As the global population increases and the economy grows rapidly, the demand for livestock products such as meat, egg and milk continue to increase. The shortage of feed in livestock production is a worldwide problem restricting the development of the animal industry. Natural woody plants are widely distributed and have a huge biomass yield. The fresh leaves and branches of some woody plants are rich in nutrients such as proteins, amino acids, vitamins and minerals and can be used to produce storage feed such as silage for livestock. Therefore, the development and utilization of natural woody plants for clean fermented feed is important for the sustainable production of livestock product. This paper presents a comprehensive review of the research progress, current status and development prospects of forageable natural woody plant feed resources. The nutritional composition and uses of natural woody plants, the main factors affecting the fermentation of woody plant silage and the interaction mechanism between microbial co-occurrence network and secondary metabolite are reviewed. Various preparation technologies for clean fermentation of woody plant silage were summarized comprehensively, which provided a sustainable production mode for improving the production efficiency of livestock and producing high-quality livestock product. Therefore, woody plants play an increasingly important role as a potential natural feed resource in alleviating feed shortage and promoting sustainable development of livestock product. A review of recent advances in the renewable use of natural woody plant.Natural woody plant produces clean feed to alleviate feed shortage.Fermented feed of woody plant produces livestock product with added value.Woody plant contributes to the sustainable production of livestock product.1With the rapid development of the global economy, per capita consumption levels and demand for livestock products such as meat, eggs and milk are increasing . Along wMorus alba (L.)], moringa [Moringa oleifera (L.)], gliricidia [Gliricidia sepium (Jacq.)], leucaena [Kunth ex Walp. leucocephala (L.) de Wit], and paper mulberry [Broussonetia papyrifera (L.)]. These woody plants are deciduous trees or shrubs that are highly adaptable, widely distributed, drought tolerant and thrive in infertile soil, and can grow in a wide range of soil pH conditions, with high growth rates, high biomass yields, and low planting production costs , and is cultivated in tropical regions  and consist of 17−27% CP, 3−5% ether extract (EE), 11−21% true protein (TP) and 53−71% total digestible nutrient (TDN), with these ranges being generally higher than in forage crops and grasses Table 2.3Generally, forage crops and grasses grow well in the summer or tropical rainy season, but in the winter or dry season, cold and dry climatic conditions prevent forage crops from growing, resulting in the demand for feed from livestock far exceeding the production of feed . Therefo3-N), thus reducing the fermentation quality of the silage. If the silage moisture content is too low, lactic acid bacteria (LAB) will be affected by the water activity and their growth will be inhibited, preventing them from producing large amounts of lactic acid to lower the pH of the silage. In addition, low moisture levels result in residual air not being effectively removed from the raw material, thus providing better conditions for harmful microorganisms such as aerobic bacteria and mold to survive, leading to poor quality fermentation (5 LAB colony-forming unit per gram (cfu/g) in fresh matter (FM). As shown in +, Ca2+ and Mg2+, and these cations neutralize the lactic acid and other organic acids produced by silage fermentation and inhibit the reduction of pH. This allows harmful microorganisms to grow and decompose proteins and produce NH3-N, resulting in low-quality silage fermentation  sequencing technology. The Venn diagrams in Pantoea, Enterobacter and Pseudomonas, is high  in woody plants, rice bran and wheat bran have been added to adjust the moisture content and increase the fermentation substrate . MicrobiL. plantarum from the woody plant material was below the detection level, but increased significantly after ensiling  and hydrogen (H2), thereby reducing the fermentation quality of the silage  form a mutually constraining opposition during silage fermentation; their community structure and metabolites interact with each other and influence the fermentation quality of the silage.A positive correlation was found between the moisture content and entation . TherefoL. plantarum and Weissella paramesenteroides, and negatively correlated with other bacterial community members, such as C. tyrobutyricum and E. asburiae  formulated with 10−15% paper mulberry instead of maize silage, alfalfa hay and oat hay had a similar DM intake and milk production to those fed with conventional TMR. However, the addition of paper mulberry to TMR diets significantly increased the serum levels of immunoglobulin A (IgA), immunoglobulin (IgG), catalase and superoxide dismutase and the total antioxidant capacity, but decreased the levels of 8-hydroxy-2′-deoxyguanosine. In addition, paper mulberry TMR can cause a significant decrease in the milk somatic cell count, enhance the immune and antioxidant function of cows and increase the polyunsaturated fatty acid content of milk . The freIn sheep feeding trials, replacing some of the soybean meal and corn stover with paper mulberry silage reduced total volatile fatty acids in the rumen, and increased DM intake and average daily gain of lambs . When soIn poultry feeding trials, the use of woody plants, such as paper mulberry and mulberry, in place of some of the commercial feeds maintained good indicators in terms of the egg production rate, egg weight, fertilized egg hatching rate, growth performance and meat quality . There i7To develop and utilize new woody feed resources to produce high-quality livestock products, this review provided a comprehensive overview of the composition and uses of natural woody plants that can be fed to animals, the dominant factors affecting woody plant silage fermentation, microbial succession patterns and the mechanisms of interaction between microbial co-occurrence networks and secondary metabolites. Woody plants are rich in nutrients and can be used for the preparation of fermented feeds and the production of value-added livestock products Figure 8ZD and YC: Writing - original draft, Investigation. ZD, YC, and FY: Writing–original draft, Formal analysis. ZD and JF: Validation, Writing−review & editing; SY: Conceptualization, Visualization. TO, DN, and HK: Supervision, Resources. YC and FY: Resources, Writing−review & editing, Supervision, Funding acquisition. All authors contributed to the article and approved the submitted version.


