Clinicians need reliable outcome predictors to improve the prognosis of septic patients. Mouse models are widely used in sepsis research. We aimed to review how mouse models were used to search for novel prognostic biomarkers of sepsis in order to optimize their use for future biomarker discovery.We searched PubMed from 2012 to July 2022 using “((sepsis) AND (mice)) AND ((prognosis) OR (prognostic biomarker))”.A total of 412 publications were retrieved. We selected those studies in which mouse sepsis was used to demonstrate prognostic potential of biomarker candidates and/or assist the subsequent evaluation in human sepsis for further appraisal. The most frequent models were lipopolysaccharide (LPS) injection and caecal ligation and puncture (CLP) using young male mice. Discovery technologies applied on mice include setting survival and nonsurvivable groups, detecting changes of biomarker levels and measuring physiological parameters during sepsis. None of the biomarkers achieved sufficient clinical performance for clinical use.The number of studies and strategies using mouse models to discover prognostic biomarkers of sepsis are limited. Current mouse models need to be further optimized to better conform to human sepsis. Current biomarker platforms do not achieve predictive performance for clinical use. It accoAlthough sepsis is the leading cause of death in non-coronary, critically ill patients, the identification of patients at high risk remains a challenge . Many biThe heterogeneity of human patients with sepsis together with difficulties in controlling study conditions makes it complicated to work directly from human samples . Murine This review aimed to appraise those studies which utilized mouse models of sepsis to investigate biomarkers for sepsis prognosis prior to clinical studies. We sought to answer the following questions. What types of septic mouse models have been used and how closely do they reflect human sepsis? What technologies have been applied in discovering prognostic biomarkers using mouse models of sepsis? What prognostic biomarkers achieve the highest sensitivity and specificity and how clinically relevant are these biomarkers? We aimed to comprehend how mouse models were used to search for novel prognostic biomarkers of sepsis in order to optimize their use for future biomarker discovery.2We searched the PubMed database from 2012 to July 2022 using the query “((sepsis) AND (mice)) AND ((prognosis) OR (prognostic biomarker))” and retrieved 412 publications. We removed non-research articles, e.g., review articles. We excluded those publications not focusing on sepsis, sepsis prognosis and/or septic mouse models. We included the studies in which mouse models of sepsis were applied to discover prognostic potential of biomarker candidates directly in mice and/or assist the identification of prognostic value for human sepsis. We finally narrowed to eight relevant articles . The fulWe described the types of septic mouse models which have been utilized in the identified studies, compared and contrasted these mouse models with human sepsis in latter sessions, with reference to their strengths and weaknesses. We recorded the technologies applied on septic mouse models in order to discover prognostic values of biomarker candidates. For those biomarkers with clinical evaluations, we recorded the details of the clinical trials including the types of clinical study, the study population and the number of participants, and we presented the results of the survival analysis where this technique was applied to measure sensitivity and specificity of biomarkers.3Among the retrieved 412 publications, 167 articles did not focus on sepsis; 93 addressed therapy/intervention/treatment investigation; 49 were about pathophysiology investigation; 55 were on sepsis-induced organ  injury; 20 were review or protocol articles; 4 were clinical evaluations without using septic mouse models; and only 21 were found to have used septic mice to discover biomarkers for sepsis prognosis . Out of 3.1Seven studies were found to apply mouse sepsis to demonstrate prognostic potential of candidates directly in septic mice. There is yet no following clinical assessment to support the findings. One study tested the potential of using peritoneal wash contents to predict mortality in septic mice, in which peritoneal wash contents were used as a source to measure immune parameters, e.g., IL-6 levels ; one stu3.2Escherichia coli lipopolysaccharide; 20 mg/kg) and high-dose of LPS (40 mg/kg) intraperitoneally into 8–12 weeks old male Kunming mice, respectively [The prognostic values of the expression of six genes  in peripheral blood were identified using septic mouse models and RNA sequencing technology . Survivoectively . The perectively . Subsequectively . Though ectively ,23. Overectively .3.3+ cells [+ neutrophils in peripheral blood (24 h after CLP) were compared to have a higher percentage in sepsis non-survival mice than survival mice , indicating the B7–H1+ neutrophils in peripheral blood have the potential to be used as a prognostic biomarker in sepsis. Moreover, higher levels of inflammatory cytokines in blood correlated with the higher expression of B7–H1 on peripheral neutrophils [B7–H1 is the primary ligand of Programmed cell death 1 protein (PD-1) ,24. Wide+ cells . Then, Btrophils .3.4E. coli LPS; intraperitoneal; 5 mg/kg) and CLP, were constructed on 7–12 weeks old male C57BL/6 mice, and subsequent assessments were conducted at 2, 4, 6, 12 and 24 h after inducing sepsis [Cardiac function was used as a prognostic biomarker for sepsis in mice. Septic models, both of LPS injection  and CLP models were used, and both models were constructed on male C57BL/6 mice , serum miR-223, plasma heat shock protein A12B (HSPA12B), redox state of pentraxin 3 (PTX3), serum miR-133a and serum triggering receptor expressed on myeloid cells-1 (TREM-1) were initially studied in septic mice with the aim to support the subsequent clinical evaluation of their prognostic values in patients with sepsis. Apart from serum miR-223 which was shown to be ineffective, all the other five biomarkers demonstrated convincing prognostic potential in clinical studies.As we will focus on circulating/blood biomarkers in this section, we will not discuss the redox state of PTX3. MiR-133a was investigated its prognostic value for critically ill patients but not in particular for sepsis, thus we will also not discuss it. The other four biomarkers will be briefly described for their nature and the discovery techniques used. Although the four biomarkers have been evaluated in clinical settings, only two, ApoA5 and HSPA12B, have reports on their clinical performance with a sensitivity and specificity see .Table 2C3.7ApoA5 modulates triglyceride homeostasis, whilst elevated plasma triglycerides occur in the acute-phase of sepsis . The cli3.8HSPA12B, mainly located in endothelial cells and responsible for angiogenesis and endothelial functions . HSP12B 3.9Streptococcus progenies-induced sepsis was investigated in both mouse models and patients. The mouse model of S. progenies sepsis was constructed on C3H/HeN female mice by intravenously inoculating 105 CFU of S. progenies strain A20 [. Using this mouse model, TREM-1 expression was upregulated in the liver and peritoneal cells during S. progenies infection; and the serum TREM-1 levels correlated positively with the bacterial loads in the blood and liver of S. progenies infected mice [S. progenies infection in mice. The results from mice were then translated into patients with streptococcal toxic shock  [S. progenie-induced sepsis.TREM-1 is an immunoglobulin expressed on the surface of neutrophils and macrophages, which can amplify inflammatory responses . The plarain A20 . Using tted mice . Therefo n = 18) . Consist n = 18) . In addi n = 18) . The cli3.10The identified study reported negative values of miR-223 for being used as a sepsis biomarker. Previous clinical studies have reported contradictory results of using miR-223 serum levels as a septic biomarker . InitialIn the discovery of ApoA5 and miR-223, septic mice were mainly used to measure the biomarker levels and then confirm whether the changes are consistent with septic patients in following clinical trials. In the discovery of HSPA12B and TREM-1, besides measuring the changes of candidate biomarkers in mouse sepsis, the disease severity of mouse sepsis, either controlled by the CLP puncture numbers or monitored by bacterial loads, was used to analyse the correlation with candidate biomarkers. In terms of using septic models to assist the biomarker discovery for the prognosis of human sepsis, the techniques applied on mice seem to be limited.3.11Among the eight studies mentioned above, five studies used C57BL/6 mice, one study used Kunming mice and one used C3H/HeN mice to establish mouse sepsis . C57BL/63.12C57BL/6 and C3H/HeN mice are inbred strains while Kunming mice are outbred strains. For inbred mice, their almost identical genetics facilitate the interpretation of experimental results and ensure the reproducibility; for outbred strains, due to their diverse genetics, mice are more robust and prolific. Generally, inbred mice are more widely used in sepsis research than outbred mice . Controv3.13S. progenies-induced model used female C3H/HeN mice  alteration of the animal's endogenous protective barrier, e.g., CLP; 2) exogenous administration of a viable pathogen; or 3) exogenous administration of a toxin, e.g., LPS. Septic mouse models hold an irreplaceable position for us to acquire fundamental information related with the mechanism of sepsis pathophysiology and treatment. Different types of septic models come with their own strengths and weaknesses which have been reviewed extensively by numerous experts in the field ,13,48,62+ neutrophils and HSPA12B were discovered using the CLP model; in two studies, the expression of six genes  and ApoA5 were discovered using the LPS injection model; and in three studies, miR-223, cardiac output at 2 h post-CLP and quantification of microcirculatory blood flow were identified using both CLP and LPS injection models. Dissimilar changes between these two models were found for miR-223, and clinical findings were eventually proven to be consistent with CLP models. This phenomenon may reflect the innate differences between the two types of septic models. LPS injection induces sterile inflammation yet CLP features bacteremia. Thus, it appears to be safer to test candidate biomarkers in multiple, different models prior to large-scale clinical trials [CLP and LPS injection were the models predominately used in the above eight appraised studies . In two l trials . In the CLP model involves anesthetizing mice and performing a midline laparotomy to expose, ligate and puncture the cecum ,9,63. FaI.P.) route, and sometimes via intravenous (I.V.) route. Among the five identified studies using LPS injection models, three used the I.P. route, one used I.V. route and one did not provide this information [50) of LPS in mice is about 1–25 mg/kg, which may be influenced by the age, sex and strain of mice. For C57BL/6 male mice used in the identified studies, 2.5 mg/kg and 5 mg/kg of I.P. LPS were administrated to 6–8 weeks old mice and 7–12 weeks old mice, respectively; and 12.5 mg/kg of I.V. LPS was also utilized but without mentioning the mouse age (I.P. LPS (20 mg/kg and 40 mg/kg) were required to produce sepsis with different severity , for correlation. In our future study on biomarker discovery, we would like to incorporate the exploration of potential biomarkers in this type of human dataset.This literature search only identified eight publications using mouse models with aims to discover biomarkers for sepsis prognosis, which is small. This phenomenon reflects the fact that, although mouse models of sepsis have been commonly