNA was isolated from blood remaining after standard laboratory test. All women agreed to use their blood for research. The study obtained the permission of the Bioethics Committee of the Poznan University of Medical University, No. 568/18.LEP and LEPR genes fragments was performed using specific primers at the optimal annealing temperature and reaction conditions that were determined experimentally (Table LEP gene polymorphism with a length 242 bp were digested with a specific restriction enzyme (CfoI) . Amplification of ly Table . The comly Table . Then 1 s Tables . All priTo assess the specificity of restriction enzymes digestion, 10% of the samples were subjected to sequencing using the BigDye v3.1 kit  and separation by ethanol extraction using the ABI Prism 3130XL  in a 36 cm capillary in a POP7 polymer.t-test. The occurrence of genotypes in the study group with different tumor stage and grade was assessed using the Hardy–Weinberg equilibrium (χ2 test). Odds ratio (OR) and 95% confidence intervals (CIs) was also calculated. A p-value of < 0.05 was considered statistically significant (Statistica 6.0).We used Fisher’s exact test to examine the distinction in the genotypic and allelic frequencies between the cases and control. The continuous variables between the studied groups were com-pared with the Student’s The observed genotype frequency distribution did not show significant deviation from Hardy Weinberg equilibrium Table . The anaLEP (2548G>A) and the LEPR gene (109Lys>Arg) in the group of women with breast cancer and healthy women. Genotype distributions and allele frequencies of the leptin gene 2548G>A polymorphism in the group of women with breast cancer were 34% for WW, 47% for WV, 19% for VV, and in the group of healthy women it was 33% 43.5%, and 23.5% respectively.Analysis of the results did not show a statistically significant difference between the frequency of polymorphisms of the LEPR polymorphism 109 Lys>Arg occur in the group of women with breast cancer with frequency 47% for WW, 44% for WV, 9%for VV, and the group of control subjects 50.5%, 37%, and 12.5%. These differences are also not statistically significant. However, analysis of polymorphism 223Gln>Arg showed that the polymorphic allele occurred statistically more often in the control group than in the study group (p = 0.05)  Table .Table 6ILEP and LEPR genes polymorphisms on the body mass of women with breast cancer and control subjects was assessed. It was shown that the polymorphic allele 109Arg>Arg (LEPR) correlated with the increased body weight of healthy women . However, there was no association between LEP (2548G>A) and LEPR (223Gln>Arg) genes polymorphisms and the body mass index weight in both groups (data not shown).Leptin is produced by adipose tissue which amount directly affects plasma concentration of the protein. The influence of LEPR) were shown to significantly less frequently express HER2 (HER2+ 24.5% vs. HER2− 46.5%). Moreover, patients who were wild type homozygotes 2548 G>G (LEP) were statistically more likely to express PR receptors than women who were heterozygous and polymorphic homozygous. However, no association between the polymorphism and ER or PR expression was observed. There was also no relationship between LEPR 109Lys>Arg polymorphisms and the expression of ER, PR, and HER2 receptors . Additionally, women with different body weight and BMI were enrolled in the study. Consequently, we definitely lack a broader picture of the potential correlation between genetic and environmental factor which implies further detailed studies in the context of breast cancer risk.It is possible that lower plasma concentration of the hormone, resulting from the lower amount of adipose tissue, reduces the risk of breast cancer development. However, some women show high levels of leptin independent of the amount of adipose tissue, which may result from orphisms . Women worphisms . Howeverorphisms . TherefoImportantly, no differences were found in the incidence of 2548G>A polymorphism in healthy women with average and high body mass index (BMI>25) , and the results are comparable to the Mexican and Romanian populations , 29.LEPR gene among healthy women with normal and high (BMI > 25) body weight. The influence of 223Gln>Arg polymorphism on the body mass index of women with breast cancer also has not been demonstrated. However, it was shown that 109Arg>Arg polymorphisms occur significantly more often in individuals with breast cancer and normal weight than in overweight and obese women. Therefore, it is possible, that the presence of arginine in the leptin receptor results in a change of the structure of the leptin receptor and thus the binding of leptin [Furthermore, there were no statistically significant differences in the incidence of individual polymorphisms 223Gln>Arg and 109Lys>Arg of the f leptin . Eventuaf leptin , 32. Wilf leptin  as well f leptin , 32.LEP and LEPR gene polymorphisms and expression of ER, PR, and HER2 receptors in women with breast cancer was evaluated. It was shown, that wild type 223Gln>Gln LEPR is statistically more common in women with HER2 negative breast cancer (W vs. V p = 0.019) and wild type form of 2548G>A LEP is more common in women with PR positive breast cancer . . Table  None of ferences . These dLEPR gene polymorphism correlates with obesity in healthy women but does not increase the risk and stage of breast cancer. Moreover, the occurrence of LEPR gene polymorphisms (LEPR Gln>Arg) correlated with HER2 receptor expression in breast cancer cells of women from Greater Poland. However, the conducted analyzes did not show the relationship between the LEP and LEPR gene polymorphisms and the risk of breast cancer development and its stage. To the best of our knowledge, this is the first study to evaluate the correlation between LEP/LEPR polymorphisms status and breast cancer in the population of women from Greater Poland.Statistical analysis confirmed that obesity is a significant risk factor for breast cancer in Polish menopausal women from The Grater Poland region. This relationship positively correlates with data from other populations. 109Lys>Arg


FUNCT). In order to reach the aims, burnt and unburnt soils were collected under different vegetation cover types  within the Vesuvius National Park. The soils were analyzed for the main abiotic  and biotic  characteristics. On the basis of the investigated soil characteristics, several soil functions , and the soil quality indices were calculated. The results showed that the impact of fire on soil quality and functionality was mediated by the vegetation cover type. In fact, fire occurrence led to a decrease in water and C/N ratio under herbs, a decrease in C concentration under holm oak and a decrease in Cu and Pb concentrations under pine. Although the soil characteristics showed significant changes according to vegetation cover types and fire occurrence, both the additive and weighted function soil quality indices did not significantly vary according to both fire occurrence and the vegetation cover type. Among the different vegetation cover types, pine was the most impacted one.Mediterranean regions are the most impacted by fire in Europe. The effects of fire on soil greatly vary according to several factors such as vegetation cover type, but they are scarcely studied. Therefore, this research aimed at evaluating the combined impacts of fire and vegetation on single soil characteristics and on the overall soil quality and functionality through two soil quality indices, simple additive (SQI) and a weighted function (SQI Wildfires were particularly severe in 2017, a year characterized by an intense heatwave coupled with a severe drought. Fires were particularly severe in southern Europe, causing extensive economic and ecological damages  and human casualties [Over the last decades, wildfires have burnt an average of about 4500 kmThe dynamics of fire regimes in Southern Europe are driven by both natural and human factors, such as seasonal aridity, wind intensity, land cover heterogeneity, rural area abandonment, forest management practices and tourism . In MediSeveral studies have highlighted the impacts of fire on soil characteristics. The immediate and direct effects of fire are usually short-term and are restricted to the first few centimeters of the topsoil . The indAlthough the effects of fire on a single soil factor have been widely studied, those on the overall soil quality are scarce, particularly in the Mediterranean area. Soil quality represents “the capacity of a soil to function, within ecosystem and land use boundaries, to sustain productivity, maintain environmental