The study was aimed to explore cell division cycle-associated protein-3 (CDCA3) expression and its correlation with clinicopathological characteristics, and identification of co-expressed genes of CDCA3 in prostate cancer (PCa).Data for CDCA3 mRNA expression in PCa were obtained from The Cancer Genome Atlas database. Furtherly, CDCA3 protein expression was examined by immunohistochemistry in 80 cases, including 20 normal prostate samples and 60 PCa samples. Then we used “survival” package to obtain the differentially expressed CDCA3 mRNA associated with prognosis of PCa patients. “pROC” package was used to analyze receiver operating characteristic of CDCA3. We used chi-square test, Kruskal–Wallis test and Wilcoxon rank sum test to identify clinicopathological parameters that correlated with CDCA3 expression. In order to determine the effects of CDCA3 expression and clinicopathological parameters on survival, univariate cox regression analysis was performed. Finally, the co-expressed genes of CDCA3 in PCa were explored by search tool for the retrieval of interacting genes, Kyoto encyclopedia of genes and genomes enrichment analysis and Spearman correlation analysis.In this study, we found that CDCA3 expression was increased in PCa. PCa patients with higher CDCA3 expression had poor outcomes. In terms of receiver operating characteristic, CDCA3 had an area under the curve of 0.857. High CDCA3 expression was positively correlated with advanced T stage, N stage, Gleason score, and served as an independent predictor of progress free interval in PCa patients. Then 20 proteins closely related to CDCA3 were screened through STRING website. Functional enrichment analysis revealed that, Kyoto encyclopedia of genes and genomes pathway was mainly enriched in cell cycle, including 6 genes, BUB1, CCNA2, CDK1, CDC20, TTK, and CCNB2.CDCA3 is significantly associated with the prognosis of PCa, which may be an indicator of the diagnosis and prognosis of PCa and a new therapeutic target. Currently, the cornerstones of PCa management include serum prostate-specific antigen (PSA) quantification, digital rectal examination, and systemic transrectal ultrasound-guided biopsies. Molecular biomarkers supplement existing clinicopathologic tools for PCa diagnosis and prognosis by providing additional and valuable information about the biological behavior of PCa. Therefore, the identification of new targets is of great significance to improve the management of PCa patients.Prostate cancer (PCa) is the second most common solid tumor in men and the fifth cause of cancer mortality, Cell division cycle-associated protein-3 (CDCA3), also known as trigger of mitosis entry 1, is involved in the regulation of cell cycle progression. CDCA3 is a part of the Skp1/Cullin 1/F-box (SCF) ubiquitin ligase (E3) protein complex, which effectively degrades tyrosine kinase wee1 and modulates cell cycle.–7 Moreover, CDCA3 emerges with up-regulated expression in a variety of cancers, such as bladder urothelial carcinoma, colorectal cancer, non-small cell lung cancer, hepatocellular carcinoma, and ovarian cancer, and plays a critical role in promoting tumor progression. CDCA3 also has been found to be a good biomarker candidate to predict the prognosis of renal cell carcinoma and kidney renal papillary cell carcinoma patients.,14 We have reported that knockdown of CDCA3 potentially suppressed PCa progression via the significant accumulation of p21 and via inhibiting the expression of cyclin D1 by regulating the NF-κB signaling pathway. The study aims to determine whether CDCA3 is associated with prognosis and clinicopathological characteristics in PCa and identify possible downstream target genes co-expressed with CDCA3.Abnormal regulation of cell cycle will lead to uncontrolled excessive proliferation of cells and promote the formation of cancer, which is of great significance in the occurrence and development of cancer. Therefore, the study of cell cycle regulation-related factors is of great significance for revealing the occurrence and development of cancer.https://portal.gdc.cancer.gov/), RNA sequencing (RNA-seq) data on PCa and related cancers were obtained. In total, 549 samples were selected as the TCGA cohort including 497 PCa samples and 52 normal samples. Level 3 high-throughput RNA-seq data and corresponding clinicopathological information data were downloaded from the PCa project of the TCGA GDC data portal. RNA-seq data in fragments per kilobase per million format were converted into transcripts per million reads format for comparisons of CDCA3 expression levels between samples.From The Cancer Genome Atlas database (TCGA) data  prognostic value of the CDCA3 mRNA expression level in PCa was analyzed using the “survival” package of R. Based on the median values of CDCA3 expression (transcripts per million reads), patients with PCa were divided into CDCA3-low expression group and CDCA3-high expression group. Results with CDCA3 expression was analyzed using TCGA database, “ggplot2” package was used to visual CDCA3 expression from TCGA. “pROC” package was used to analyze ROC. The area under curve (AUC)of the ROC curve was generated to evaluate the predictive value of the gene. AUC values closer to 1.0 indicated a better diagnosis, 0.5 to 0.7 indicated a low predictive value, 0.7 to 0.9 indicated moderate predictive accuracy, and >0.9 indicated a high accuracy.The study was performed after approval by the Ethics Committee of Xishan People’s Hospital of Wuxi City . A total of 60 samples were collected to detect CDCA3 expression in PCa. All PCa patients were treated with radical prostatectomy between January 2021 and October 2022. Patients were excluded