developed as proxy for the human condition to study sepsis, most of them are used to investigate the pathophysiology and evaluate novel therapeutic interventions with their pharmacokinetics, toxicity and underlying mechanisms ,13. ThesAs mentioned, the discovery techniques applied on mice are also very limited, in which case mouse sepsis was mainly used to detect the changes of biomarker levels during sepsis. Mice have been used to set survival and nonsurvivable groups, and candidate biomarkers were then compared between the two groups, mimicking the traditional strategy of evaluating prognostic biomarkers in clinical studies. Other than that, it is hard to categorize new strategies of biomarker discovery from this small number of studies. Screening DEGs in mice after setting survival and nonsurvivable groups may be novel but even this number of studies are very few. These limitations indicate a huge space of further exploring how to use septic mice to discover prognostic biomarkers for sepsis. Mice will remain promising for biomarker discovery but it requires thorough development in both model itself mimicking human sepsis and techniques as well as discovery strategy. We have formed three perspectives to fill in this space, which will be discussed below.Firstly, it is important to optimize current models to maximize the extent to mimic human sepsis. The discovery mostly relies on human samples, and this lack of using mouse models may be due to the differences between human sepsis and mouse sepsis. As mentioned before, most mouse models poorly reflect human sepsis and fail to demonstrate clinical efficacy . KnowledSecondly, it may hold advantages to test biomarkers in multiple, different models prior to large-scale clinical trials, as inspired by the contrasting results of testing miR-223 levels between LPS injection and CLP. Most studies used only one type of septic models to test biomarkers. However, different models come with their own strengths and weaknesses which have been reviewed numerously and also briefly described in the section of “Septic mouse models”. For instance, CLP features a delayed course of inflammation but LPS injection induces an acute sterile inflammation. The innate differences between different types of septic models may lead to striking differences in biomarker changes. Though testing biomarkers in multiple models may increase preclinical labour and cost, it could offer stronger evidence to support clinical evaluation and lower the risk of clinical failure. On the other hand, new U.S. Food and Drug Administration (FDA) regulations aim to minimise the use of pre-clinical models . TherefoThirdly, advanced techniques can be applied in mice . Mice arHalf of the identified biomarkers advanced to clinical evaluation, but only ApoA5 and HSPA12B provided data from survival analysis. Though both achieved similar AUC, sensitivity and specificity, ApoA5 focuses on ICU mortality of paediatric patients, and HSPA12B focuses on 28-day mortality of patients with severe sepsis. Also, there is no common standard used during their clinical evaluation, making it difficult to compare their clinical performance. Hence, biomarker evaluation ought to not only require researchers to provide the data of prediction performance, i.e., AUC, sensitivity and specificity, but also use some common standards, such as APACHE II score and CRP, to report results, which will facilitate the comparison between identified biomarkers so as to aid researchers to prioritize potential biomarkers for further advance.None of the clinical trials features a large cohort number more than 300, and none of the biomarkers have been evaluated in repeated, large studies . Althoug5Though mouse models have been widely used in sepsis research, the number of studies and strategies using septic mice to discover prognostic biomarkers of sepsis are very limited, and the identified biomarkers still require substantial assessment of their clinical potential. Current mouse models of sepsis cannot truly reflect human sepsis and need to be further optimized to better conform to human sepsis. Nonetheless, mouse models can create reproducible and rapid sepsis, hold the capability to access various techniques and will remain promising to facilitate the discovery of biomarker platforms with sufficient sensitivity and specificity for use in clinical practice.YJ conceived the study, performed the literature search, drafted the manuscript, and approved the submitted version of the manuscript. CT revised the manuscript for critical content, and approved the submitted version of the manuscript. TR conceived the study, revised the manuscript for critical content, and approved the submitted version of the manuscript.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


IntroductionUnresectable pancreatic tumors are frequently diagnosed. Initial treatment is carried out with chemotherapy. Eventually, in selected cases, radiotherapy may be used to improve local control rates and relieve the symptoms. The volume of radiotherapy treatment fields is the subject of controversy in the literature. The use of involved fields with the gross tumor volume encompassing the primary tumor and lymph nodes considered clinically positive is associated with a lower rate of side effects, but can lead to a higher rate of regional loco failures, especially in regional lymph nodes. The purpose of this article is to analyze the failure pattern of chemotherapy and involved-field radiation therapy (IFRT) for treating patients with unresectable pancreatic adenocarcinomas.MethodsClinical records of thirty consecutive patients treated from March 2016 to June 2020 for unresectable pancreatic adenocarcinoma were analyzed. The patients were treated with initial systemic chemotherapy (median: 6 cycles) with regimens based on gemcitabine or oxaliplatin-irinotecan (folfirinox/folfox) followed by radiotherapy . The patients were treated with IFRT. Local failure (LF) was defined as an increase in radiographic abnormality within the planning target volume (PTV). Elective nodal failure (ENF) was defined as recurrence in any lymph node region outside the PTV. Any other failure was defined as distant failure (DF).ResultsThe median age of the patients was 68 years (range: 44-80 years); 20 patients (66.7%) were men, and 11 (36.6%) and 19 (63.4%) patients presented with tumors of stage II and III, respectively. Most patients (63.3%) had tumors in the pancreatic head. The median survival was 17.2 months. Tumor recurrences were classified as LF, DF, LF and DF in 7 (23.3%), 17 (56.7%), and 5 (16.7%) patients, respectively. Only one patient (3.3%) had both LF and ENF. No severe side effects related to radiotherapy were reported.ConclusionThe use of IFRT did not cause a significant amount of ENF, besides presenting low morbidity, which is of special importance for patients with locally advanced tumors or low performance status. The predominant failure pattern was distant metastases. Despite the progress achieved in various treatment modalities, pancreatic cancer remains one of the leading causes of cancer-related mortality. During 2022, approximately 62,210 diagnoses of this neoplasm were made in the United States, with an estimated 49,380 deaths. Pancreatic cancer is the fourth most common cause of cancer-related death among American men, after lung, prostate, and colorectal cancers [At diagnosis, 20% of patients have resectable tumors, 50% are diagnosed with metastatic disease, and 30% with locally advanced tumors considered unresectable [The preferred initial treatment for this specific group of patients is chemotherapy whenever possible. Radiotherapy after chemotherapy may be considered for some carefully selected patients with favorable clinical conditions who have not developed metastases. Radiotherapy can improve local control and reduce morbidity caused by local symptoms of tumor progression, thereby improving the quality of life . HoweverThis study retrospectively analyzed the clinical records of 30 patients diagnosed with pancreatic adenocarcinoma, with tumors considered unresectable, and treated from March 2016 to June 2020. All cases were discussed in a tumor board comprising surgeons, clinical oncologists, radio-oncologists, radiologists, anesthesiologists, and palliative-care specialists before making a therapeutic decision. The patients were evaluated with computed tomography (CT) scans of the chest, pelvis, and abdomen under a protocol for the pancreas; magnetic resonance imaging of the upper abdomen if CT was inconclusive; CA 19‑9 after adequate drainage of the biliary tract; and complementary tests, such as blood count, aspartate aminotransferase, alanine aminotransferase, bilirubin , gamma-glutamyl transferase, alkaline phosphatase, urea, and creatinine. The tumor stage, nodal stage, and clinical prognostic groups were classified according to the International Union against Cancer (UICC) tumor-node-metastasis (TNM) classification, eighth edition, 2017.2, intravenous (IV), weekly), gemcitabine-capecitabine  days 1, 8, 15), folfirinox , 2400 mg/m2 via infusor device, over 46 hours, every 14 days for a maximum of 12 cycles), folfox . The number of cycles was determined after obtaining a maximum benefit, limiting toxicity for treatment continuation, or both. At the end of chemotherapy, the patients were restaged with computed tomography (CT) scans of the chest, pelvis, and abdomen under a protocol for the pancreas; CA 19‑9 and complementary tests, such as blood count, aspartate aminotransferase, alanine aminotransferase, bilirubin , gamma-glutamyl transferase, alkaline phosphatase, urea, and creatinine, and when they did not present clinical evidence of distant metastasis and were in a satisfactory clinical condition, they were referred for radiotherapy after a new discussion in the tumor board. All patients were treated with IFRT. The gross tumor volume (GTV) included the primary residual tumor after chemotherapy and the lymph node chains considered positive on imaging at initial staging. For planning target volume (PTV), margins of 2 cm in the craniocaudal axis and 1.0-1.5 cm in the other axes were used. The dose used ranged from 50 to 54 Gy with daily fractionation of 2 Gy according to the dose tolerance protocol for normal organs adjacent to the PTV. The dose restrictions for normal organs were: for the kidney no more than 30% of the total volume can receive a dose equal to or greater than 30 Gy, for the stomach, duodenum and jejunum the maximum dose was 55 Gy, for the liver the mean dose cannot exceed 30 Gy and for the spinal cord the maximum dose to a volume of at least 0.03 cc must be less than or equal to 45 Gy. All patients underwent a clinical review consultation and nutritional status assessment during the treatment.All patients received initial treatment with initial systemic chemotherapy. The chemotherapy regimens used were based on gemcitabine  was defined as an increase in radiographic abnormality within the PTV. Elective nodal failure (ENF) was defined as recurrence in any lymph node region outside the PTV. Any other failure was defined as distant failure (DF).Study endpoints and statistical analysisThe study endpoints of LF, ENF, and DF were evaluated. Initially, a descriptive analysis of the variables was performed, in which the absolute (n) and relative (%) frequency distributions were presented for qualitative variables, and the main summary measures, such as mean, standard deviation, median, and minimum and maximum values, were calculated for quantitative variables. To assess associations between categorical variables, the chi-square test or Fisher’s exact test was used when appropriate. The Kaplan-Meier estimator was considered when determining the survival curve. A 5% significance level was adopted, and statistical analyses were performed using SPSS version 28 .A predominance