quality, and promote plant and animal health” ,15. SoilFUNCT) to evaluate the overall soil quality and functionality; (iii) highlight which among the studied vegetation cover types mitigated or enhanced the fire impact. Starting from a previous study [FUNCT) could be more informative than the SQI. Moreover, the SQIFUNCT could also highlight different fire impacts on the quality of soils under the studied vegetation cover types.With this framework, the research objectives were to: (i) evaluate the impact of fire and vegetation and their interaction on single soil; (ii) use a simple additive method (SQI) and a weighted additive method  within the Vesuvius National Park. The soils were analyzed for the main abiotic characteristics and several soil functions.Quercus ilex L.), pines , herbs and shrubs  [Robinia pseudoacacia L.), an invasive species, were randomly associated with the dominant species [The study area is located at 12 km SE far from Naples, inside the Vesuvius National Park . The Vesuvius National Park, established in 1995, covers an area of 8482 ha and contains the original volcano, Mt. Somma  and Mt. Vesuvius , originated from the 79 A.D. eruption. In June 2017, the Vesuvius National Park was affected by a severe fire [sta sp.) . AdditioThe Vesuvius mountain is characterized by Mediterranean climatic conditions with dry summers and rainy autumns and winters .2 each) were equally divided into four different vegetation cover types: herbs and shrubs (H), black locust (BL), pines (P) and holm oak (HO). Within each vegetation cover type, three sites (affected by the same fire intensity) were collected in burnt (B) and three in unburnt (UB) areas. At each site, eight soil cores , after removing the ash and the thin layer of litter at the burnt sites and the deeper layer of litter at the unburnt sites, were collected and mixed together in order to obtain a homogeneous sample. The soil samples were put into sterile flasks and transported on ice to the laboratory [The soils of the Vesuvius National Park show a silty-clay texture  and are boratory ,21.org [v:v); total carbon and nitrogen concentrations were determined by Elemental analyzer on dried and pulverized samples.In the laboratory, the soil samples were sieved (<2 mm) and analyzed for water and organic matter contents as well as for the total C and N contents. Soil water content (WC) was determined gravimetrically by drying fresh soil at 105 °C until reaching constant weight ; organic matter content (OM) was calculated multiplying by 1.724 the Corg  that wasv:v) in a microwave oven (Milestone-Digestion/Drying Module mls 1200). The element concentrations in the digests were measured by Inductively Coupled Plasma Mass Spectrometry . The accuracy of Ca, Cu, K and Pb measurements was checked by concurrent analysis of standard reference material . The overall element recovery ranged from 80–120% for all the investigated soil samples.Total Ca, Cu, K and Pb concentrations were measured in oven-dried (75 °C) and pulverized soil samples, previously digested by hydrofluoric acid (50%) and nitric acid (65%) at a ratio of 1:2  and incubation in sealed vials (30 mL) for 4 h at 25 °C in the darkness was measured through an infrared gas analyzer . The fungal biomass (FB) was evaluated, after staining with aniline blue, through the membrane filter technique [The microbial biomass (MB) was evaluated by SIR, the substrate-induced respiration method . CO2 evoechnique  determin2 evolution from the samples at 55% of water holding capacity after incubation in tight containers for 10 days at 25 °C by NaOH absorption followed by two-phase titration with HCl [Basal respiration (Resp) was estimated as COwith HCl .2 and 4 mL of 0.1 M tris-hydroxymethilaminomethane-sodium hydroxide (THAM-NaOH) pH 12 was added. In the control, the substrate was added before the addition of CaCl2 and NaOH. The absorbance of the supernatant was measured at 420 nm and the results were expressed as mmol of PNP produced for 1 g of dry soil in 1 min [β-glucosidase activity (β-glu) was determined by adding 4 mL of modified universal buffer (MUB) pH 6 and 1 mL of 0.025 M p-nitrophenyl β-D-glucopyranoside (PNP) to 1 g of soil. The mixture was then incubated at 37 °C for 1 h, after which the enzymatic reaction was stopped by cooling on ice for 15 min. Then, 1 mL of 0.5 M CaClin 1 min ,28. The Microbial and fungal biomasses, basal respiration and ♌-glucosidase activity were performed on soil samples stored at 4 °C within three days of the soil sampling. All the above-described procedural steps were performed on three subsamples from each previously mixed sample.All the SQI methods involved a set of 96 soil samples and of 13 soil characteristics considered as indicators of soil quality. The 13 indicators used for developing SQIs were soil water content, organic matter, total C and N contents, C/N ratio, total Ca, Cu, K and Pb concentrations, microbial and fungal biomasses, microbial respiration and ♌-glucosidase activity. Under the proposed framework, an ideal soil would have an SQI value of 1 for the highest quality soil and 0 for severely degraded soil. more is better or less is better criteria, following this formula:An integrated soil quality index was calculated taking into account the physico-chemical and biological characteristics that were ranked from 0 to 1, respectively reflecting low and high quality, according to Leitgib et al. . The scomore is better: x’ = (x − xmin)/(xmax − xmin)For less is better: x’ = 1 − (x − xmin)/(xmax − xmin)For more is better criterion was applied to water and organic matter contents, C and N concentrations, total nutrient concentrations (Ca and K), microbial and fungal biomasses, microbial respiration and ♌-glucosidase activity, for their roles in soil fertility, water partitioning and nutrient availability. On the contrary, the less is better criterion was applied to total trace metal (Cu and Pb) concentrations because their high concentration is potentially toxic for soil organisms, according to Marzaioli et al. [more is better criterion for the values between 9 and 11 and the less is better criterion for the values <9 and >11.The i et al. . Cu and i et al. ,31. Regan is the number of the investigated parameters.For each site, the SQI was calculated, summing the parameter scores and dividing for the number of parameters, as reported by Andrews et al. :SQI=∑i=1In this approach, the aforementioned 13 soil characteristics, scored 0 to 1 as above described, were grouped into the following five categories  that expFUNCT) by calculating their arithmetic average, which assumes equal importance of each function [FUNCT was calculated as follows:The SQIs calculated for each function were integrated into a single index (SQIfunction . The SQIn = 96) and the Wilcoxon test  were performed to evaluate the differences in each investigated soil characteristics and SQIs between burnt (B) and unburnt (UB) sites, and the Kruskal–Wallis Rank-Sum test  with Bonferonni adjustment was performed to compare the differences in each investigated soil characteristic and SQI among the different vegetation cover types.As the investigated soil characteristics and the SQI did not match the basic assumptions of normality and homoscedasticity required for parametric statistics, the Wilk–Shapiro test  linear mixed effect models (LME) were used. For each soil characteristic and index, the influence of vegetation and fire, considered as fixed effects, and of sampling time, considered as a random effect, was calculated using restricted maximum likelihood (REML) for better estimation of the variance components for the present dataset. The significant impacts and interactions among vegetation, fire and sampling time on soil characteristics and indices were calculated with the comparison of models, using the likelihood ratio test with the Anova function (for a = 0.05).In order to exclude the influence of the sampling time and to highlight the direct influences of vegetation and fire and their interactions on soil characteristics  and on soil quality indices and functions  was used to perform the statistical analyses and the linear mixed effect models (lme4 package). The graphs were created by SigmaPlot12 software .