if they were treated with hormonal therapy, radiation therapy, or chemotherapy prior to surgery, if they lack clinical and follow-up information. In addition, 20 benign prostatic hyperplasia samples were collected to determine CDCA3 expression in normal prostate tissues. Benign prostatic hyperplasia patients were randomly selected from patients treated by transurethral resection of prostate between January 2021 and October 2022.Tissues were fixed in 4% paraformaldehyde  and embedded in paraffin. Immunohistochemical staining was performed on 4 µm sections of paraffin blocks. After blocking with 3% hydrogen peroxide for 10 minutes at room temperature, the slides were then incubated overnight at 4 °C with primary antibody. The primary antibodies, CDCA3  was used for staining. The slides were then incubated with the biotinylated goat-anti-rabbit secondary antibody  for 30 minutes at room temperature, and visualized by peroxidase substrate DAB kit  according to the manufacturer’s instructions. The slides were analyzed using an Olympus CKX41 fluorescence microscope .https://string-db.org) for constructing protein–protein interaction networks, providing a system-wide view of interactions between each member. Firstly, top 20 proteins closely related to CDCA3 were screened through STRING, and an interaction with a combined score >0.4 was considered statistically significant. In order to investigate functions of the 20 proteins closely related to CDCA3, the gene ontology, and Kyoto encyclopedia of genes and genomes (KEGG) enrichment analysis were performed. We used the “clusterProfiler” package to automate the processes of gene ontology and KEGG term. Finally, spearman correlation analysis was performed on CDCA3 and co-expressed genes by R. We used “ggplot2” package to visual a heat map of CDCA3 with its co-expressed mRNA. Statistical significance was set at P < .05.The co-expressed genes of CDCA3 in PCa were analyzed by bioinformatics in TCGA database. Search tool for the retrieval of interacting genes (STRING) is a biological database . The Wilcoxon rank-sum test and Wilcoxon signed-rank test were used to compare the expression of CDCA3 in unpaired samples and paired samples, respectively. The chi-square test, Kruskal–Wallis test and Wilcoxon rank sum test was used to evaluate the correlation between CDCA3 expression and clinicopathological parameters. Univariate analysis was used to analyze the effects of CDCA3 expression and the clinicopathological parameters on survival. t test was used to analyze statistical differences between 2 groups. Nonnormally distributed data were expressed in median with interquartile range, and compared by Kruskal–Wallis rank test. The chi-squared test was performed to evaluate categorical variables. P < .05 was considered to indicate a statistically significant difference.Statistical analyses in the part of immunohistochemistry were performed using SPSS 17.0 software. Each value was acquired from at least 3 independent experiments. Normally distributed continuous variables were expressed as mean ± SD, and a 2-tailed unpaired Student P < .001, Fig. Investigating the differential expression of CDCA3 between human tumors and normal tissues, the expression levels of CDCA3 in pan-cancer were analyzed using the TCGA database. The results showed that CDCA3 was highly expressed in prostate adenocarcinoma, and other cancer types compared with each normal tissue Fig. A. VisualP < .05, Table When analyzing the correlation between CDCA3 expression and clinicopathological characteristics of PCa patients. 497 prostate samples were downloaded from the TCGA database, including the low CDCA3 expression group n = 248) and the high CDCA3 expression group (n = 249). Chi-squared test showed that the high CDCA3 expression was positively correlated with pathologic T3–T4, pathologic N1 and Gleason score 8–10 . Furthermore, CDCA3 high expression was significantly positive related to PSA, tumor stage and Gleason score  of normal prostate samples. In addition, CDCA3 high expression was detected in 66.7% (40/60) of PCa samples  closely related to CDCA3 were screened through STRING website. The protein–protein interaction networks was shown in Figure  In our previous study, we have analyzed microarray data of localized PCa, metastatic PCa and normal prostate tissue samples from clinical specimens to discover key molecular changes in PCa development and metastasis. We also have reported CDCA family (CDCA1–8) had important clinical relevance in the development and progression of prostate cancer by bioinformatics analysis. It has reported that the expression of CDCA1 were more than 3-fold up-regulated in human PCa tissue compared to the adjacent normal tissues. For PCa, molecular targeted therapy and immunotherapy have played certain therapeutic roles in recent years. Additionally, CDCA1-derived peptide vaccine treatment was tolerable and might effectively induce peptide specific cytotoxic T lymphocytes for castration resistant prostate cancer patients in a phase I clinical trial. CDCA2, another member of the CDCA family, was overexpressed in primary PCa and positively correlated with poor prognosis in patients with PCa. Similarly, CDCA5 expression affected the prognosis of PCa patients, it has revealed that patients with high CDCA5 expression had a high initial PSA. Additionally, seminal vesicle invasion and lymph node metastasis were more likely to occur. CDCA6, also known as CBX2, has reported up-regulated in metastatic castration resistant prostate cancer and elevated expression was correlated with poor clinical outcome in PCa cohorts. In a study of CDCA8, high CDCA8 expression predicted poor prognosis in PCa