of male patients with clinical stage III pancreatic head tumors was observed. The other clinical characteristics of the patients are listed in Table The characteristics of the chemotherapy and radiotherapy treatments are presented in Table All patients died because of tumor progression and were followed up until the date of death. Overall survival ranged from 7.2 to 38.1 months, and the median survival was 17.2 months. The overall survival curve is shown in Figure Failure patternRegarding the main site of disease progression, DF was observed in isolation in 17 patients and in combination with LF in five patients. The sites of disease progression for all patients are shown in Table No statistically significant correlation in univariate analysis was observed for the variables tumor, lymph node status, clinical stage, radiotherapy dose, and number of chemotherapy cycles in relation to LF or DF Tables , 6.MorbidityTwenty-two patients presented with toxicity symptoms during radiotherapy treatment. There were six cases of diarrhea, six cases of myelotoxicity, six cases of nausea, three cases of vomiting, and one case of cholangitis. All cases were resolved with clinical treatments, and no deaths were caused by these complications in any of the patients.Some aspects related to the use of radiotherapy for treating unresectable pancreatic lesions are controversial.IndicationThe use of chemoradiation after induction chemotherapy for patients is a therapeutic option to be considered in specific clinical situations, and the aim is to reduce the risk of local tumor progression and relieve the symptoms. This approach is generally recommended for patients in whom it is highly unlikely that the lesion will become resectable owing to arterial impairment or for those definitively not considered as candidates for surgery after completion of induction chemotherapy. An analysis of patients with this clinical condition by the US National Cancer Data Base showed favorable results when the patients were treated using radiotherapy with conventional fractionations or using stereotactic body radiation therapy (SBRT) .The influence of adding radiotherapy to treatments that exclusively involve chemotherapy on patient survival is doubtful. The SCALOP phase‑II trial analyzed the outcomes of patients treated with gemcitabine-based chemotherapy or chemoradiation with capecitabine-based chemotherapy. There was no statistically significant difference in overall survival and disease-free survival between the two groups. Similar to the median survival results obtained in our study, with chemotherapy treatments followed by radiotherapy, the median survival was 17.6 months in the group receiving chemoradiation and 12 months in the group treated with chemotherapy alone . In the Vornhülz et al. conducted a systematic review of the use of SBRT for treating locally advanced tumors of the pancreas, with an emphasis on symptom improvement. This review analyzed 11 studies with 292 patients treated using 3-6 fractions with a dose of 4-15 Gy per fraction, and 73% of the patients underwent chemotherapy prior to radiotherapy. The authors observed significant improvement in pain, weight loss, and nausea [VolumeThe volume to be treated in patients with pancreatic tumors that are not candidates for surgery is controversial in the literature, especially regarding the inclusion of elective lymphatic drainage. In favor of this inclusion, there is a high incidence of lymph node involvement in locally advanced tumors. The potential ability to treat subclinical lymph node disease with chemotherapy using more effective regimens, the ability of PTV to cover high-risk vascular structures and lymph nodes in the periphery of the primary lesion, the predominance of LF and DF as the most common sites of recurrence, and the lower morbidity favor the adoption of IFRT.Even patients undergoing surgery have high rates of LF (15%-50%) and DF 60%-90%) as the most common sites of failure. Hishinuma et al., in an analysis of autopsies of patients treated surgically, found LF in 75% of them, which was associated with perineural or lymphatic infiltration or extension to peripancreatic tissues. DF was also a common finding and was present in 75% of the patients, with a predominance of liver (50%) and peritoneum metastases (33%) . Yu et a0% as the2) and radiotherapy with a median dose of 36 Gy in 15 fractions using IFRT (GTV plus 1 cm of margins). With a median survival of 11.2 months, lymph node failure was observed in only four patients (5%), in three of whom the failure was located within the PTV and was similar to what was observed in the present study. Only one lymph node failure was located outside the PTV [The occurrence of regional lymph node failure is a relatively rare event in the literature, especially when the treatment involves modern chemotherapy regimens based on gemcitabine or FOLFIRINOX. These are considered effective for controlling micrometastases in regional lymph nodes. Murphy et al. treated 74 patients with pancreatic tumors considered unresectable using a combination of gemcitabine (1000 mg/m3 (range: 115-937 cm3). With the inclusion of elective lymph node drainage, the median PTV increased to 463 cm3 (range: 366-988 cm3), which would also lead to the inclusion of much higher volumes of organs at risk, especially the small intestine [Treatments with IFRT result in a significant reduction in the volume of the stomach and small intestine compared with those with the elective inclusion of lymphatic drainage. A direct correlation was observed between PTV volume and gastrointestinal toxicity. Murphy et al. found a statistically significant association between high PTV and high morbidity. In the present study, the median PTV was 350 cm3 range: 5-937 cm3Based on this evidence, some authors and societies of the specialty have indicated specific volumes for locally advanced tumors, with the majority being favorable to IFRT treatments -14. The DoseLocal failure is a frequent outcome after treatment of locally advanced pancreatic tumor. Recent technical advances have been employed in an attempt to safely administer larger doses and improve local control rates.SBRT offers the advantages of being performed with more precision and the biological effective dose being higher than that in conventional fractionations with fewer fractions. Planning done with more advanced techniques and treatments with a greater number of fractions have significantly reduced the complications and allowed treatment of larger volumes around the primary lesion -24.It is still doubtful whether increasing the dose causes a corresponding increase in local control and overall survival. Studies using this technique have not been able to show significantly higher survival rates in relation to treatments performed using conventional fractionation -28. CompMoningi et al. analyzed the contemporary use of combined radiotherapy and chemotherapy treatments in 5,624 patients with locally advanced tumors. Owing to the availability of more therapeutic resources, especially with new systemic agents and better clinical selection of patients, these authors observed a decline in the use of radiotherapy from 55% to 45% among patients over 65 years of age during the period 2006-2013 and from 52% to 47% during the period 2006-2016 for younger patients. In both groups, there was an increase in the use of SBRT, more remarkable in recent years, of 10% and 12% for these groups of patients, respectively. Of the 2,522 patients over the age of 65 years, 53% underwent radiotherapy after induction chemotherapy, and 47% were treated with chemotherapy alone, with a predominance of gemcitabine-based regimens. Of the patients who received radiotherapy, 92% received conventional fractionations, with a median of 28 fractions. Similar results were observed in the group of younger patients, with 51% undergoing both chemotherapy and radiotherapy. The median survival was 11.5 months and 12 months, respectively, for patients undergoing radiotherapy with conventional fractionation and SBRT. These authors have identified greater selectivity in the use of radiotherapy in recent years. The results of this study also showed a reduction in the rate of complications owing to technological improvements observed in the treatments .We carried out a retrospective analysis with a limited number of patients with a specific clinical situation. Probably, due to this, it was not possible to obtain a statistically significant correlation with the clinical and therapeutic variables in relation to the influence on local control or distant metastasis.The use of radiotherapy as a complementary therapy for patients with unresectable tumors after chemotherapy in carefully selected cases is a viable and safe option to improve local control rates and quality of life. In this study, IFRT was not correlated with significant lymph node therapeutic failure outside the limits of PTV and presented low morbidity rates. DF remained the predominant failure pattern.


Overall, we envision that the hydrophilic plasticene should satisfy a wide range of requirements for superhydrophilic structures and update our understanding of superhydrophilic materials in both fabrication and application.The rational design of superhydrophilic materials with a controllable structure is a critical component in various applications, including solar steam generation, liquid spontaneous transport, etc. The arbitrary manipulation of the 2D, 3D, and hierarchical structures of superhydrophilic substrates is highly desirable for smart liquid manipulation in both research and application fields. To design versatile superhydrophilic interfaces with various structures, here we introduce a hydrophilic plasticene that possesses high flexibility, deformability, water absorption, and crosslinking capabilities. Through a pattern-pressing process with a specific template, 2D prior fast spreading of liquids at speeds up to 600 mm/s was achieved on the superhydrophilic surface with designed channels. Additionally, 3D superhydrophilic structures can be facilely designed by combining the hydrophilic plasticene with a 3D-printed template. The assembly of 3D superhydrophilic microstructure arrays were explored, providing a promising route to facilitate the continuous and spontaneous liquid transport. The further modification of superhydrophilic 3D structures with pyrrole can promote the applications of solar steam generation. The optimal evaporation rate of an as-prepared superhydrophilic evaporator reached ~1.60 kg·m Interfaces possessing special functions have emerged as a powerful platform for innovating materials and devices in both scientific research and modern technology ,3,4,5,6.To realize such unique properties, the micro-/nano-scale structure and the chemical composition of the surface should be cooperatively designed ,22. As a−1, exhibiting a significant acceleration as compared with the smooth conical spine [The rational design of superhydrophilic surfaces with hierarchical structures should unlock more possibilities for their development and application . A Chineal spine . Throughal spine .Although the superhydrophilic structure has a series of unique liquid manipulation abilities, the universal and facile strategies of design and fabrication should be further investigated to meet the requirement of hierarchical structure and complicated design. To this end, here we report a hydrophilic plasticene for designing versatile superhydrophilic interfaces. The alginate-based plasticene can be easily shaped with proper templates and rapidly solidified by calcium ions. Silica microparticles and wood microfibers acted as the fillers of this plasticene, which endowed the as-solidified superhydrophilic structure with a hydrophilic capillary structure and fire retardation. Taking the advantages of the high