−1 d.w. and from 0.4 to 1.2 mg g−1 d.w. with values significantly higher in soil under holm oak  water content and C/N ratios were significantly higher in unburnt soils under herbs, (2) C concentrations were significantly higher in unburnt soils under holm oak and (3) total Cu and Pb concentrations were significantly higher in unburnt soils under pine .The linear mixed-effect model showed that sampling time (random effects) had no significant influence on any soil characteristics whereas vegetation cover type and fire occurrence and, to a lesser extent, their interactions (fixed effects) influenced soil indicators . In partThe Soil Quality Index (SQI), calculated taking into account all the soil characteristics, ranged from 0.4 to 0.5 in unburnt soils and from 0.4 to 0.6 in burnt sites and did not show significant differences among the vegetation cover types . MoreoveWR) ranged from 0.3 to 0.6 with values significantly higher under pine and holm oak (NS) ranged from 0.4 to 0.7 and was significantly higher under pine (C) ranged from 0.6 to 0.8 (MA) was approximately 0.4 (MH) ranged from 0.3 to 0.8, with values significantly higher under pine and black locust (FUNCT) ranged from 0.4 to 0.6 with lower values under herbs  were mainly dependent on vegetation cover type, fire and their interactions (fixed effects) and they were not dependent on sampling time (random effects) . In parter types ; SQIC an by fire  whereas currence .WR, SQINS and SQIMH. These results highlight the positive effects of tree species on the soil functionality of the Mediterranean environment, as it has been shown that dense plant cover limits nutrient loss, erosion and fast organic matter degradation [In the investigated area, vegetation cover type had the largest and most consistent influence on soil characteristics and functions. Within a vegetation cover type, there were few significant differences between burnt and unburnt soils. Then, in the unburnt study area, soil quality and functionality mainly depended on vegetation cover types. In particular, the presence of trees positively affected water and organic matter contents, C and N concentrations, microbial and fungal biomasses, β-glu activity were significantly higher under holm oak, pine and, to a lesser extent, under black locust than under herbs. The highest soil organic matter content, responsible for high water retention  under trradation .WR) under pine and holm oak as well, probably because of the destruction of the litter layer strongly involved in soil humidity retention [NS) due to the widespread leaching or erosion phenomena occurring in the early post-fire succession stage [C under pine and holm oak. By contrast, in burnt soils covered by pine and black locust, the microorganism habitat function decreased, especially for fungal biomass as compared to microbial biomass. These findings confirm the negative impact of fire on soil microorganisms. Burning of the organic layer and heat transfer to the soil during fires leads to microbial mortality immediately after the fire [In the investigated area, fire impact was mediated by the dominant cover type, similar results were reported by Wragg et al.  for burnetention , which ion stage . For simthe fire . Howeverthe fire .FUNCT) soil quality indices showed a medium soil quality and did not significantly vary according to the vegetation cover type. The results obtained by the SQI agree with Memoli et al. [FUNCT) also did not vary among vegetation cover type and fire occurrence, but their values were slightly higher than SQI in all the treatments. This result indicated that the soil quality can be predicted from appropriate weightage on soil functions (SQIFUNCT) in accordance with several studies [Although the soil characteristics and functions showed significant changes according to vegetation cover type and fire occurrence, both the additive (SQI) and weighted function  soil quality indices did not significantly vary according to both fire occurrence and the vegetation cover type. This could suggest that the overall soil quality was slightly impacted by fire, as soil indicators and functions showed opposite responses which masked the overall effect on the whole soil quality.Although the soil indicators showed significant changes according to vegetation cover types and fire occurrence, both the additive (SQI) and weighted function (SQISoils under pine were the most fire-impacted, as variations in water retention, nutrient supply, contamination and microorganism habitat were of greater extent as compared to those under the other vegetation cover types; by contrast, soils under herbs seemed to be less impacted by fire, as no differences in soil functions were observed between burnt and unburnt soils.The simultaneous investigation of burnt and unburnt soils under the investigated vegetation cover types could be informative for fire management in order to prevent and mitigate fire impacts on soil and to restore burnt areas in the Mediterranean environment.


Some jurisdictions are considering substantial reductions. Methods: This review assesses the scientific evidence used in these recommendations and presents a new systematic review of human studies from 2006–20, identifying 33 studies. Results: The three major reports all give most weight to two sets of studies: of physiological effects in human volunteers, and of effects in the nasal passages of rats and mice. The human studies were done in one laboratory over 20 years ago and give inconsistent results. The breathing style and nasal anatomy of rats and mice would make them more sensitive than humans to inhaled agents. Each expert group applied different uncertainly factors. From these reports and the further literature review, no clear evidence of detrimental health effects from chronic occupational exposures specific to H2S was found. Detailed studies of individuals in communities with natural sources in New Zealand have shown no detrimental effects. Studies in Iceland and Italy show some associations; these and various other small studies need verification. Conclusions: The scientific justification for lowering occupational exposure limits is very limited. There is no clear evidence, based on currently available studies, that lower limits will protect the health of workers further than will the current exposure limits used in most countries. Further review and assessment of relevant evidence is justified before exposure limits are set.Objectives: Occupational exposure limits for hydrogen sulphide (H It is present in volcanic gases and other geothermal emissions, and produced by decomposition in sewers and stagnant water. Occupational exposure occurs in the ‘sour gas’ segment of the natural gas industry, processing gas with high sulphur concentrations. Hydrogen sulphide can be generated in petroleum refineries, natural gas plants, petrochemical plants, coke oven plants, kraft paper mills, viscose rayon manufacture, sulphur production, iron smelters, food processing plants, tanneries, landfills, manure treatment plants and waste water treatment plants [Hydrogen sulphide (molecular formula H3 (0.5 ppb), although Rotorua residents can tolerate 100 times this threshold routinely [Hydrogen sulphide has a simple physiological effect, that of its unpleasant smell. Some communities live with this, the largest being Rotorua, a city of about 60,000 population situated on a geothermal field in New Zealand. A report shows the threshold limit of detection as 0.7 μg/m2S has been used in suicide [At the other extreme, hydrogen sulphide can cause death and severe illness in high concentrations , well ab suicide .2S have been produced by three major groups: the ACGIH , SCOEL  in Europe, DECOS  in The Netherlands. These limits differ. Some countries, such as New Zealand, have recently recommended reducing their current limits to those recommended by ACGIH [Occupational exposure limits for Hby ACGIH .2S and the scientific evidence used to develop these, and addresses the key question of whether workers’ health will be better protected by the adoption of lower limits. The present report considers the recommendations of major groups concerning occupational exposure to H2S exposures and health outcomes, 7 of occupational and 24 of community exposures. These were considered in detail and are reviewed here. This literature search was updated in February 2021 and 2 further studies added. The three expert reports and the studies cited in them were assessed. A further search was made in PubMed and Embase for publications using the terms ‘hydrogen sulphide/sulfide’, and ‘occupation’ or ‘community’ or ‘population’ or ‘ambient’, and ‘human’, from 1 Jan 2006 to 31 Dec 2018, published in English or with an abstract in English. Of 404 citations screened, 254 dealt with other exposures such as carbon disulphide or issues other than health, 36 only with high dose acute exposures, 11 with physiological mechanisms, 49 only with exposures, not outcomes, and 23 were review articles. This left 31 new original studies of H3), and short-term limits  of 10 to 20 ppm (14 to 30 mg/m3). Two