patients, and CDCA8 expression was higher in high-grade PCa. Although, we have reported that CDCA3 knockdown in DU145 and PC-3 cells led to decreased cell proliferation and increased apoptosis, the prognostic value of CDCA3 in patients and its relationship with clinicopathological characteristics in PCa remain unclear.Recent studies of high throughput gene chips for analysis of patient average and tumor tissue samples have provided us with an opportunity to discover and explore the entire molecular landscape of tumors at various levels, from copy number changes and somatic mutations at the genomic level to altered gene expression at the transcriptional level.In our study, according to the TCGA database and results of immunohistochemistry, as compared to prostate normal samples, PCa had higher level of CDCA3 expression. Upregulated CDCA3 expression in PCa was related to advanced clinicopathological parameters  and bad PFI prognosis, and CDCA3 had a high diagnostic rate. Furthermore, the CDCA3 was an independent factor of PFI prognosis according to univariate regression analysis, suggesting that patients with PCa might benefit from the use of CDCA3 as a biomarker for diagnosis and prognosis. Based on STRING and KEGG pathway enrichment analysis, it showed CDCA3 and the 6 genes closely related to CDCA3 mainly enriched in cell cycle signaling pathway. Spearman correlation analysis indicated significant and positive correlations between CDCA3 and the 6 genes, and we called them co-expressed genes . It was reported that everolimus resistance in prostate cancer cells was characterized by an increased level of cdk1 and cyclin B, driving the cells towards G2/M. Reduction of cdk1 or cyclin B considerably diminished tumor growth activity. BUB1, a mitotic serine/threonine kinase, has multiple functions in chromosome segregation. It has been found that BUB1 phosphorylates Cdc20 and histone H2A, resulting in active transcription in human cells. BUB1 was also found to be deregulated and linked to tumorigenesis. In PCa, BUB1 was significantly upregulated. Kaplan–Meier survival curves demonstrated that a high level of BUB1 was significantly associated with poor prognostic. Altogether, BUB1 is a potential tumor-promoting gene and partly renders prostate cancer cells the docetaxel resistance via circ_0004087/SND1/MYB/BUB1 axis. CCNA2 is a type of cycling protein, which was first detected in primary liver cancer cells, which appeared in the late G1 and could bind to CDK2 and CDC2. In PCa, CCNA2 was significantly associated with biochemical recurrence, disease-free survival and overall survival rate of PCa patients. The ability of cancer cells proliferation, invasion and metastasis was decreased, and cells were arrested in the S phase after down-regulated expression of CCNA2 in PCa cell lines. CDC20, a key E3 ligase, is a regulator of cell cycle checkpoint that activates the anaphase promoting complex. Previous research has identified CDC20 was over expressed in PCa and correlated with postoperative Gleason scores. Over expression of CDC20 may be a potential biomarker for prediction of biochemical recurrence after radical prostatectomy of clinically localized PCa. The present study revealed that CDC20 and PTTG1 contribute more to migration, progression, and poorer prognoses in metastatic prostate cancer (mPCa) compared with PCa. CDC20 and PTTG1 could represent therapeutic targets in mPCa medical research and clinical studies. The protein kinase TTK is a dual specificity kinase that can phosphorylate not only tyrosine but also serine/threonine residues. The functions of TTK include promoting mitotic checkpoint complex formation, regulating cytokinesis, responding to DNA damage, and facilitating proper chromosome alignment. It was reported that expression of the TTK protein kinase was significantly higher in mPCa cells lines and advanced PCa tissues with high Gleason scores. TTK may inhibit the proliferation of prostate cancer and the progression of prostate cancer by inhibiting the expression of CDK2 and CCNE1 complex.CDCA3 is a cytosolic protein required for proper activation of CDK1/cyclin B and mitotic entry. Degradation of CDCA3 during G1 allows for wee1 accumulation during interphase, thereby providing a critical link between the anaphase promoting complex and SCF pathways in regulation of CDK1/cyclin B activity and thus mitotic entry and exit.To conclude, our study combined bioinformatics analysis and immunohistochemistry suggested that CDCA3 was over expressed in PCa. It was also significantly associated with the prognosis of prostate cancer, which may be an indicator of the prognosis of PCa and a new therapeutic target. Our next step will be to explore the relationship between CDCA3 and its co-expressed genes, BUB1, CCNA2, CDK1, CDC20, TTK, and CCNB2. Furthermore, it is determined which co-expressed gene could act as the downstream target of CDCA3.Conceptualization: Minhao Zhang, Lu Chen, Xiaoliang He, Meilin Li.Data curation: Peng Gu, Minhao Zhang, Xinhua Chen, Jie Du, Lu Chen.Formal analysis: Peng Gu, Minhao Zhang.Funding acquisition: Peng Gu, Minhao Zhang, Xiaoliang He.Investigation: Peng Gu, Minhao Zhang, Lu Chen, Meilin Li.Methodology: Peng Gu, Minhao Zhang, Xinhua Chen, Jie Du, Lu Chen, Meilin Li.Project administration: Peng Gu, Minhao Zhang, Xinhua Chen, Jie Du, Meilin Li.Resources: Peng Gu, Minhao Zhang, Lu Chen.Software: Peng Gu, Minhao Zhang, Xinhua Chen, Lu Chen.Supervision: Peng Gu, Minhao Zhang, Jie Du, Xiaoliang He, Meilin Li.Validation: Peng Gu, Minhao Zhang.Visualization: Peng Gu, Minhao Zhang.Writing – original draft: Peng Gu, Minhao Zhang.Writing – review & editing: Peng Gu, Minhao Zhang, Xiaoliang He, Meilin Li.