deformability of the plasticene, versatility of the superhydrophilic structures for liquid manipulation can be designed such as the 2D-patterned paper, 3D microstructure arrays, complex and hierarchical channels, etc. Furthermore, the superhydrophilic structure is able to be modified with pyrrole molecules, resulting in a light-absorbing substrate for constructing the solar steam generator with promising performance. We envision that this hydrophilic plasticene can be a good candidate for the preparation of superhydrophilic structures, which provides a useful platform for incorporating superhydrophilic interfaces into different application systems.2 particles were obtained from Shanghai Yingjia Industrial Development Co., Ltd.  and Dongwan Xinweijin Industrial Co., Ltd. , respectively. Sodium alginate, calcium chloride, hydrochloric acid, sodium hydroxide, 5% H2O2 solution, ammonium persulfate, and Pyrrole solution were purchased from Shanghai Macklin Chemical Co., Ltd.  without any further treatment. The surface morphology of the black and white hydrophilic plasticene, as well as different parts of the hydrophilic plasticene cube after six minutes of combustion under a butane flame, was analyzed using a scanning electron microscope . Tailored molds were printed using a 3D printer , and water contact angles of the surfaces were measured using an SDC-200 geometer  with a 10 μL droplet. The detailed droplet growing processes were recorded using an industrial microscope , while the processes of 2D prior spreading on the hydrophilic plasticene were recorded using a high-speed camera . A syringe pump  was utilized to discharge water droplets at a constant flow rate of 20 mL min−1. Solar steam generation was measured using a solar simulator  with an AM 1.5 optical filter. The light intensity was regulated to 1 sun (1000 W m−2) with a solar power meter  and the solar absorption at 200–2500 nm was measured using a UV–VIS-NIR spectrophotometer  equipped with a 150 mm integrating sphere. A thermal infrared camera  was utilized to capture the thermal images, while the mechanical properties of the hydrophilic plasticene were analyzed using an electromechanical universal testing machine . Materials and Characterization: In this study, wood fiber (FB-300) and SiO2 particles, and sodium alginate in a mass ratio of 8:16:1 was prepared and pressed into various shapes using 3D-printed molds. The resulting samples were then immersed in a 10 wt% CaCl2 solution for 1 h and washed to remove excess particles before being air-dried. To fabricate the black hydrophilic plasticene, the hydrophilic plasticene was first crosslinked and dried. It was then wetted with a dropwise addition of 1 mL of an aqueous ammonium persulfate solution (10 wt%) and dried again at 50 °C for 1 h. A 5% solution of pyrrole ethanol was then dripped onto the treated hydrophilic plasticene and dried for an additional hour at 50 °C, resulting in the formation of the black hydrophilic plasticene material.Preparation of the hydrophilic plasticene with Complex Structure: To create the hydrophilic plasticene material, a mixture of wood fibers, SiO2 particles (40 μm particle size), and an alginate-based polymer. This mixture was then pressed into a 3D printing mold to form the original hydrophilic plasticene. The hydrophilic slurry composed of sodium alginate, wood fibers, and SiO2 particles was filled into the internal or surface channels of the 3D printing mold with force, as shown in 2 solution for 1 h, and the untethered particles were removed using water flushing. The SEM analysis  upon contact. For droplet spreading on the stripes, the spreading speed in the X direction was found to be 1.6–2.2 times higher than that in the Y direction. This finding suggests that the channels generated by the imprint on hydrophilic plasticene have a guiding and facilitating effect on liquid spreading. In an effort to extend the channel advantage, a square pattern with channels in both the X and Y directions was designed. The droplet spreading speed on this square pattern was the fastest, reaching up to 600 mm/s, with spreading speed and spreading time in the X direction being similar to those in the Y direction. Ultimately, the surface-oriented patterned channels were found to contribute to monolayer spreading of the water droplets, a unique wettability attributed to the layered micro/nanostructure of the surface, which facilitates multilayer spreading.Hydrophilic plasticene, owing to its arbitrary moldability, offers a promising avenue for continuous liquid transport. The hydrophilic nature of the material and the 3D-embossed complex structure makes it an ideal candidate for liquid-conducting devices. A plethora of attempts have been undertaken to enhance the speed and efficiency of liquid transport, leading to the discovery of some fascinating phenomena. In this regard, five distinct types of single-row, cylindrical arrays were fabricated by pressing hydrophilic plasticene into 3D-printed molds, which served as an experimental platform to study the liquid transport process. The five types of cylindrical arrays include the following: sample Ⅰ, which is a solid pillar with a solid channel (the diameter of the pillar is 1.5 mm and the height is 5 mm); sample Ⅱ, which is a solid pillar with a hollow channel (the width and depth of the channel are 2 mm); sample Ⅲ, which is a half-solid pillar with a hollow channel (the diameter of the hollow part of pillar is 1 mm); sample Ⅳ, which is a hollow pillar with a hollow channel; and sample Ⅴ, which is an open pillar with a hollow channel.To investigate the fluid transport in different types of 3D superhydrophilic arrays, a 200 µL fluid injection at a speed of 2 mL/min was performed from the bottom of each 3D sample. The experiment was recorded using The 3D superhydrophilic structure has shown great potential in facilitating liquid evaporation processes due to its inherent liquid-pumping and spreading ability. To enhance the evaporation efficiency, we aimed to increase the actual air–liquid interface area per unit area by introducing micro-cones onto the superhydrophilic sheet using a template pressing method . To appl2 to accelerate the interfacial evaporation. The evaporation capacity was assessed quantitatively by monitoring the water mass loss (In order to evaluate the evaporation performance of hydrophilic plasticene, we conducted laboratory experiments using simulated solar light with a density of 1000 W/mass loss d over a ass loss e. The reass loss .−2·h−1 with a conversion efficiency of approximately 92.96%. In contrast, the evaporation rate of black Ⅰ was only ~1.35 kg·m−2·h−1 with a conversion efficiency of approximately 78.71%. These results clearly indicate that the evaporation efficiency of hydrophilic plasticene can be enhanced by increasing the exposed area.The evaporation performance of the black light-absorbing hydrophilic plasticene was evaluated under one sun irradiation. The water mass change was monitored every 30 min, and the evaporation rate of black Ⅴ was found to be ~1.60 kg·mMoreover, this advantage will be further magnified under daylight evaporation, making it highly suitable for similar evaporation scenarios. Furthermore, the approach of shaping hydrophilic plasticene can be extended to other shape arrays , paving −2·h−1 with a conversion efficiency of approximately 92.96%. The use of hydrophilic plasticene expands the research scope of superhydrophilic interfaces and solar evaporation to meet the needs of various fields, such as wound dressing, oil/water separation, and microfluidics.The development of versatile and simple superhydrophilic structures can advance the current state of superwetting interfaces. This study reports the use of hydrophilic plasticene to fabricate 2D-patterned papers, 3D microstructure arrays, and complex layered channels. The establishment of surface-oriented patterned channels enables monolayer spreading of water droplets, and this unique wettability is attributed to the layered micro/nanostructure, which facilitates multilayer spreading. The square-patterned surface exhibits the fastest spreading speed of droplets, up to 600 mm/s. Different 3D microstructure arrays were tested for continuous fluid transport, and structures with hollow pillars and channels were found to contribute to efficient liquid transport. The array design of hydrophilic plasticene inspires a method to improve the efficiency of solar evaporation. The achieved evaporation rate is ~1.60 kg·m


Here, we show that in sepsis, neural nuclear autophagy is extremely activated, and nuclear LaminB decreases and is accompanied by an increase in the ratio of LC3BII/I. These effects can be reversed in GSDMD−/− mice. The behavioral outcomes of septic wild-type mice are impaired by the evidence from the novel object recognition test (NORT) and open field test (OFT), but are improved in septic GSDMD−/− mice. In conclusion, our study demonstrates the activation of neural nuclear autophagy in SAE. The absence of GSDMD inhibits nuclear autophagy and improves the behavioral outcomes of SAE.Sepsis-associated encephalopathy (SAE) is a common complication of sepsis, which is a life-threatening condition resulting from a dysregulated host response to infection. Pyroptosis, a pro-inflammatory mode of lytic cell death mediated by GSDMD (Gasdermin D), is involved in the pathogenesis of SAE. While autophagy has been extensively studied in SAE, the role of nuclear autophagy is not yet well understood. In this study, we aimed to investigate the involvement of pyroptosis and neural nuclear autophagy in the pathogenesis of SAE. We analyzed a CLP -induced SAE model in wild-type and GSDMD In recent times, there has been increasing focus on the pyroptosis mechanism in relation to sepsis-associated encephalopathy (SAE) ,2,3,4,5.Nuclear autophagy selectively degrades the nucleus of a cell through the cellular mechanism of autophagy, which is essential for maintaining cellular homeostasis by eliminating abnormal nuclei, preventing genetic mutations, and promoting cell survival ,17. In nSeveral markers exist that specifically identify nuclear autophagy. LaminB, a type of intermediate filament protein, participates in the formation and maintenance of the nuclear envelope, ensuring the nucleus’s integrity and organization . During In addition to nuclear autophagy, mitochondrial damage is also observed in SAE, which manifests as a shorter and smaller mitochondria with a disrupted membrane structure ,36,37,38−/− mice and analyze the autophagy in the nucleus and cytoplasm.Nuclear autophagy is observed in SAE but is poorly understood. A previous study reported that the nuclear LaminB1 acts as a substrate for nuclear autophagy in primary human cells , triggerAntibodies used in this study are listed in −/− mice were purchased from GemPharmatech Co., Ltd. The mice were kept in a temperature-controlled environment and were given standard food and unlimited access to water. The experimental animal ethics committee of Tongji Hospital, affiliated with Huazhong University of Science and Technology (TJH-201901022), approved all animal experiments and ensured that they were conducted in accordance with the ARRIVE guidelines [Male C57BL/6 mice  were obtained from the Experimental Animal Center of Tongji Medical College at Huazhong University of Science and Technology. The GSDMDidelines  and the −/− sham group; and the GSDMD−/− CLP group.Male C57BL/6 mice were subjected to cecal ligation and puncture to induce polymicrobial abdominal sepsis . To anesThe mice were subjected to a locomotor activity test three days after surgery. Each mouse was placed in the center of a square arena with dimensions of 40 cm in height, 50 cm in width and length, with a camera overhead. During the 5 min trial, the total distance traveled was recorded to evaluate locomotion. The arena was divided