jurisdictions have lower 8-hr limits: The Netherlands, 1.7 ppm, and Spain, 1 ppm. Spain has a 5 ppm short-term limit, as has Austria, as their short and long-term limits are the same. Occupational exposure limits for hydrogen sulphide vary considerably . Of 30 jFrom 2006 to 2010, three expert groups reviewed the relevant scientific evidence and produced differing recommendations . The ACGTherefore, the evidence relevant to occupational guidelines is evidence of effects above the minimum recommended levels of 1 ppm long-term and 5 ppm short-term, but below the levels of 10 ppm and 20 ppm, respectively, used in some jurisdictions at present.2S at levels within the existing guidelines. Such evidence would be directly relevant to the potential benefits of reducing exposure limits. Indeed, only such evidence would reliably show if there would be health benefits from reducing limits. The clearest evidence to justify lowering exposure limits would be good evidence of detrimental health effects in workers who have been exposed to H2S in their occupations would be particularly valuable. However, in such studies exposures to H2S are usually accompanied by other potentially noxious exposures, and also measurement of H2S concentrations is usually lacking.Studies, especially long-term studies, of workers exposed to H2S and to CS2, and only at over 20 ppm. In a later study of 123 workers [2 gas, and that no effects of H2S alone at levels below 20 ppm, 28 mg/m3 have been documented (page 7). Studies of eye irritation and occupational exposures are noted in the SCOEL report . In the 2S, finding no respiratory effects.The SCOEL report also notes studies reporting lung function impairment, but with no estimates of exposure levels. Jappinen  studied 2S and organic sulphides, there was a significant excess of cardiovascular deaths  150, 95% confidence interval (CI) 105–206), due to an excess of coronary deaths which was not quite significant . However, the increased risk was lower in those with longer exposure (5+ years compared to <5 years). Workers in the study had higher smoking rates than the general population, and there was no information on other risk factors. There was no increase in total deaths . Exposures to H2S and to organic sulphides could not be separated. A study of these mills many years later showed concentrations of up to 20 ppm H2S, up to 15 ppm methyl mercaptan, and dimethyl disulphide up to 1.5 ppm [Jappinen  assessed2S along with other exposures have been addressed in studies of pulp and paper and viscose rayon manufacturing workers, and have been reviewed and assessed as giving ‘inadequate evidence of carcinogenicity’ by the International Agency for Research on Cancer [2S alone.Carcinogenic effects of Hn Cancer . This re2S. No data on exposure levels is given. However, many associations were assessed and increased risks were found for most chemical exposures, being significant for benzene and gasoline. In a large study of female workers in petrochemical plants in China, Xu  found an2S concentrations of 0.5, 2, 5, or 10 ppm for 15 to 30 min during exercise. As these experiments deal with precisely measured exposure levels, they are given prominence in these assessments. Studies have been performed with controlled inhalation of HThese studies were published by one laboratory group in Canada between 1991 and 1997. The studies have not been replicated or confirmed by any other laboratory. 2S during exercise up to maximal levels. There were no effects on heart rate or expired ventilation. At the highest exposure, 5 ppm, and the maximal exercise level, maximum oxygen uptake (VO2) was significantly increased, and blood lactate concentrations increased significantly. Despite this, the maximal power output of the subjects was not significantly changed. The authors state: “healthy young male subjects could safely exercise at their maximum metabolic rates while breathing 5.0 ppm H2S without experiencing a significant reduction in their maximum physical work capacity during short-term incremental exercise.”In the first of these papers , 16 youn2S while exercising to submaximal levels. The previous results were not confirmed. There were no significant effects on any metabolic, cardiovascular, or arterial blood parameter, or on perceptual responses (rating of perceived exertion) in either sex. None of the subjects reported any adverse health effects. There was no change in oxygen uptake or blood lactate levels, unlike in the previous study at maximal exercise levels.In a second, larger, study using the same methods , 13 men 2S, muscle biopsies were analysed for markers of anaerobic and aerobic metabolism: lactate, lactate dehydrogenase, citrate synthase, and cytochrome oxidase. Citrate synthase concentration decreased significantly after H2S exposure in male subjects, but not in female subjects. There were no other significant results. As noted below, this change in citrate synthase was not confirmed in a later study at 10 ppm exposure [In a further paper from the same study , with 13exposure .2S exposure. Further papers deal with exposures of 10 ppm. In a 1996 study , there w2S [A further study, published in 1997, assessed cardiovascular, metabolic and biochemical responses to 10 ppm H2S  on 28 vo2S ). There 2, a measure of oxygen uptake, showed a significant decrease. The authors mention that this differs from their earlier study where 5 ppm exposure at the same exercise level as in this study gave no change in VO2 [2 [2 is the product of cardiac output and the difference between oxygen levels in arterial and in venous blood. The authors conclude that the oxygen carrying capacity of the blood was unaffected, so the reduction in VO2 would relate to the ability of the tissues to extract oxygen from the blood. There was a related increase in blood lactate levels; but only a non-significant change in muscle lactate. The authors conclude “These findings question the scientific validity of the current occupational exposure limit for H2S”. They do not comment on whether the results are clinically important or related to any likely health effect.However, VOe in VO2 . They don VO2 [2 . VO2 is Thus these studies of small numbers of young, healthy volunteer subjects in laboratory conditions were done many years ago by one team of investigators, have not been confirmed by any other research, and show a small number of physiological effects amongst the many outcomes tested. They are inconsistent, with effects seen in one study not seen in others. None of the effects is clearly a health detriment; the clinical significance of the effects seen is unknown. 2S. Total symptom severity was not significantly elevated at any dose. Anxiety symptoms were significantly greater at the 5 ppm than at the 0.05 ppm exposure, and related to the odor experienced. No dose–response effect was observed for sensory or cognitive measures. Verbal learning was compromised during each exposure condition. The authors conclude: “Although some symptoms increased with exposure, the magnitude of these changes was relatively minor. Increased anxiety was significantly related to ratings of irritation due to odor.”, and further “Our findings cannot be directly generalized to communities or workers chronically exposed…”, although cautioning that their results in healthy adults could underestimate effects in subjects with other health conditions. The ACGIH report cites a study by Fiedler at al. , who stuThe ACGIH report also notes an abstract presented in 2000 , which aThe ACGIH report  cites seThe animal data emphasised in the ACGIH report (page 1) are the ‘minimal changes in the nasal mucosae’ of rats and mice, produced by ‘repeated exposures at 30 ppm, but not 10 ppm’). The basis of the ACGIH limits (page 1) is stated to be upper respiratory tract irritation and central nervous system impairment , but theThe studies emphasised most are of ‘subchronic’ exposures. The ACGIH report cites reports (not peer reviewed papers) by Toxigenics, showing no effects below 80 ppm, and therefore a NOAEL (no observed adverse effect level) is the next lower dose tested, 30 ppm. 2S for 6 h/day for at least 90 days. There was an increased incidence of olfactory neuronal loss (ONL) after exposures at 30 ppm and above in most groups. Rhinitis was found in mice at 80 ppm H2S. In the lung, bronchiolar epithelial hypertrophy and hyperplasia was found at 30 ppm in male and female Sprague Dawley rats, and in male Fischer-344 rats exposed to 80 ppm H2S. The authors conclude that “Our results confirm that the rodent nose, and less so the lung, are highly sensitive to H2S-induced toxicity, with 10 ppm representing the NOAEL for ONL  