Gout represents a metabolic ailment resulting from the accumulation of monosodium urate crystals within joints, causing both inflammation and, harm to tissues. The primary contributor to gout’s emergence is an elevated presence of serum urate, which is under the regulation of kidney and, gut urate transporters. Mitigating this risk factor is crucial for averting gout’s onset. Several treatments rooted in TCM and related active compounds have demonstrated efficacy in managing gout, skillfully regulating serum uric acid (UA) levels and curbing inflammation’s progression. This analysis compiles key foundational research concerning the molecular signaling pathways and UA transporters linked to gout, under the regulation of TCM. The focus includes individual botanical drug, active compounds, and TCM formulations, which have been consolidated and examined in this overview. The primary keywords chosen were “gout, hyperuricemia, gouty arthritis, traditional Chinese medicine, Chinese botanical drug, medicinal botanical drug, and natural plant”. Various relevant literature published within the last 5 years were gathered from electronic databases, including PubMed, Web of Science, CNKI, and others. The findings revealed that TCM has the capacity to modulate various signaling pathways, including MAPK, NF-κB, PI3K/Akt, NLRP3 and JAK/STAT. Additionally, it impacts UA transporters like URAT1, GLUT9, ABCG2, as well as OATs and OCTs, thereby contributing to gout treatment. TCM helps maintain a balanced inflammatory interaction and facilitates UA excretion. This study enhances our understanding of TCM’s anti-gout mechanisms and introduces novel perspectives for establishing the clinical significance and future prospects of TCM-based gout treatment.  Gout represents a painful type of arthritis triggered by the accumulation of monosodium urate (MSU) crystals within synovial fluid and other bodily tissues in people with hyperuricaemia. Intermittent flaring condition of gout often bring along unforeseeable discomfort, swelling of joints, reddening, and damage to joints as a result of recurrent flare-ups . The enhGout presents a multifaceted pathological sequence, encompassing diverse underlying factors. These include urate accumulation , hindran(Phellodendron chinense C.K.Schneid. (Coptis chinensis Franch. (Atractylodes lancea (Thunb.) DC.  DC. , Achyrana Blume. , Smilax ra Roxb. , Eucommies Oliv. , Ermiao es Oliv. , Simiao es Oliv. , Sanmiaoes Oliv. , Wuling es Oliv.  and Erdies Oliv.  demonstrIn clinical practice, the core strategy for effective treatment can be considered as two aspects in early-onset and intermittent of gout: 1) in early-onset of gout: urate-lowering therapy to hyperuricemia, which relate to dissolute MSU crystals and prevent long-term of gout flares; and 2) in intermittent of gout: anti-inflammatory therapy to intermittent episodes of severely painful arthritis (gout flares) caused by deposited MSU crystals . Thus, tOne of the most extensively studied and vital inflammasomes is the NOD-like receptor thermal protein domain-associated protein 3 (NLRP3). This vital component comprises the sensing molecule NLRP3, coupled with apoptosis-associated speck-like (ASC) adaptors, caspase activating recruitment domain, and recruitment caspase-1. Activation of nuclear factor κ-light-chain-enhancer of activated B cells (NF-κB) prompts the upregulation of NLRP3 expression. Following this, it combines and forms an intricate configuration with an adapting protein, ASC, and procaspase-1. Caspase-1 is subsequently activated through the autolysis of procaspase-1. This sequential process subsequently triggers the handling and liberation of interleukin (IL)-1β, IL-18, along with alarm signals. Additionally, it leads to the initiation of pyroptotic cell demise . PathogeScutellaria baicalensis Georgi. This compound exhibits neuroprotective, antioxidant, anti-inflammatory, and anti-tumor properties  W.T.Wang, has demonstrated a noteworthy ability to reduce the levels of NLRP3, caspase-1, and IL-1β in the paw tissues of mice with MSU-induced acute gout. It also diminishes proinflammatory cytokines such as TNF-α, IL-1β, IL-6, and IL-18, and thereby alleviating gout-related pain and swelling. This compound acts therapeutically by inhibiting the activation of the NLRP3 inflammasome and the subsequent caspase-1 formation  and reducing p65 within the nucleus. Additionally, it lessens NF-κB DNA-binding activity in synovial tissues of rats experiencing inflammation induced by MSU . Furthermore, it inhibits the nuclear translocation of p65 and IκB, thus effectively mitigating the symptoms of acute gout arthritis (Curcuma Longa L. hinders the degradation of IκBα and phosphorylation of NF-κB subunits (p50 and p65). This dual effect leads to decreased expression of pro-inflammatory cytokines such as TNF-α, IL-1β, and IL-6, as well as cyclooxygenase-2 (COX-2) and PGE2. As a consequence, a protective impact of curcumin is exerted against gout by alleviating the inflammatory response via modulation of the NF-κB signaling pathway , myeloid differentiation factor 88 (MyD88), as well as several key proteins involved in the NF-κB pathway, including phospho-IKBα, IKBα, phospho-p65, and p65. This led to the inhibition of the TLR4/MyD88/NF-κB pathway’s activation triggered by MSU, ultimately providing relief from gout symptoms  . It alsoPhosphatidylinositol 3 kinase (PI3K) and protein kinase B (AKT) are upstream elements of the NF-κB signaling cascade, pivotal in the initiation and release of various inflammatory factors . ElevateCoptis chinensis Franch. diminishes the levels of cleaved poly ADP-ribose polymerase (PARP), cleaved-caspase-3, Bax, cytochrome C (cytC), and apoptosis-inducing factor (AIF). Concurrently, it elevates the protein levels of Bcl-2 and p-Bad, thereby offering protection against oxidative stress, mitochondrialapoptosis, and renal inflammatory harm triggered by hyperuricemia. This safeguarding effect is achieved by modulating the PI3K/AKT signaling pathway , PI3K, and mTOR. It effectively safeguards against hyperuricemia-induced kidney damage by activating the PI3K/AKT signaling cascade , and the signal transducer and activator of transcription (STAT) signaling pathway is