into 25 equal parts, and the amount of time spent in the border parts was determined as the border-zone duration. After each trial, the arena was thoroughly cleaned using 75% alcohol.One hour after the OFT, the mice were introduced into an arena containing two identical objects and were allowed to explore freely for 10 min. After a one-hour interval, the mice were returned to the arena where one of the objects had been replaced with a new one, and they were again given 10 min to explore. To eliminate any olfactory cues, the objects and the arena were cleaned thoroughly with 75% ethanol between each trial.The mice were anesthetized using pentobarbital sodium and perfused transcardially with 0.1 M phosphate-buffered solution (PBS), followed by 4% paraformaldehyde. Subsequently, the brain samples were fixed in a solution of 4% paraformaldehyde for 36 h, followed by a soak in 30% sucrose for 72 h. The brains were sliced into 30 μm-thick sections using a cryotome  and then were treated with 0.5% Triton X-100, followed by blocking with 3% bovine serum albumin. Next, each brain slice was incubated with the relevant primary antibody overnight at 4 °C, and then incubated with a secondary antibody for 2 h at room temperature. The slices were finally stained with DAPI for 10 min. The images were captured using a fluorescence microscope . The antibodies used are listed in Cytoplasmic and nuclear fractions of brain tissues were extracted by using a Nuclear and Cytoplasmic Protein Extraction kit ). To obtain the whole-cell lysate, the brain tissue was homogenized with a RIPA lysis buffer that contained a protease inhibitor, then centrifuged at 12,000 RPM and 4 °C for 15 min. The protein concentration of each sample was determined using a BCA kit ). The proteins were separated using SDS-PAGE, then transferred onto PVDF membranes. After blocking with 5% bovine serum albumin, the membranes were incubated with specific primary antibodies overnight at 4 °C, followed by incubation with horseradish peroxidase-conjugated secondary antibodies for 1 h at room temperature. The protein bands were visualized using electrochemiluminescence (ECL) and the imaging system ). The ImageJ software was used for optical density analysis.The mice were anesthetized using pentobarbital sodium and perfused transcardially with 0.1M phosphate-buffered solution (PBS). Fresh prefrontal cortex tissues were harvested and immersed in 2% glutaraldehyde at 4 °C for 24 h. The tissues were then rinsed in 0.1 M PBS and fixed with 2% OsO4 at 4 °C for 60 min. After undergoing dehydration and embedding in resin, the tissues were cut into 700 nm-thick sections. The sections were stained with 4% uranyl acetate for 20 min and 5% lead citrate for 5 min. Images were scanned with a transmission electron microscope.The immunofluorescence staining was performed on each group, as previously described . The imap-value less than 0.05 was considered statistically significant.The data were expressed as the mean ± SEM. Statistical analysis was performed using GraphPad Prism 8. The results underwent the analysis of variance and the Newman–Keuls test, while the survival curve was analyzed through the Kaplan–Meier test and differences between groups were evaluated through a log-rank test. A The absence of GSDMD improves the prognosis in mice with SAE.−/− mice, the survival rates were 73% (11 out of 15 mice), 53% (8 out of 15 mice), and 53% (8 out of 15 mice) on the first, second, and third days, respectively  on the first day, 35% on the second day (7 out of 20 mice), and 35% on the third day (7 out of 20 mice), while in GSDMDectively A. On theectively B. The opectively C,G.−/− CLP mice showed an improved cognitive function compared to the WT+CLP group  was found to be reduced in mice with sepsis compared to those in the sham group. Additionally, we noticed that the circularity of the nuclei in GSDMDCLP mice G,H.The digestion of LaminB caused by nuclear autophagy is independent to GSDMD.−/− CLP mice was not reduced but instead, it was even higher compared to that in GSDMD−/− sham mice (We then question how sepsis activates nuclear autophagy. In a previous study, LaminB was digested by nuclear autophagy in primary human cells . We thenham mice A,B. The ham mice G,H. Thisham mice D.−/− mice, the LC3BII/I ratio in the nuclei of septic mice showed no difference when compared to the sham group, while the ratio in the cytoplasm and whole-cell lysate was higher in septic mice than in sham mice, confirming the TEM results that cytoplasmic autophagy was reduced in the GSDMD−/− septic mice compared to wild-type septic mice. In comparison to their respective sham controls, a decrease in the levels of P62 was observed in the cytoplasmic and whole-cell lysates of both the wild-type and GSDMD−/− septic mice. The level of P62 was found to be even lower in wild-type CLP mice compared to GSDMD−/− CLP mice. Additionally, an increase in GSDMD-N was observed in wild-type CLP mice, and it was predominantly located in the cytoplasmic lysate (In wild-type mice, the LC3BII/I ratio was observed to be higher in the CLP group compared to the sham group in the nuclear component, cytoplasm, and whole-cell lysate (c lysate . The resc lysate L.In our study, we discovered that CLP-induced sepsis caused an increase in brain nuclear autophagy. We also found that knocking out GSDMD in mice improved their survival rate and reversed the pathological changes in SAE. These improvements included better cognitive function and a reduction in abnormal nuclear morphology. Interestingly, we did not find any evidence that GSDMD was associated with LaminB digestion induced by nuclear autophagy.−/− mice. Nevertheless, high levels of mitophagy were still observed. The results obtained from TEM were further supported by our analysis of LC3B and P62, which showed the activation of autophagy in both the nuclear and cytoplasmic components during sepsis. However, cytoplasmic autophagy remained high even in the GSDMD−/− CLP mice. During autophagy, the autophagosome fuses with the lysosome, and the contents of the autophagosome are degraded, including p62. Thus, increasing autophagic flux results in decreasing levels of p62 [From our TEM analysis of cerebral tissue in septic wild-type mice, we observed a heightened nuclear autophagy in neurons and reduced perinuclear heterochromatin. Additionally, we found that mitophagy was also activated. The autophagosome and lysosome were observed to be concentrated near the nucleus. In comparison, nuclear autophagy was alleviated in neurons and perinuclear heterochromatin was preserved in septic GSDMDs of p62 .−/− mice, and the upregulation of LC3B was observed in both cytoplasmic and nuclear components, implying that GSDMD was involved in the process of nuclear autophagy. To further analyze the interaction between LC3B and GSDMD, a more comprehensive study is needed using techniques such as immunoprecipitation and immunofluorescence. LaminB is a substrate of nuclear autophagy [Additional examination needs to be conducted to ascertain how pyroptosis affects nuclear autophagy in SAE. A recent study demonstrated that GSDMD-N can also be found on the membranes of various intracellular organelles . These dutophagy . Our stuutophagy  indicate−/− CLP mice could be attributed to the anti-inflammatory effects resulting from the absence of GSDMD.In addition to LaminB, numerous other nuclear components are expected to bind with LC3 , suggestCLP-induced sepsis triggers an increase in brain nuclear autophagy. The absence of GSDMD inhibits nuclear autophagy and improves the behavioral outcomes of SAE. This finding may pave the way for the development of new treatments for SAE that target GSDMD and nuclear autophagy. This study also adds to our understanding of the pathophysiology of SAE, which could lead to improved diagnosis and management of this condition in clinical practice.


Using patient-reported outcome measures was associated with student role (χ2(2) = 21.6, p < 0.001), length of encounter (χ2(4) = 34.5, p < 0.001), and clinical site (χ2(3) = 17.3, p = 0.001). Implementing clinician-rated outcome measures was affected by length of encounter (χ2(4) = 27.9, p < 0.001) and clinical site (χ2(3) = 8.6, p = 0.04). PCC behaviors were largely associated with student role and length of encounters; clinical site had less impact. Athletic training educators should emphasize progressive autonomous supervision with preceptors and encourage students to facilitate slightly longer patient visits, when possible, to incorporate more PCC behaviors.Patient-centered care (PCC) is a core competency that should be required by all healthcare education programs, but little is known about its implementation in athletic training clinical experiences. Therefore, we examined characteristics of patient encounters documented by athletic training students implementing PCC behaviors. A multisite panel design was used to recruit 363 students from twelve professional athletic training programs . Over 1.5 years, clinical experience patient encounter data were logged in E*Value Case Logs, including student role during the encounter, length of encounter, and clinical site. Generalized estimating equations models characterized the likelihood students included PCC behaviors in 30,522 encounters. Discussing patient goals was associated with student role (χ More than 20 years ago, the Institute of Medicine identified patient-centered care (PCC) as one of the essential components of quality healthcare ,2,3. AltIn athletic training education, PCC was first introduced in the advanced practice landscape, with requirements to incorporate it into post-professional degree and residency programs in 2014 , and becTo increase the implementation of PCC, we need a greater understanding of the characteristics of individual patient interactions that facilitate consistent PCC behaviors. Therefore, the purpose of the current study was to examine the characteristics of PEs documented by athletic training students implementing PCC behaviors.A multisite panel design was used to track the PEs of athletic training students during their clinical experiences. Data from 12 athletic training programs were collected for 1.5 academic years. All PEs were entered in the E*Value Case Logs software, which is a web-based data management system . Before data collection, institutional review board approval was granted by the sponsoring institutions and, as needed, the participating institutions. Within the United States of America, athletic training education is a healthcare education program that prepares students to engage in patient care with physically active individuals across five domains of practice: (1) Risk Reduction, Wellness, and Health Literacy; (2) Assessment, Evaluation, and Diagnosis; (3) Critical Incident Management; (4) Therapeutic Interventions; and (5) Healthcare Administration and Professional Responsibility. Students within such programs engage in clinical experiences in which they participate in actual patient care under the supervision of a preceptor, otherwise known as a clinical instructor or clinical supervisor. Educational programs may choose to use software programs, such as E*Value, to have students log the patient cases they experience during clinical experiences to use for program and student assessment.We recruited Commission on Accreditation of Athletic Training Education (CAATE)-accredited professional athletic training programs by contacting the program directors and clinical education coordinators of each program to determine interest and eligibility to participate. Our inclusion criteria for participation consisted of the following: (1) the program used E*Value to track student PEs during clinical experiences for at least 1 year before the study, (2) the program required students to track PEs using the Case Logs module in E*Value during clinical