following subchronic inhalation.” Dorman et al.  used adu2S than humans [2S.”However, the authors describe several factors that would make rodents more sensitive to Hn humans , noting 2S 6 h/d and 7 d/wk. for 10 weeks. Following exposure to 30 and 80 ppm H2S, there was a significant increase in nasal lesions, limited to the olfactory mucosa. The NOAEL for olfactory lesions in this study is 10 ppm. The authors note three factors that would increase rats’ sensitivity to inhaled exposures more than humans’: rats are obligatory nasal breathers; 50% of their nasal cavity is lined by olfactory mucosa, compared to 5–10% in humans; and rats’ nasal anatomy greatly expands the surface area exposed and slows the air flow. Therefore, they conclude “However, because of differences in the breathing style and nasal anatomy of rats and humans, additional research is required to determine the significance of these results for human health risk assessment.”Brenneman et al.  exposed 2S flux predicted using a computational fluid dynamics (CFD) model of rat nasal passages. Rats were exposed by inhalation to 0, 10, 30, or 80 ppm H2S for 6 h/day for 70 days. At 30 ppm, lesions were only seen in regions lined by olfactory epithelium, and were related to the H2S flux. The authors conclude: “These results indicate that airflow-driven patterns of H2S uptake within the inherently sensitive olfactory epithelium play an important role in the distribution of H2S-induced lesions and should therefore be taken into consideration when extrapolating from nasal lesions in rats to estimates of risk to human health.”They reinforce this caution in another paper  comparinThe ‘no effect’ level—NOAEL—reported in these studies is the exposure dose at which no effects were seen . However, the no effect level may extend from this up as far as the ‘minimum effect level’–the lowest exposure dose at which changes were observed . The gap between different dose levels tested may be large. Using a computational model shown to be valid for nasal lesions in rats, but assuming the same responses in humans, a NOAEL of 5ppm for humans was predicted . The several expert groups have considered the scientific evidence and recommended various exposure limits .The European SCOEL report  provides3) is accepted, referring to 4 studies [3).Their recommendations are mainly based on animal experimental studies of nasal lesions in rats. It is stated (p. 12) that the nasal lesions found in rats are considered the critical effect, and a NOAEL of 10ppm . To account for differences in exposure pattern between the experimental and the occupational setting, and for the limited data set concerning the pathological effects, they propose a factor of 2. Thus far, their arguments are identical to those of SCEOL. 3, 1.6 ppm. They make no recommendation about a short-term limit.They then state that “differences among people should be taken into account”, and propose a factor of three for this. They note two groups that could be more sensitive, each based on one study: subjects with asthma could be susceptible at levels as low as 2 ppm , pregnanThe difference between the limits of SCOEL and DECOS is therefore not in the scientific information reviewed, nor in the interpretation of it, and both groups use an uncertainty factor of 2 on the basis of differences in setting and limitations of pathology. The differences arise because the DECOS group adds an additional reduction factor of 3 to allow for ‘differences among people’.The derivation of the ACGIH recommended limits is less clear. The scientific studies reviewed by ACGIH are basically the same as those reviewed by SCOEL and DECOS; only the Fiedler study  is not cp < 0.05 significant change was reported in 57 comparisons made at these dosages. For the human studies, it stated that metabolic changes were seen at 5 ppm (citing ), althou2 and blood lactate increased, while carbon dioxide output VCO2 decreased.” However, none of these changes was statistically significant, and to make this interpretation from a study of 16 subjects seems to go beyond the data. Further, while [2 at 5 ppm, these investigators later reported no change at 5 ppm [2, at 10ppm [For human studies, ACGIH concludes that 2 ppm is the NOAEL level and 5 ppm the LOAEL (lowest adverse effect). They justify this by referring to , saying r, while  reportedat 5 ppm , and in at 10ppm . ACGIH aat 10ppm  which shFor animal studies, they cite two of the studies in rats on nasal effects at 30 ppm, and also a study of metabolic changes in animals at 20 ppm  which isFollowing this they simply state their recommendation that a 1 ppm longer term limit “should be sufficient to protect against all the unwanted effects of hydrogen sulphide”. They note that peak exposures of 5ppm “would not be expected to produce more serious effects on the respiratory, central nervous, or cardiovascular systems” and so recommend 5 ppm as a short-term limit. 2S without likely contamination with other exposures. The interpretation of these studies in terms of exposure limit guidelines is therefore limited.There have been several occupational studies published since the major reviews. However, none of these has clearly shown specific health effects related to a reliably documented dose of H2S exposure monitoring studies. Exposure levels of H2S in all monitored tasks were under 1 ppm. Endotoxin levels were also monitored. Increased respiratory, ocular and skin irritation, neurological, and gastrointestinal symptoms were recorded by wastewater workers. Tasks involving sludge handling and plant inspection were associated with memory/concentration difficulties, throat irritation, and stomach pain. A study of wastewater treatment plant workers in Iowa compared them to water treatment plant workers regarded as unexposed . Of 140 2S, but also of ammonia and of inorganic and organic dusts. The effects of different exposures could not be separated [In Norway, a large study of farmers with measurement of many exposures at 127 randomly selected farms showed increases in chronic bronchitis and chronic obstructive pulmonary disease associated with levels of Heparated . 2S for 1–30 years, were compared to those of 110 unexposed males [In Iran, blood parameters for 110 workers in natural gas processing plants, with exposures of 0–90 ppb Hed males . The mea2S exposure, and clinical neurological examinations and cognitive tests were applied to 33 male exposed sewage workers and to 30 comparison subjects [In Egypt, urinary thiosulphate was used as a marker of Hsubjects . Neurolo2S exposure, the most common symptoms were bleeding from the nose, pharynx, gum or mouth; no asthmatic attacks were reported. The levels of exposure were unknown and this seems likely to relate to high, accidental exposures [In a study of 34 male oil field workers in Iraq seen at an occupational clinic, whose symptoms were clinically assessed as related to Hxposures . 2S concentrations in the boats’ cabins of 99 +/− 38 mg/m3 [2S concentrations in the boats before the caught fish were discharged were 219 +/− 31 mg/m3, dispersing by 90% after 1 h in boats with ventilation and spraying but by only 18% in those using only natural ventilation. The threshold concentration that could cause the eye burns was estimated as 38 mg/m3, with an exposure time of 120 min .In 56 fishermen assessed in China, 46 had eye burns; they came from 21 vessels, with H38 mg/m3 . H2S con2S emissions recorded in the previous 10 years (n = 237), and in areas with H2S emissions recorded (n = 88) were compared [2S toxicity, and no detectable sulfhemoglobin. The exposed group tended to have higher serum levels of enzymes involved in the synthesis of H2S, cystathionine beta-synthase and cystathionine gamma-lyase, and higher activity of angiotensin converting enzyme. The objective was to study levels of the enzyme for H2S toxicity, cytochrome C oxidase (COX), and decreased levels were found: the authors suggest COX may be an indicator for H2S exposure .In Poland, groups of copper miners working in areas with no Hcompared . There w2S from geothermal sources. The levels of exposure are much lower than occupational exposure limits; but these exposures are 24 h, every day, and can be for life. Long-term monitoring results show ambient levels of up to 110 ppb, equivalent in total dose terms to a working week level of 460 ppb [2S monitoring networks across Rotorua. Four metrics for H2S exposure, representing current and long-term (last 30 years) exposure, and time-weighted average and peak exposures, were calculated. The maximum exposure group (top quartile) had an exposure level by time weighted average over 30 years, of 19 to 58 ppb; and maximum exposure levels of 32 to 60 ppb [The most detailed community studies, involving individual health assessments and exposure estimates based on extensive monitoring, are from Rotorua, New Zealand, which has the world’s largest population exposed to ambient Ho 60 ppb .2S exposure. Indeed, there were results suggesting improved lung function associated with recent ambient H2S exposures. An earlier study of 1637 subjects also showed no associations with self-reported asthma or asthma symptoms [These studies have shown no detrimental health effects. For lung function, chronic obstructive pulmonary disease and asthma, 1204 subjects had spirometry studies . The stusymptoms . 