composed of tyrosine kinase-related receptors called JAK, and STAT , This paPhellodendron chinense C.K.Schneid., has exhibited the capacity to diminish the expression of phospho-JAK2, phospho -STAT3, and suppressor of cytokine signaling 3 (SOCS3). Moreover, it lessens renal concentrations of TNF-α, IL-1β, and IL-6 in mouse models of hyperuricemia, thereby mitigating renal impairment. This is achieved through the inhibition of the JAK-STAT signaling pathway’s activation and the attenuation of the inflammatory response triggered by UA  and hepatitis, is capable of reducing the expression of phospho-JAK2 and phospho-STAT3. It also operates to hinder the JAK2/STAT3 signaling cascade within synovial tissues, thereby alleviating ankle joint swelling and gout-induced inflammation in rats (Liriodendron chinense (Hemsl.) Sarg., a component of TCM employed to expel “wind and dampness”, has been observed to impede the advancement of hyperuricemic nephropathy. This is achieved by curbing the activation of the JAK2/STAT3 signaling cascade, lessening the influx of inflammatory agents, and diminishing the buildup of UA within the kidney , comprising extracellular signal-regulated kinases (ERK1/2), Jun N-terminal kinase (JNK), and P38, play crucial roles in the onset of gouty arthritis episodes. Serving as precursor kinases, mitogen-activated protein kinase kinase 4/7 (MKK4/7), MKK3/6 andmitogen-activated extracellular signal-regulated kinase 1/2 (MEK1/2) govern the activation of JNK, P38, and ERK1/2, respectively . Recent Dioscorea polystachya Turcz., the total saponin fraction exhibits the ability to ameliorate synovial tissue conditions. Additionally, it diminishes the protein expressions of phospho-MEK1/2, phospho-ERK1/2, phospho-JNK, and MKK4 in rats induced with MSU crystals. This process effectively mitigates inflammation in gout arthritis by inhibiting the MAPK signaling pathway , has been found to widespread use in TCM for various forms of arthritis  Decne., and Terminalia chebula Retz., exhibits the ability to alleviate ankle joint swelling and diminish TNF-α and IL-1β concentrations within MSU-induced mice air pouch lavage fluid. This is accomplished by restraining the levels of p-p38/p38 through the modulation of the MAPK signaling cascade, thus effectively mitigating gout-related inflammation , organic anion transporter 4 (OAT4/SLC22A11), OAT10/SLC22A13, and urate anion transporter 1 (URAT1/SLC22A12) . ATP BinAn additional path for UA elimination occurs within the intestines. ABCG2 is a pivotal regulator of urate excretion primarily in the gastrointestinal tract , signifyCurrently, it has been widely proven that TCM can effectively reduce UA in clinical practice. The multi-target function of TCM simultaneously affects multiple UA transporters, achieving the reduction of UA and the protection of the kidneys. Various herbal extracts used in TCM and natural bioactive compounds have been demonstrated to be beneficial in treating gout .This comprehensive analysis has substantiated that Chinese medicine monomers, individual herbal remedies from Chinese tradition, and formulations of TCM offer significant assistance in gout management by impacting the expression and function of urate transporters. These encompass GLUT9, URAT1, OATs, and ABCG2, as well as their associated regulatory cascades like NLRP3, NF-κB, JAK/STAT, PI3K/AKT, and MAPK pathways. However, there are still several limitations must be considered in the gout therapy using TCM.As we reviewed, these botanical drugs have shown positive anti-gout effects. Yet it is worth noting that the therapeutic effect of inhibiting inflammatory signaling pathways and uric acid transporters on gout has only been experimentally validated in cells and animals. Due to the differences between species, the therapeutic effects of some plant drugs with anti-inflammatory and reducing uric acid effects at the cellular and animal levels may not be satisfactory in the human, so more in-depth research is needed.Another point to consider is that more studies are needed to confirm whether TCM can be effective targets for gout treatment. In recent literature, a compelling association between UA transporters and signaling pathways has come to light. UA drives excretion through the activation of signaling cascades involving NLRP3, PI3K/Akt and MAPK, leading to the augmentation of PDZK1 and ABCG2 expression, thereby mitigating the effects of hyperuricemia . The PI3Notably, studies on the regulatory mechanisms the therapeutic applications of small molecule metabolites in gout by regulating protein functions are particularly lacking, which may be a weak direction for understanding the role in the pathogenesis and treatment of gout. Utilizing a metabolomics approach, researchers have employed a strategy to unveil the underlying metabolic mechanisms and plausible targets associated with TCM. Likewise, the interplay between metabolites and receptors offers an avenue to investigate potential therapeutic targets and the regulatory function of TCM within signaling pathways, facilitating internal signaling communication for addressing gout. A prime illustration lies in the distinctive involvement of purine metabolism in both inflammatory responses and immune system modulation in the context of gout. Notably, purinergic receptors, including P2X1, P2X7, P2Y2, and P2Y14, are found expressed across a wide spectrum of immune cells . ATP stiAt present, we are engaged in clinical experimental investigations focusing on the role of biomarkers influenced by protein targets in the initiation of gout. Simultaneously, we are exploring the potential of utilizing TCM-regulated proteins to modulate metabolic pathways for gout management in mouse models. Furthermore, by combining and synthesizing the results of multiple studies that investigate TCM’s inhibitory effects on signaling pathways like NLRP3, along with its positive effects on gout, we are optimistic about substantial progress in the field of anti-gout TCM. This advancement involves a direct emphasis on proteins and biomarkers in the approaching phase, potentially leading to a smooth transition into clinical application and improving the current scenario of gout detection, prediction, and therapy.