experiences, and (3) the program had a 3-year aggregate Board of Certification first-time pass rate greater than 85% . Twelve n = 363) were informed that their program had chosen to participate in the study and that informed consent forms had been completed by the program director. Since all PEs recorded by the students were a required part of their program’s organized clinical experiences, obtaining informed consent from individual students was deemed unnecessary. Before data collection, one member of the research team worked with the program director of each program to confirm that the E*Value Case Logs module included all the pertinent data fields [Students enrolled in the participating programs , each participating program received a research study honorarium. A detailed description of the study procedures, including program and student-level training procedures, has been published elsewhere [We used descriptive statistics, including frequencies (percentages) and means (standard deviations), to summarize PCC behaviors performed by students during PEs. Generalized estimating equations models (GEE) with Poisson distributions and robust covariance estimators were used to characterize the likelihood (relative risk ratios) that students included the following at each encounter: (1) discussed patient goals with the patient, (2) collected information using a patient-reported outcome measure (PROM), (3) collected information using a clinician-rated outcome measure (CROM), and (4) implemented no PCC behaviors. Potential predictors (PE characteristics) included student role , length of encounter (1 min to >60 min), and type of clinical site . An analogous GEE approach was employed to analyze the association of PE characteristics on the composite opportunities  for all PCC behaviors that students included during PEs. Only predictors that significantly contributed to the equation were retained in the final model. Sequential Bonferroni corrections were applied to pairwise comparisons. An a priori significance threshold of α < 0.05 was set for all analyses. Data were analyzed using SPSS version 27 .n = 30,630) included a response for PCC behaviors documented by 338 athletic training students. Descriptive information about the participating programs has already been published elsewhere [For the 12 participating programs, 30,522 PEs  = 40.6, p < 0.001) and length of encounter (χ2(4) = 67.6, p < 0.001) were associated with whether the student discussed the patient’s goals with the patient. Students who performed the PE  under the supervision of their preceptor  and those (n = 5052 PEs) who assisted their preceptor throughout the PE  were more likely to discuss the patient’s goals with the patient than those who observed their preceptor completing the PE (n = 3669 PEs). When the length of PEs was 31–45 min (n = 2328 PEs), students were more likely to discuss the patient’s goals  than in PEs of 1–15 min . When compared with PEs of 1–15 min, PEs of 16–30 min , PEs of 46–60 min , and PEs longer than 60 min  were more likely to include this professional behavior.Student role (χ2(2) = 21.6, p < 0.001), length of the encounter (χ2(4) = 34.5, p < 0.001), and type of clinical site (χ2(3) = 17.3, p = 0.001). When performing the PE under the supervision of their preceptor  and when assisting their preceptor during the PE , students were more likely to use a PROM than when observing their preceptor perform the PE. When compared with PEs of 1–15 min, students were more likely to use a PROM in PEs of 16–30 min , PEs of 31–45 min , PEs of 46–60 min , and PEs longer than 60 min .The use of PROMs by students was associated with student role  and high school (n = 8307 PEs) sites relative to PROM use (p = 0.12). However, when compared with college/university sites, students who performed the PE at another site were less likely to use a PROM , and those who performed the PE at clinical sites were more likely to use a PROM .For type of clinical site, no differences were found between college/university (2(4) = 27.9, p < 0.001) and type of clinical site (χ2(3) = 8.6, p = 0.04). When compared with PEs of 1–15 min, students were more likely to use a CROM in PEs of 16–30min , PEs of 31–45 min , PEs of 46–60 min , and PEs longer than 60 min . Relative to type of site, PEs performed at clinical sites were more likely to involve a CROM than those at college/university sites .Student use of CROMs during PEs was associated with length of the encounter (χ2(2) = 43.6, p < 0.001) and length of the encounter (χ2(4) = 53.9, p < 0.001). Students who performed the PE  or assisted their preceptor with the PE  were less likely to implement no PCC behaviors than those who observed the PE. When compared with PEs of 1–15 min, students were less likely to implement no PCC behaviors in PEs of 16–30 min , PEs of 31–45 min , PEs of 46–60 min , and PEs longer than 60 min .Similar to discussing patient goals with the patient, the likelihood that students implemented no PCC behaviors was associated with student role (χ2(4) = 30.0, p < 0.001) and length of the encounter (χ2(4) = 111.1, p < 0.001). Students who performed the PE  or assisted their preceptor with the PE  were more likely to implement more PCC behaviors than those who observed the PE. When compared with PEs of 1–15 min, students were likely to implement more PCC behaviors during PEs of 16–30 min , PEs of 31–45 min , PEs of 46–60 min , and PEs longer than 60 min .The overall clinical associations of PCC behaviors and associated characteristics of documented PEs are presented in Although the overall project collected a wide variety of variables to represent the characteristics of PEs, in the current study, only three variables were associated with the use of PCC behaviors by athletic training students: student role during the PE, length of the encounter, and type of clinical site where the PE occurred.Our findings for student role during PEs suggested that increased student autonomy during their clinical experiences resulted in an increase in PCC behaviors. Students who performed the PE were the most likely to ask the patient about their goals, use a PROM, and include more PCC behaviors overall. This finding slightly conflicts with previous research in athletic training education that reported students who assisted their preceptor during PEs had the greatest odds of implementing PCC . In our A participatory action research study conducted in family medicine education determined that clinical supervisors must intentionally introduce and describe core competencies during patient interactions in order for students to embrace their use in clinical practice . SimilarStudents who observed their preceptor during PEs were the most likely to indicate that no PCC behaviors were implemented during encounters. Researchers have previously reported that observation of working clinicians, especially when working in interprofessional teams, gives students the opportunity to reflect on attitudes to other healthcare professions, the power dynamics between clinicians and patients and between clinicians and other healthcare professionals, and the influence of communication on patient care . One sugThe amount of time spent with the patient was associated with all PCC behaviors, including the likelihood of implementing no PCC behaviors or the greatest number of PCC behaviors. The PEs that lasted 31–45 min seemed to hit the metaphorical sweet spot for PCC; this length of encounter had the greatest likelihood of students discussing the patient’s goals with the patient, using a PROM, and implementing more PCC behaviors. This length of time also had the lowest likelihood of students implementing no PCC behaviors during PEs. This finding was somewhat consistent with previous research in athletic training education that reported longer PEs had an increased odds ratio of implementing PCC . HoweverIn ambulatory healthcare practice settings that employ athletic trainers, average patient visit times were 31 min for new patients and 19 min for established patients . AlthougImportantly, the length of the patient interaction influences much more than just the use of PCC behaviors, as measured in the current study. Shorter patient visits have been associated with decreases in patient and clinician satisfaction, poorer patient outcomes with chronic disease treatment, and an increase in malpractice claims . To imprAlthough not as consistently related to PCC behaviors as student role or length of encounter, the type of clinical site where the student was interacting with patients had some association with the use of PROMs and CROMs. This finding was consistent with the literature in athletic training education that indicated the clinical site had minimal influence on the use of PCC behaviors during PEs; however, differences in that study were found between college and high school settings , which wIn medical education, students who spent an entire year at one clinical site had less degradation of PCC behaviors and attitudes than those who attended multiple clinical rotations during the year . HoweverOther researchers have reported that implementation of PCC behaviors may have less to do with site type and more to do with the informatics infrastructure of the site . For exaThe strength of this study is the longitudinal nature of examining PEs over a year of time across different athletic training programs. Another strength that built upon the existing body of evidence was the identification of behaviors associated with PCC to increase the specificity of which aspects of PCC were being used. A limitation of our study was that we only examined aspects of PCC behaviors that could be implemented during PEs. We did not examine the role of organizational culture or other institution-wide contributors on these PCC behaviors in the healthcare system. The data collection process also relied on the participating athletic training students accurately self-reporting their behaviors during PEs. Future research should examine the interrelatedness of PCC and informatics infrastructure at various clinical sites to characterize the relationship of PCC and informatics more accurately. Future research should also aim to evaluate how students are assessed on the implementation of patient-centered care by preceptors or programmatic faculty. If a similar study is implemented in the future, researchers should aim to triangulate student perceptions with preceptor observations to strengthen the accuracy of the findings.In the current study, student role and length of the encounter had an overall greater association with the implementation of PCC behaviors during PEs, and the type of clinical site had a minimal role on the implementation of PCC behaviors. However, our clinical site findings may have been influenced more by the informatics infrastructure of the site rather than the type of site. Therefore, athletic training education programs should evaluate the informatics available at clinical sites to identify opportunities for increasing student proficiency in both PCC behaviors and healthcare informatics. According to our results, as autonomy increased, students were more likely to ask the patient about their goals and use PROMs. As the length of the encounter increased, there was a general increase in overall PCC behaviors; the optimal length of time for implementing PCC behaviors during a PE was 31–45 min. For program administrators hoping to increase the PCC behaviors of their students during clinical rotations, clinical site data should be analyzed to determine which sites promote greater patient autonomy and have average PE lengths of 31–45 min. Alternatively, program faculty should focus on patient-centered communication to increase the likelihood that PCC behaviors are implemented during shorter PEs or that preceptors have increased supervision and involvement.