2S exposures and any of the four ophthalmic outcome measures, including cataract. The authors conclude that an association reported previously based only on hospital discharges [For eye disease, 1637 adults ages 18 to 65, underwent a comprehensive ophthalmic examination to assess nuclear opacity, nuclear colour, and cortical and posterior subcapsular opacity . No assoscharges  was due 2S exposure increases risks of peripheral neuropathy [A further study gave no evidence that Huropathy . In a deuropathy . There wuropathy .2S exposure with nervous system, respiratory and cardiovascular diseases and cataract [Only earlier, weaker, ecological studies in Rotorua were included in the ACGIH report, one suggesting associations of Hcataract , and anocataract . 2S, with various lag periods [2S exposure induces premature deaths.”Several studies from other areas are also ecological studies. In Reykjavik, Iceland, from 2003–2009, daily deaths from all natural causes and from cardiovascular disease were compared to daily ambient concentrations of H periods . Positiv2S exposures from a geothermal power plant were modelled, and compared to the numbers of emergency hospital visits [3, more pronounced in males and in those over age 73; no associations were found with other diseases. Further studies showed associations between daily ambient levels of H2S  and dispensing of anti-asthma drugs [2S or particulates [In a related study in Reykjavik, from 2007 to 2014, daily area-level Hl visits . Increasma drugs . A similiculates . 2S, and other pollutants, with residents in other areas. In Iceland, a comparison of cancer incidence in residents of a high-temperature geothermal area with residents of a cold, non-geothermal area showed excesses of all cancers combined and of several specific types of cancer; the results were adjusted for age, gender and social status, but other confounders could not be taken into account [Several studies compare people living in areas assumed to have higher exposure to H account . In cont account .2S and sulphur dioxide noted [2S exposure has been associated with asthma symptoms in the United Arab Emirates [Several studies related to the Kilauea volcano in Hawaii showed increases in respiratory and various other acute illnesses, but likely related to sulphur dioxide and sulphur particles ,53,54,55de noted . Likely Emirates  and in VEmirates , but in In Beijing, China, in a small study of patients with chronic obstructive pulmonary disease (23 subjects), increased daily air pollution was associated with increased biomarkers and with symptoms .2S, but these effects may be related to odour or to other emissions. In New Mexico, USA, 49 subjects likely to have been exposed to community levels of H2S from a sewage plant, oil refineries, natural gas or oil wells, and a cheese-manufacturing plant and its waste lagoons, were assessed, and compared to 42 unexposed subjects from Arizona [2S exposures (over 0.09 ppm) and 64 residents in a comparison area with less than 0.05 ppm; no significant differences were seen. Several small studies have shown health effects in residents near sources likely to produce H Arizona . Very ma Arizona , neurobe2S levels recorded, with a maximum of 2.3 ppb [2S levels in 101 adults living near swine feeding operations in North Carolina, and other symptoms were associated with particulate levels and odour [2S, but without measurements. Health and mood symptoms were related to odor in 23 residents near landfills in North Carolina who kept diaries, and odour increased with higher H 2.3 ppb . Acute end odour . Similarnd odour  were attn = 33,804) were categorised into three groups by estimated average exposure to H2S , and linked to information on deaths up to 2014 and hospital discharges up to 2016. Comparisons were done between exposure categories, by sex and in total, and with a dose trend analysis, with 19 major categories of death and of hospitalisation; so 266 comparisons are presented. Due to the large volume of data, all the differences, even if statistically significant, are small in absolute terms. For mortality, there were small but significant excesses in deaths from diseases of the respiratory system (12% increase per 7 mcg/m3) and, within that category, for pneumonia; there were significant decreases in total non-accidental mortality, total cancers, ischaemic heart disease, and myocardial infarction (25% decrease). For hospitalisations, there were significant increases in pneumonia and in chronic obstructive pulmonary disease (COPD), but a significant decrease in other respiratory diseases, giving no significant difference in total respiratory hospitalisations. There were significant increases in hospitalisations for heart failure, diseases of the circulatory and nervous systems and diseases of the ovary; and a significant decrease for all cancers. The authors emphasise respiratory disease in their summary, claiming consistency between mortality and morbidity data, but the excess in mortality for total respiratory diseases was small and marginally significant ; and there was no increase in hospitalisations .In a geothermal area in Tuscany Italy , residen2S being associated with increased respiratory disease, but exposure to high levels associated with a decrease in cancer mortality. They regard the studies as limited because of their ecological design and inadequate exposure assessment.Bustaffa et al.  have rev2S with a wide range of health conditions. While such wastes may have H2S emissions, these are mentioned specifically only with reference to acute effects related to illegal dumping in Abidjan [2S from oil and gas fields has been assessed as causing considerable health costs in Kazakhstan [A large review of health effects of hazardous waste  consider Abidjan  with higzakhstan . 2S has recently received much interest as a physiological signaling molecule involved in a number of physiological processes, and shows some cytoprotective effects [In addition to its established effects, H effects ,71,72. I effects . Similar effects ,75. The recommendations from ACGIH are for limitations of occupational exposure well below the minimum level at which any effect has been documented. Such limits should indeed protect against health effects; but whether they provide any further protection than do current limits is questionable.Setting appropriate exposure limits for occupational exposure, or for public exposure, also requires consideration of other issues. These include the feasibility of restricting human activities; the costs of doing so; the logistics and costs of measuring exposure levels accurately and routinely; and any detrimental effects of adhering to such limits. For instance, if the limits meant that workers had to use breathing equipment for some tasks that could involve other risks.2S and CS2 has been seen; but no eye or respiratory effects have been seen in studies of H2S exposure alone below existing limits. On the basis of the available scientific evidence, there is no firm evidence that exposures up to current occupational exposure levels cause any detrimental health effects. Eye irritation, after exposures to both H2S is accepted in communities such as Rotorua, New Zealand. Extensive high-quality studies of individuals in this community have assessed respiratory diseases including asthma, eye disease, peripheral neuropathy, and intellectual function, amongst other outcomes, and have shown no adverse effects. Earlier ecological studies in Rotorua had suggested several positive associations, not confirmed by these more detailed studies. Thus, the ecological studies in Iceland and Italy showing associations with various measures of disease require verification from more powerful studies. There are several small studies showing associations which also need validation, and most of these cannot separate effects of H2S from those of other pollutants.Although exposed at lower levels, long-term, indeed lifetime, exposure to unusually