To provide ways to improve the clinical practice of fertility preservation (FP) for children, adolescents, and young adults (AYA) with cancer.A systematic research of online databases was undertaken in March 2020 following the PRISMA criteria, including Medline and Web of Science.Fifty‐nine articles were included. Surveys, interviews, and focus groups were used to collect data from patients, parents, and health care providers (HCPs). Four themes worth exploring emerged: (a) what do patients and professionals think of and know about FP? (b) what makes the fertility discussion happen or not? (c) what, retrospectively, led to FP being pursued or not? and (d) how do patients and HCPs feel about fertility issues?A minority of AYAs preserve their fertility (banking assay for 45% of boys and 23% of girls). Yet fertility concerns have a significant impact on the quality of life of young cancer survivors. Although recommendations and guidelines regarding FP are available internationally, there are no specific guidelines as to how to conduct fertility counseling for children and adolescents. Some barriers are not removable, such as a poor prognosis of an obvious severe disease, time constraints for starting treatment, and cultural and religious beliefs. In response to aspects hindering patients and families to be receptive to any discussion at the time of diagnosis, psychological support could reduce the level of emotional distress and help restore a degree of open‐mindedness to open a window for discussion. Moreover, as the lack of knowledge of professionals about fertility is frequently pointed out as a limiting factor for fertility discussion, reinforcing professional training regarding FP could be proposed to promote fertility discussion and eventually referral for FP. This review studies the mechanisms leading to fertility preservation with a focus on the behavior and psychosocial issues surrounding FP in young cancer survivors, their parents and health care professionals. We hence chose to compile the perspectives of patients, parents, and health care professionals (HCPs) to better decipher the complexity of the realities of the practice and focus on the behavior and psychosocial issues surrounding FP. To do so, this SLR will strive to answer four questions: (a) what do patients and professionals think and know about FP? (b) what makes the fertility discussion happen or not? (c) what, retrospectively, led to FP being pursued or not? and (d) how do patients and HCPs feel about fertility issues?22.1A systematic search of online databases available at the University of Lorraine was undertaken in March 2020 following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA).The inclusion criteria were met when (a) the populations of interest were children and adolescents, whether it was their point of view, that of the parent’ or the physician/health care providers, (b) the study was conducted retrospectively and patients had finished their treatments, (c) it contained data on the fertility‐related concerns, distress, discussion, and practice, (d) the methodology was qualitative, quantitative, or both and based on surveys, interviews or focus groups. In total, 58 articles were included in this review.2.2The quality of the articles was independently assessed by two researchers (K.E and I.K). The selection was based on the clinical relevance and validity of the methodology. Qualitative studies were evaluated using factors that accounted for relevance and validity2.3The populations were sorted by the age reported in the inclusion criteria, representing children (0–13), adolescents and young adults (13–21), and young adults (21–25). When available, both “age at diagnosis” and “age at research” were reported. Due to the lack of consensus in defining age categories for children and adolescents with cancer, some studies overlapped between the two intervals Table .2.4After the initial identification of 609 articles, the 58 articles meeting the inclusion criteria and quality requirements proved to be rather heterogenous in terms of the research question, content, and methodology. Therefore, a systematic review of the literature was more appropriate than a meta‐analysis. A pilot study was undertaken on 10 random articles from the final 58 to identify the criteria to be analyzed. The following four themes emerged from this preliminary analysis: (a) patient and professional knowledge and opinion regarding fertility preservation, (b) facilitators and barriers to fertility discussion, (c) reasons for pursuing or forgoing fertility preservation, and (d) emotions and concerns related to potential infertility. This classification was validated by all the authors. Each article was assigned to at least one theme.Facilitators and barriers were defined by personal, clinical, and institutional factors that were described in the original articles as reasons why the fertility discussion took place or not3n = 39), Europe (n = 16), Australia (n = 5), and Asia (n = 1).Forty‐one of the 58 selected articles utilized quantitative methods, 11 utilized qualitative analyses, and 7 utilized mixed methods (Table 3.1n = 34), 12 surveyed HCPs, and 2 surveyed only parents of children or adolescents who had been treated for cancer. Eight articles studied both patients and parents, one included patients and HCPs, and one included patients, parents, and HCPs. Finally, 25 studies were related exclusively to prepubescent patients  and 115 male (5–1167) patients were included in the studies. Parents were included in 11 studies . HCPs were included in 14 studies .The most common diagnoses were hematological cancers (47%), germ cell cancers, and gynecological cancers (30%). Neurological cancers and sarcomas represented 4% and 3%, respectively of the patients.3.23.2.1Less than 20% (94/549) of the patients surveyed did not know their reproductive health statusOnly 12% of eligible pubescent girls underwent oocyte preservation (225/1797),Evaluation of fertility testing after cancer treatment was mentioned in only two studies,3.2.2The papers on the outlook of HCPs either provided information regarding the practice3.3Twenty‐seven parameters considered to be facilitators and/or barriers to fertility discussion were identified for patients and/or HCPs Figure . They arPubertal status,Apart from breast cancer which was borderline data considering the focus of this review on CCS, there was no link between the type of cancer and the fertility discussion.Some factors stood out as facilitators as well as barriers for both patients and HCPs: the general health status,The patient's attitude could have been the source of additional barriers to fertility discussion: emotional distressIn HCP's attitude, barriers were found in: the lack of time to discuss fertility,3.4The reasons for pursuing or foregoing FP were sorted into six categories and analyzed from the point of view of patients and HCPs Figure : (a) CliFor patients, the most important reason to pursue FP was their knowledge of fertility (38% of the cases), especially when endorsing the benefits of banking.In contrast, for HCPs, fertility knowledge,Patients and HCPs agreed that the