Patients who have short peripheral venous catheters (PVC) face an elevated risk of developing bloodstream infections. Preventing catheter-related infections relies on implementing multiple measures, including practicing proper hand hygiene (HH) during catheter placement.We conducted a four-part study: (1) an evaluation of HH practices through direct observation of PVC placements, coupled with the study of the microbial flora of the HCWs fingers just before the placement; (2) the development of an educational tool based on the collected observational and microbiological data; (3) the training to the HCWs observed during the first part, using this tool; and (4) the subsequent observation of the trained HCWs to measure the impact of the training on practice improvement.p = 0.003). The comparison of practices before and after training, assessed among 180 HCWs, showed an increase in the proportion of HCWs performing compliant HH .Compliant HH was observed in 23.5% of the 647 HCWs observed during PVC placement before training. The microbiological study revealed fewer pathogens on the fingertips of the HCWs practicing compliant HH compared other HCWs , identifying professionals deviating from best practices (simulation videos), and objectively assessing fingertip contamination , significantly improved compliance with HH gestures and glove usage. We encourage infection control teams to utilize this tool to raise awareness among HCWs responsible for PVC placement about the risk of infection associated inadequate hand hygiene.The online version contains supplementary material available at 10.1186/s12909-023-04727-x. The placement of short-term peripheral intravenous catheters (PVCs) is a common medical procedure, estimated at around 25 million cases in France in 2005 . PVC-relPVC-related infections occur as a result of catheter contamination and the factors favouring these infections are multiple , 4. PVC Preventing PVC-related infections relies on implementing a bundle of measures during PVC placement, including hand hygiene (HH) , 5–10. HNumerous studies consistently show that HCWs often do not adequately adhere to HH opportunities and technical compliance, with rates generally below 50% , 11. LowInterventions aimed at improving HH in patient care are abundant , but datWhile HH procedures are straightforward, improving their implementation by HCWs is a complex challenge . Numeroup < 0.001), and 0.5% before PVC insertion, compared to 45.5% after intervention (p < 0.001). However, this study appeared to require a significant time commitment in the field, considering the current workload burdens in clinical services and the need for repeated interventions.Many tools are available for promoting HH , 19–21. To facilitate behaviour change, HCWs must recognize the risk and comprehend the mechanisms of microorganism transmission during patient care , 14. In To begin, we developed an educational tool tailored for the context of PVC placement. This tool was intended for use during concise educational sessions lasting less than 30 min. It incorporated data acquired from observations and microbiological analyses, complemented by instructional videos showcasing a range of PVC placement scenarios, encompassing both correct procedures and instances with errors. We conducted observations of HCWs both prior to and following their training with our tool to assess its effectiveness in improving hand hygiene.Since 2019, the French Ministry of Health has mandated that all hospitals in France require their local infection prevention teams to execute the 2022–2025 National Strategy for Infection Prevention and Antibiotic Resistance. Within this initiative, the reduction of catheter-related infections is a primary focus. The national SPIADI network’s role is to aid local infection prevention teams in implementing catheter-related infection monitoring and prevention within their respective facilities. In this context, the SPIADI team extended invitations to all infection control teams from French hospitals to participate in the study. The study, conducted from January to September 2022, consisted of four phases: (1) an evaluation of HH practices was conducted in each participating center, with direct observation of HCWs placing PVCs and the study of the microbial flora present on the fingers of the observed HCWs; (2) the national-level development of an educational tool was conducted using the data obtained during the first phase, including the results of the HH practices evaluation and microbiological data; (3) the local infection control teams trained the HCWs observed during the first phase using the tool; and (4) a second observation of HH practices was conducted by the local infection control teams. This second evaluation aimed to measure the impact of the training on the improvement of HH practices. Comprehensive details regarding the study protocol and participation guidelines can be found in a downloadable technical guide accessible on the SPIADI national network’s website (spiadi.fr).https://www.spiadi.fr/results?tab=0).At each participating center, the infection control team leader was tasked with selecting the ward(s) in which to carry out the study; The recommendation was to choose a specific entity  and observe graduate or student HCWs placing a PVC in adult patients within that geographical entity. The observations were conducted during the first phase for eight different HCWs. If the number of professionals responsible for PVC insertions within that geographical entity exceeded eight, it was suggested to select the professionals for observation randomly. The observations were conducted during the fourth phase for all the HCWs observed during the first phase and trained during the third phase, with a minimum of 2 months between the second observation and the training. The observations were conducted using a standardized grid examining HH at the beginning of the procedure and immediately prior to PVC insertion , presence/absence of prerequisites  and conformity of the gesture if applicable), and glove use (presence/absence of gloves and time of gloving if applicable), and skin preparation . Supplementary Figure S. aureus, Enterobacteriales and Enterococci were tested for antibiotic susceptibility according to French guidelines [During the first phase, the local infection control teams used sterile systems  to swab the fingertips and palm of the hands of the HCWs immediately prior to PVC insertion, following a standardised procedure. The swabs were stored at room temperature and sent to the national laboratory. Upon receipt, they were labeled and paired with observation sheets, and then inoculated onto Trypticase Soja sheep blood agar . All visible microbial colonies after a 48-h incubation at 37 °C under aerobic conditions were identified using MALDI-TOF technology . idelines . The michttps://www.spiadi.fr/tools?tab=1). The local infection control teams then trained the HCWs observed during the first phase of the study using the national tool. For the study, a single session may have been conducted in each hospital, with consideration for the acceptability of the study by the local infection control teams. An evaluation of the acceptability of the tool was conducted using a questionnaire intended for trained HCWs and trainers.A training tool was developed by the national team, underwent testing by local teams before the final version was delivered. The tool was introduced to the local teams during a web conference, where they had the opportunity to ask any questions. A technical guide accompanied the tool to assist with its usage. The tool is available for download on the national network’s website (n = 581) were nurses, 6% radiographers (n = 40), 2% were doctors (n = 10), and 1% were midwives (n = 8). For 8 cases, the status was not documented (1%). The HCWs were very diverse and distributed as follows: 62% in short-stay medical units, 25% in surgical departments, 8% in long-stay care units, and 5% in intensive care units. Considering that the insertion of PVCs should meet the same standards regardless of the department, we did not conduct an analysis of observation results based on the HCWs’ origins.A total of 91 French hospitals participated in the first phase of the study: six university and regional hospitals, one military hospital, 38 general hospitals, 37 short-stay clinics, three home care centers, two oncology centers, two rehabilitation centers, one long-stay hospital and one haemodialysis center  performed the two expected HH gestures in a compliant manner (Table n = 263) performed a single compliant HH, while 46.9% (n = 232) did not comply with either of the 2 HH gestures. HH compliance was higher for the first HH  than for the second one  (390 (60.3%) vs 177 (37.3%); p < 0.001). For the first opportunity, HH was not performed at all in 10.8% of cases (n = 70), and for the second opportunity, this omission was observed in 45.9% of cases (n = 297) (p < 0.001).Out of the 647 HCWs observed, 23.5% n = 52 perforn = 147) gloved their hands at the correct time  gloved too early  or before carrying out the skin preparation ), and missed the second HH opportunity. Gloving compliance was higher among HCWs who performed two compliant HH compared to those who performed one or none in a compliant manner (72 (47.4%) vs 75 (15.1%); p < 0,001).The remaining HCWs  revealed the presence of at least one pathogen (one pathogen (n = 56) or more (n = 6)), and 42.0% (n = 272) showed a culture of various microorganisms, mainly skin organisms, such as non-aureus Staphylococci and Micrococci, without any presence of pathogenic bacteria. Among the 334 swabs exhibiting visible microbial growth, 75.0% (n = 251) presented at least one bacterium commonly found in the skin flora. The most common species were coagulase-negative Staphylococci (n = 126), Micrococcus (n = 63), Moraxella (n = 55) and Corynebacterium (n = 18). Additionally, 43.7% (n = 146) of the swabs contained at least one environmental microorganism such as Bacillus species not belonging to the cereus complex (n = 76), Paenibacillus (n = 20), Brevundimonas (n = 17) and Brachybacterum (n = 13). Among the 71 identified pathogens, the predominant ones were Acinetobacter , 13 Bacillus belonging to the cereus complex (18.3%), ten Enterobacteriales (14.1%) including one Enterobacter cloacae, one Proteus mirabilis, one Serratia proteamaculans, one Ewingella americana and six Pantoea, eight Enterococci (11.3%) including six E. faecalis, two E. faecium, eight S. aureus (11.3%), two Stenotrophomonas (2.8%) and three yeasts (4.2%). Among the S. aureus isolates, six had a wild phenotype, one was an erythromycin and fluoroquinolone resistant MSSA, and one was a fluoroquinolone resistant MRSA. The Enterobacteriales were susceptible to third generation cephalosporins and carbapenems, and the Enterococci were susceptible to vancomycin. The pathogens identified did not vary based on the number of compliant HH performed prior to swabbing.Each observation of PVC placement led to a microbiological sampling of the HCWs’ fingertips (gloved or not). Out of the 647 swabs analysed, 9.6% (p = 0.003) (Table p = 0.539). By contrast, for the HCWs who did not perform two compliant HH, we found a higher presence of pathogens on the fingertips of HCWs who did not glove compared to other HCWs .We investigated the correlation between the presence of pathogens on the fingers and the level of HH compliance among HCWs before PVC placement, and found a lower presence of pathogens on the fingertips of HCWs who performed 2 compliant HH gestures in a compliant manner compared to other HCWs  Reminder of the importance of PVC-related infection prevention, (2) current guidelines for HH during PVC placement, with a particular focus on the necessity of performing two HH gestures, (3) results of the practice evaluation and microbiological study conducted in Phase 1, (4) correlation between the level of finger contamination among HCWs and HH compliance, (5) three short videos: the first two videos illustrating common inappropriate situations observed , and the third video showing proper PVC placement with both HH performed, and (6) a debriefing framework designed to ensure that training participants have a thorough understaanding of the mechanisms of finger contamination during CVP placement when HH is not adequate. A total of 48 local teams conducted on-site training sessions using the provided tool for the HCWs observed during the first phase. An evaluation of the tool’s acceptability was conducted using a questionnaire administred to trained HCWs and trainers. The analysis of the questionnaires completed by 48 trainers and 280 trained HCWs at the end of the training, revealed an average training duration of 70 min (15–180), divided into an average training time of 44 min (10–90) and an average discussion time of 26 min (5–90). Trained HCWs expressed a strong interest in the microbiological results (mean score of 8.5/10) and the videos . They reported a willingness to change their practices (mean 8.2/10) and recommend the training (mean 8.8/10). The duration of the training was considered satisfactory, as was the duration of the discussion with the trainer. For the trainers, the training helped them better understand the challenges faced by HCWs in carrying out the two HH gestures at the right time . They appreciated the educational tool (8.4/10) and the technical guide (8.6/10) and expressed readiness to use the tool again (mean 8.5/10).n = 177) of the 280 HCWs performing the two expected HH gestures, compared to only 25.0% (n = 70) of these HCWs before the training (p < 0.001)  of the 280 HCWs donning gloves immediately before PVC placement, compared to 24.6% (n = 69) before the training (p < 0.001) .In total, 48 centers participated in both first and fourth phases of the study, allowing for a comparison of the results of practice observations before and after the training for the 280 HCWs in these centers. HH compliance was higher after the training, with 63.2% n = 77 of thep = 0.430). Furthermore, the proportion of HCWs who donned gloves immediately prior to PVC placement was similar in both populations . Therefore, we considered the 280 HCWs observed before and after the training to be representative of the entire population of HCWs observed in Phase 1.The 280 HCWs followed in Phase 4 and the 367 lost to follow-up after Phase 1 performed the two expected HH gestures in the same proportion , which may have limited the growth of fastidious bacteria present on the hands of HCWs. However, since the objective of the study was to detect the pathogens tipically responsible for PVC-BSI , our results demonstrated that this objective was achieved. A third limitation was the two-month delay between the training and the second observation of PVC placement. The selection of a relatively brief time frame was deliberate, aimed at reducing the likelihood of losing subjects to follow-up and enabling the observation of the same HCWs both before and after training. This decision took into account the considerable turnover among HCWs in French hospitals. We investigated the reasons for the non-participation of some participants in the second (training) and third (practice observation after training) parts of the study. Several hypotheses can be formulated. The particular interest in microbiological sampling during the initial phase motivated a larger number of local teams. The imposition of a tight schedule for conducting the training may have discouraged or made it impossible for some teams to complete the training session. Lastly, conducting direct observations requires a significant commitment from the local team, and some teams were unable to allocate the necessary time for the second observation.Our study has several limitations. Firstly, due to the demanding nature of the study, half of the centers did not continue their participation beyond the 1The national SPIADI team urged the local infection control teams to regularly conduct training sessions using our tool and to observe the trained HCWs to ensure the ongoing effectiveness of the training. A fourth limitation was the absence of observations for HCWs who did not undergo training, serving as controls.Our study demonstrated that training HCWs using our educational tool, which combines reminders of best practices and risk factors associated with PVC-related infections, engaging HCWs , identifying professionals deviating from best practices (simulation videos), and objectively assessing fingertip contamination , significantly improved compliance with HH gestures and glove usage. We encourage infection control teams to utilize this tool to raise awareness among HCWs responsible for PVC placement about the risk of infection associated inadequate hand hygiene.Additional file 1: Supplementary Figure 1.Additional file 2: Supplementary Figure 2.