high ambient levels of H2S exposure on the nasal passages in rats and mice. The documentation for the German MAK (maximum workplace exposure) levels [3 is accepted. This group notes that considerable odour annoyance is to be expected at exposures at 5 mg/m3, although they state that it is not possible to assess if this interferes with occupational activities or produces adverse effects. On this basis they recommend a MAK value of 5 mg/m3. Three expert group reports have been reviewed, from SCOEL, DECOS, and ACGIH. All of them base their recommendations primarily on respiratory and related effects in human volunteers under laboratory testing, and on studies of H) levels  is generThe human studies were studies of small groups of young healthy volunteers by one investigator group, and conducted over 20 years ago. They have not been further validated or independently tested. The studies assess a large number of physiological parameters, all of questionable clinical importance. The effect most often emphasised, a decrease in oxygen uptake, was seen in one study, but not seen in one previous study, and the opposite effect was initially reported. The reviews by all three expert groups pay insufficient attention to the inconsistency of these effects, their small sizes, the lack of reproducible findings, and their questionable clinical relevance.For the studies of rats and mice, the extrapolation of these results to humans exposed at the same levels of exposure is questionable. The effects seen are reported only at exposures of 30 ppm and above. The investigators emphasise that the breathing style and nasal anatomy of rats is very different to humans and would make these animals much more sensitive to inhaled agents. The three review groups take no consideration of species differences. The threshold for any effect in these studies would be between 10 and 30 ppm. In formulating recommendations, the SCOEL group use a reduction factor of 2 for long-term exposure; the DECOS group uses a reduction factor of 6; and the ACGIH group does not state how its recommendations are derived, but effectively use a reduction factor of 10. These factors are not clearly justified. The derivation and use of uncertainty factors in deriving occupational exposure limits varies considerably; in a review of 128 recommendations from SCOEL, uncertainty factors were explicit in 50% of reports, and decreased over time from 64% in 1991–2003 to 37% in 2004–2017 . When exThis review shows that the substantial differences in occupational exposure limits given by three important scientific groups are not due to differences in the scientific evidence the groups have reviewed. With minor exceptions, the three groups are relying on the same scientific studies, and to a large extent they agree on the interpretation of the individual studies. The differences in the recommended exposure limits arise from differences in the application of uncertainty factors. In a review of the scientific basis of using uncertainty factors, Dankovic et al.  note thaThe review groups appear to be taking a precautionary approach by accepting inconsistent evidence, down-playing limitations of studies even when these are stressed by the original investigators, and including various reduction factors. Thus, they recommend as occupational exposure limits, levels at which no health effects, even innocent physiological changes, have ever been demonstrated; these levels are considerably below the minimum levels at which any detrimental health effect has been shown. Therefore, the scientific justification for these recent recommendations of lower occupational exposure levels is questionable. There is no clear evidence that reducing limits to follow these recommendations will protect the health of workers any further than will the current exposure limits used in most countries.These expert reports were done nearly 10 years ago, and there is considerable relevant scientific literature published since then. Further, relevant information may be in gray literature such as government and company reports. A full review, involving a multidisciplinary expert group and considerable resources, would be appropriate.In recent years, three expert groups have used essentially the same scientific evidence to recommend different occupational limits for exposure to hydrogen sulphide gas. All these differing levels are lower than currently accepted occupational exposure limits in most jurisdictions; so, industrial workers have been exposed for many years to levels of exposure likely to be higher than these new recommended low limits, while being within the existing limits. The new lower limits are justifiable only if these exposures produce a health hazard.In the scientific evidence, the human volunteer studies were done in one laboratory over 20 years ago, and give inconsistent results. The animal studies are of animals whose breathing style and nasal anatomy would make them much more sensitive than humans to inhaled agents. No clear evidence of detrimental health effects in workers has been found. Studies of lifetime exposure in communities with natural sources have shown no detrimental effects.A limited review of studies published since 2006 has shown several occupational or community studies, but these show no confirmed hazards. A further review of the relevant scientific evidence is needed to support any major changes in occupational exposure limits. The current information is of course limited, particularly in regard to the effects of human exposures within the limits of the highest current occupational exposure limits and the suggested lower limits. Further research may clarify the situation.This review suggests that expert groups have paid insufficient attention to the inconsistency of these effects, their small sizes, and their questionable relevance to human health. Each expert group applies different reduction factors without clear justification. The conclusion is that the scientific justification for lowering occupational exposure limits is very limited. There is no clear evidence, based on currently available scientific evidence, that lower limits will protect the health of workers further than will the current exposure limits used in most countries.


Open cardiac surgical patients may experience severe acute poststernotomy pain. The ultrasound-guided Pecto-intercostal Fascial Block (PIFB) can cover anterior branches of intercostal nerves from T2 to T6. The aim of this study was to investigate the effect of bilateral PIFB in patients undergoing open cardiac surgery.A group of 108 patients were randomly allocated to either receive bilateral PIFB (PIFB group) or no nerve block (SALI group). The primary endpoint was postoperative pain. The secondary outcome measures included intraoperative and postoperative sufentanil and parecoxib consumption, time to extubation, time to first feces, length of stay in the ICU and the length of hospital stay. Insulin, glucose, insulin resistance and interleukin (IL)-6 at 1, 2, 3 days after surgery were mearsured. The homeostasis model assessment (HOMA-IR) was used to measure perioperative insulin resistance.The PIFB group reported significantly less sufentanil and parecoxib consumption than the SALI group. Compared to the PIFB group, the SALI group had higher Numerical Rating Scale (NRS) pain scores at 24 h after operation both at rest and during coughing. The time to extubation, length of stay in the ICU and length of hospital stay were significantly decreased in the PIFB group compared with the SALI group. The PIFB group had a lower insulin, glucose, IL-6, HOMA-IR level than the SALI group 3 days after surgery.Bilateral PIFB provides effective analgesia and accelerates recovery in patients undergoing open cardiac surgery.ChiCTR 2000030609) on 08/03/2020.This study was registered in the Chinese Clinical Trial Registry ( There are more than 1.5 million patients worldwide undergoing open heart surgery every year . PoststeEpidural anesthesia (EA) and paravertebral blocks can provide effective analgesia with earlier extubation and reduced opioid use in cardiac surgical patients , but advThe ultrasound-guided Pecto-intercostal Fascial Block (PIFB) has been advocated by some researchers for cardiac surgery . Garcia Therefore, bilateral PIFB blocks may provide effective analgesia in patients undergoing open cardiac surgery. The aim of this study was to assess whether bilateral PIFB provide effective analgesia and promote rapid recovery after open cardiac surgery.This study was approved by the ethics committee of First Affiliated Hospital of Nanchang University and written informed consent was obtained from