One thousand sixty-one individuals were sampled from the cities of Anbar, Baghdad, Basra, Diyala, Najaf, and Wasit in Iraq and typed for 15 forensic STRs to explore the genetic structure of Iraq and develop a forensic DNA database. The total number of alleles that were identified was 203.Analyses of molecular variance (AMOVA) were then conducted Baghdad provides a good representation of the rest of the country, while Anbar is the most genetically distinct. The average heterozygosities of these loci was 0.779, homozygosities was 0.221, polymorphism information content was 0.77, power of discrimination was 0.927, and power of exclusion was 0.563. At these loci, a matching genotype will occur, on average, in 1 in 8.152 × 1017 individuals. For paternity tests, the average paternity probability for a matching profile is 99.9997%.These loci are appropriate for use in forensic and paternity testing for this population. Iraq is similar to other countries in the Middle East, particularly Iran and Turkey, and is more similar to Europe than either Asia or Africa. Short tandem repeats, also known as microsatellites, are repeated sequences of DNA, usually consisting of 2 to 6 bases. They are highly polymorphic and distributed throughout the genome. These sequences vary in the number of repeats, resulting in them being multiallelic . ConsequThe collection of samples used in the research  was approved by the Center’s Scientific Research Ethics Committee before starting work. The volunteers signed a written consent to participate in this study.n = 139), Anbar (n = 132), Wasit (n = 120), Najaf (n = 119), Baghdad (n = 354), and Basra (n = 198). The samples were collected as Buccal swabs from patients and laboratory workers at private laboratories. These samples were used to study the population genetic diversity in Iraq. The population genetics of Iraqis is important due to their ethnic diversity. Several studies have been conducted to analyze the genetic diversity of Iraqi populations, including studies on the distribution of Y chromosome haplotypes, 23-YSTR markers, and 15 STRs. These studies aimed to analyze the genetic structure of different cities in Iraq and to create a forensic DNA database for the country.A total of 1061 unrelated individuals were sampled from six Iraqi cities: Diyala , and their DNA content was quantified with NanoDrop .Fifteen autosomal STR markers (the 13 CODIS core loci and D19S433 and D2S1338) were genotyped along with the amelogenin locus on the X and Y chromosomes using the Applied Biosystems AmpFiSTR® Identifiler™ kit (3). Approximately 1ng of template DNA was amplified for each sample following the protocols described in the user’s manual (Applied Biosystems). The samples were amplified with an Applied Biosystems Veriti® PCR System (Applied Biosystems).TM-4 (Applied Biosystems) was used for higher-resolution separations.Amplification products were diluted 1:15 in Hi-Di™ formamide and GS500-LIZ internal size standard (Applied Biosystems) and analyzed on the 16-capillary ABI Prism® 3100 Genetic Analyzer. On a 36-cm array, POPData collection was performed with Data Collection v. 2.0 software (Applied Biosystems), and samples were analyzed with GeneMapper v. 3.2 software (Applied Biosystems) at the Forensic DNA Center for Research and Training of Al-Nahrain University.Allele frequencies for each locus, heterozygosities, homozygosities, polymorphic information anthropology, and content (PIC) measure the formativeness of a genetic marker, indicating how well it can distinguish between different alleles in a population. PIC = 1−∑ (pi^2) PIC ranges from 0 to 1, with higher values indicating greater allelic diversity and formativeness of the marker.Matching probability (MP), powers of discrimination (PD) is a measure of how well a genetic marker can discriminate between individuals within a population.i-th and j-th alleles at the locus, summed over all possible pairwise allele combinations.Pi and pj are the frequencies of the PD also ranges from 0 to 1, with higher values indicating better discriminatory power. PD = ∑ (pi * pj).Powers of exclusion (PE) measures the probability that two individuals randomly chosen from a population will have different genotypes at a specific locus.PE = 1–P (same genotype)P (same genotype) is the probability that two individuals chosen at random will have the same genotype at the locus.PE can also range from 0 to 1, with higher values indicating a higher probability of distinguishing between individuals.p values were calculated using Monte Carlo methods with 100,000 permutations. The Holm-Bonferroni method [And typical paternity index (TPI) was calculated at each locus using Power Stats v1.2 . The sigi method  was usedi method .A total of 203 alleles were identified in this study. The distribution of these alleles across the 15 short tandem repeat (STR) loci is detailed in Table The city of Baghdad boasted the largest sample size, comprising 354 individuals. Interestingly, five alleles were exclusive to Baghdad and were not found in the other cities or neighboring countries. Three of these five alleles were absent from the other five Iraqi cities and all countries used for comparison, including Turkey, Iran , Syria , Kuwait An additional rare allele, allele 22 at D13S317, was identified in the city of Wasit, with a frequency of 0.4%, but was not observed in any other Iraqi cities or countries in the comparison set [p values for the HWE test [To assess whether the observed genotype frequencies adhere to the expected frequencies, the population’s adherence to the Hardy-Weinberg equilibrium (HWE) was examined . Table 2HWE test , 20, whiHWE test .Table 2Details concerning each locus are provided in Table Exploring STR analysis within Iraqi populations has been somewhat limited, and the studies that have been conducted employed distinct commercial STR kits, posing challenges for direct comparisons with the current study’s outcomes. Nevertheless, there is an overlap of the 15 STR markers between the aforementioned studies and neighboring countries, as outlined in Table Among these 15 common STR markers, D2S1338 demonstrated the highest Polymorphic Information Content (PIC) value within this study, while FGA exhibited the highest PIC value among Jordanians, succeeded by D19S433 in Turkey, D18S51 and FGA in Palestinians , and D19In forensic investigations, CMP is frequently expressed as the likelihood that one individual in a certain population subset possesses a genotype matching the composite value. With the global population approximately at 7.5 billion, an average MP of 0.173 or lower across all 15 loci is necessary for the CMP to be interpreted as 1 in 7.5 billion or greater. The dataset's mean MP across 15 loci is 0.073. In paternity reports, the probability of paternity is determined by CPI/(CPI + 1), where a CPI of 100 or higher indicates a probability of 99.0% or higher. For the average TPI to reach 1.43 for 15 loci, the average TPI over 1.5 locations was 2.36 .The findings of this investigation highlight the utility of these 15 autosomal STR loci as valuable markers for forensic and paternity testing within the Iraqi population. Within certain loci, the presence of a wide range of repeated sequences suggests possible population admixture dynamics. To elucidate the origins of the less common alleles discovered in this study, it may be beneficial to conduct further allele frequency analyses within specific ethnic groups in Iraq.Lastly, the comparative evaluation of forensic genetic efficiency parameters across diverse populations, including the Middle Eastern region, is vital for comprehending genetic diversity and potential intermingling among these populations. To achieve a more accurate comparison, it is strongly recommended to conduct comparative studies employing the same STR kit across these populations, considering that different STR kits have been used previously to define forensic efficiency parameters.Looking at the values within each population, you can observe that some alleles have consistent frequencies across populations, while others vary more. This variation could be due to a variety of factors, including historical migrations, genetic drift, and natural selection.The range of allele frequencies across the different populations indicates the genetic diversity present in these regions. Higher diversity might be indicative of a more mixed or heterogeneous population.The findings from this study highlight the effectiveness of the 15 autosomal STR loci as markers for forensics and paternity testing within the Iraqi population. It is worth noting that certain loci exhibit a wide range of repeats, which may be indicative of population admixture. To gain insight into the origins of the less common alleles identified in this study, further investigations should focus on analyzing allele frequencies within specific ethnic groups in Iraq.A comprehensive assessment of forensic genetic efficiency parameters is crucial for understanding genetic diversity and admixture among different populations, including those in the Middle East. To ensure a robust comparison, it is strongly recommended that comparative studies utilize the same STR kit across these populations. Previous studies have employed disparate STR kits, which has affected the description of forensic efficiency parameters.The study discussed in the given text highlights the effectiveness of 15 autosomal STR loci as markers for forensics and paternity testing within the Iraqi population. The CMP represents the likelihood that an individual in a specific population subset possesses a genotype matching a composite value. With an average Match Probability (MP) of 0.073 across all 15 loci in a global population of 7.5 billion, the CMP can be interpreted as 1 in 7.5 billion or greater The presence of a wide range of repeated sequences within certain loci suggests possible population admixture dynamics. To understand the origins of less common alleles, further allele frequency analyses within specific ethnic groups in Iraq are recommended. Conducting comparative evaluations of forensic genetic efficiency parameters across diverse populations, including those in the Middle East, is essential for comprehending genetic diversity and potential intermingling among these populations. Using the same STR kit for these studies is crucial for accurate comparisons. The study also highlights that some alleles have consistent frequencies across populations, while others exhibit more variation, which could be attributed to factors such as historical migrations, genetic drift, and natural selection.