all subjects participating in the trial. Then it was registered in the Chinese Clinical Trial Registry (registration number ChiCTR 2000030609). Our study adheres to CONSORT guidelines.This double-blind, randomized, controlled study was performed on patients between the age groups of 20 and 70 years undergoing valve replacement surgery through median sternotomy with American Society of Anesthesiologists physical status III/ IV. Criteria for exclusion in our trial was as follows: emergency surgery, an allergy to local anesthetics, congestive heart failure, hepatic or renal failure, a history of drug abuse or chronic pain, psychiatric problems, secondary surgery, inability to provide informed consent. The patients enrolled in our study were randomly divided into two groups: PIFB group receiving bilateral PIFB with 0.4% ropivacaine and SALI group receiving the same block with saline.Inside the operating room, electrocardiography, invasive arterial blood pressure, oxyhemoglobin saturation, end-tidal carbon dioxide, central temperature, central venous pressure and urine output were continuously monitored in all patients in our study intraoperatively. Anesthetic induction was performed with midazolam 0.05 to 0.1 mg/kg, sufentanil 0.8 to 1 μg/kg, etomidate 0.3 mg/kg and rocuronium 0.6 mg/kg for tracheal intubation. The maintenance of anesthesia was achieved with sufentanil, propofol and rocuronium according to the clinical needs following induction in both groups, and the BIS was maintained between 45 and 55 in all patients. Intravenous sufentanil with patient-controlled analgesia was used to perform postoperative analgesia and 20 mg parecoxib was injected i.v. at 6 h intervals as a supplementary analgesic according to the demands of the patients. All surgeries were performed by the same group of surgeons in our trial. After the operation, the patients were sent to the cardiac surgery ICU as scheduled.After patients entered the operating room, randomization was performed at the post anesthesia care unit to either PIFB group or SALI group using a computer- generated random number table and was kept in sealed envelopes by a biostatistician. The envelopes were opened by another researcher and he prepared the normal saline or 0.4% ropivacaine according to the group allocation. The anesthesiologist administered bilateral PIFB and he had no knowledge of whether the fluid is ropivacaine or saline after induction of anesthesia. Postoperative visitors were blinded to group allocation. This was a double-blind, randomized, controlled study.The PIFB was performed in a supine position using high-frequency linear ultrasound probe . The probe was placed at 2 cm lateral from sternum and parallel to the sternum, then we could find the pectoralis major muscle, the external intercostal muscle, the costal cartilage, the pleura and the lungs. Pecto-intercostal fascial plane was located between the pectoralis major muscle and the external intercostal muscle or the costal cartilage. A 20-gage, 70 mm needle  was placed under the pectoralis major and above the external intercostal muscle with in-plane approach and a test bolus of saline (2 mL) was injected to determine that the tip has been placed in the correct fascial layers. Finally, 20 ml of 0.4% ropivacaine was injected to this plane in two locations, over 2nd and 4th rib. The method on the other side of the PIFB was the same. All PIFBs were completed by the same skilled anesthesiologist within 20 min and were completed in the operating room before anesthesia induction.The primary outcome measures of our study were postoperative pain at 2,4,8,16,24, and 48 h after extubation at rest and exercise (defined as pain experienced during coughing) and analgesia requirements (sufentanil and parecoxib consumption). Secondary outcomes included time to drain removal, time to extubation, time to first feces, length of stay in the ICU, incidence of postoperative nausea and vomiting (PONV), the length of hospital stay, and possible complications such as ropivacaine allergy, hematomas, infections. Postoperative pain was measured using the Numerical Rating Scale (NRS) score from 0 (no pain) to 10 (worst severe pain).Interleukin (IL) IL-6, insulin, glucose and insulin resistance were measured at before induction of anesthesia,1, 2, 3 days after surgery. Whole blood was immediately centrifuged at 1500 rpm for 20 min to separate the plasma. Then it was frozen at − 70 °C for subsequent analysis. Insulin resistance was assessed by the homoeostasis model assessment, that is, HOMA-IR = blood glucose (mmol/l) × blood insulin (munits/ml)/22.5.n = 11 patients in per group), which compared the primary endpoint of the postoperative pain scores. An estimated sample size of 45 patients in each group were needed with a type I error of α = 0.05, a type II error of β = 0.1 and a power of 90%. We finally included 20% more patients for analysis to compensate for possible dropout in our trial (n = 54 in each group).The authors calculated the patient sample size of our trial on the basis of a pilot study . The continuous data were expressed as the mean and standard deviation, whereas the qualitative data were expressed as the frequency and percentage. The Kolmogorov-Smirnov test was used to assess the normality of the continuous data. Student’s t test was used to assess the intergroup differences with normal distribution, whereas the WilcoxonMann-Whitney test was used to assess the differences in the non-normally distributed data. The Chi-square or Fisher’s exact test were used to analyze categorical data. Biochemical data were evaluated by ANOVA for repeated measurements and Scheffe method is also used for these data. A probability value of less than 5% was considered significant.A total of 108 patients were randomized in our trial. Of the enrolled patients, 3 had redo surgery,4 refused blood collection after surgery,3 had postoperative delirium. Ultimately, date for 98 patients were finally analyzed with 49 in each group (Fig. NRS pain scores were significantly lower in PIFB group compared with SALI group at 2, 4, 8 and 24 h after extubation both at rest and during coughing, and had no differences at 48 h after extubation Figs. . The PIFThere were no significant differences in the levels of insulin, glucose, IL-6, HOMA-IR between the PIFB group and the SALI group at base value. The PIFB group had a lower blood glucose level than the SALI group 3 days after operation Table . PostopeThe present study demonstrated that the use of ultrasound-guided PIFB could reduce postoperative insulin resistance, systemic inflammation, the perioperative sufentanil consumption, dosage of postoperative parecoxib and provide effective analgesia in patients undergoing valve replacement surgery. Furthermore, these results might be the basis for reducing time to extubation, length of stay in the ICU and length of hospital stay after surgery.The PIFB provided effective analgesia for breast surgery , sternalSufentanil was most commonly used in cardiac surgery with hemodynamic stability and effective postoperative analgesia , but sufPatients undergoing open cardiac surgery experienced severe and prolonged postoperative pain, especially at the median sternotomy site . Poorly Cardiopulmonary bypass and the great trauma of sawing the sternum would make cardiac patients have severe postoperative insulin resistance and systemic inflammation . PostopeFinally, bilateral PIFB in patients undergoing cardiac surgery decreased perioperative sufentanil and parecoxib dosage, provided effective analgesia, reduced postoperative insulin resistance and systemic inflammation, caused earlier extubation and exit from the ICU, and these results were the basis for reducing the length of hospital stay.This study has some limitations. The concentration and volume of the PIFB used in our trial was based on previous research. In further study, the optimum volume and concentration of the PIFB should be evaluated. Continuous PIFB may provide persistent postoperative analgesia in cardiac surgery, but our trial did not use this technique. Therefore, the utility of continuous PIFB should be further studied. Effective postoperative acute pain relief may prevent the development of chronic pain . But we Our study found that the use of ultrasound-guided PIFB could reduce postoperative insulin resistance, systemic inflammation, the perioperative sufentanil consumption, dosage of postoperative parecoxib and provide effective analgesia in patients undergoing open cardiac surgery. Furthermore, these results might be the basis for reducing time to extubation, length of stay in the ICU and length of hospital stay after surgery.