main factors for foregoing FP were the patient's attitudes, followed by the patient's clinical characteristics. For the patients, the attitude included fear of treatment delay,The patient's clinical characteristics age,44, 60The lack of familial and social support was in the third place for foregoing FP, for both patients (12%) and HCPs (18%). This included the absence of familial, parental, or their partner's consent for the FP, for patientsThe high cost of the procedures was raised by both the patients (18%)3.5Concerns and psychological impacts of cancer and potential infertility were reported for prepubescent and pubescent patients and categorized into “information,” “life concerns,” “parenthood,” “health risks,” “relationships,” and “psychological impact” Table .Emotional distress related to infertility was frequently reported within the transcribed verbatim of patients.Their own health risks were reported only in patients who had cancer after puberty. Concerns about the future child's health were noted mainly in patients who had cancer after puberty and who were more afraid of transmitting the disease .4This SLR was motivated by the contrast between the low proportion of AYA preserving their fertility  and the large impact of fertility concerns on the quality of life of young cancer survivors. Although there are nowadays several ways to achieve parenthood, less than half of female cancer survivorsIn the studies analyzed in this SLR, 17 articles reported on the type of FP performed and revealed a low proportion of young patients undergoing FP especially in pubescent girls and prepubescent children. In practice, for many years and in many countries, ethical and judicial reasons have limited the development of ovarian tissue cryopreservation (OTC). The patients were selected according to the very strict criteria of Edinburgh.In 2020, Shapira et al.Even in countries where OTC can be carried out in current care, its performance has not undergone significant growth for two main reasons. The first is related to time constraints and the second to uncertainty surrounding the reuse of cryopreserved gametes/gametic tissues. In young cancer patients, the start of treatment is often an emergency: stimulating ovulation would require postponing the start of treatment by at least 3 weeks , which is often not possible. For prepubescent children, the reasons for the low number of FP are probably the constraints of surgical removal of gametic tissues and the uncertainty of their reuse by autotransplantation or in vitro maturation. On the one hand, in many childhood cancers, the risk of gonadal metastases is a contraindication to subsequent autotransplantation. On the other hand, in vitro maturation of infantile germ cells has not yet led to the birth of a living child, although scientific progress is continuing and promising. Time constraints and doubts about the effectiveness of the techniques influence the information provided by HCPs and the decision made by patients and their parents.Unlike the situation with girls, referral of pubescent boys to sperm cryopreservation by health care professionals is easier and quicker and the sampling is not invasive. Utilization of frozen sperm is very common, either in artificial insemination or in in vitro fertilization, and is as effective as the use of fresh sperm and without risk for its offspring. Nevertheless, this procedure can present challenges to the young patient because it requires him to masturbate to provide a semen sample. Adolescents with a history of masturbation have higher chances of completing sperm banking.The care of children with cancer is constantly evolving, including fertility counseling. In their review, Logan and AnazodoThe 58 articles reviewed to understand the impact of fertility disorders revealed barriers and facilitators involved in fertility discussion and in continuing or discontinuing FP. One of the main barriers to fertility discussion was linked to the temporality: the emergency of oncological care leaves no room either for the initiation of fertility discussion or for reflection on life plans.Infertility concerns will surface later in life in the context of relationships and family plans.Nowadays, parenthood is not a life goal for everyone. However, for those who want to be a parent to a child irrespective of the biological origin of the gametes, other ways to become a parent are available: adoption, foster care, and step‐parenting. Another alternative to FP is gamete donation which can be reassuring for patients who fear transmitting their illness to their offspring. Altogether, gamete donation and adoption are viable strategies in place of or in complement to fertility preservation to enhance the quality of life of survivors who wish to have a child after cancer.The unknown or uncertain fertility status can lead to feelings of doubt and anxiety in some cancer survivors.In addition to the HCP's competence, the receptiveness of the patient and their family is essential. Their state of receptivity is the consequence of their level of psychological availability and of their knowledge about fertility , nurses, and social workers. When analyzing their opinions, a bias was found in the description of their practice when it was not the actual numbers provided but their approximate opinion. Another difficulty arose when a professional speaks for an entire institution,Finally, the age of the patients was never consensual among the studies Table , and it 6This SLR is an update on the reality of fertility preservation issues among patients and professionals. Although recommendations worldwideIn response to the questions presented in the introduction, this SLR showed that patients' and professionals' knowledge of FP is heterogeneous and that banking is low Figure . FertiliBy reinforcing professional training, HCPs should feel more comfortable discussing FP and more inclined to provide adequate information to the families. Understandably, treatment is a priority, however the time constraint should not be a barrier to discuss fertility and other alternatives to having children. Systematic information and systematic referral to a fertility specialist alongside oncological care would ensure that parents and patients are well‐informed.Achieving FP is an uphill battle and requires multi‐disciplinary teams working with the patients and families from the diagnosis of cancer to long‐term follow‐up. We suggest that (a) each medical team is partnered with a fertility specialist, (b) the medical team is educated about fertility issues, (c) practical training is offered to help HCPs become more comfortable discussing fertility, (d) each patient treated for cancer is provided with age‐appropriate materials, and (e) psychological counseling addressing fertility issues is offered.Karima El Alaoui‐Lasmaili: Conceptualization ; data curation (lead); investigation (lead); methodology (lead); project administration ; visualization ; writing – original draft (lead); writing – review and editing . Phi linh Nguyen‐Thi: Formal analysis (supporting); methodology . Nadine Demogeot: Resources ; supervision ; validation . Joëlle Lighezzolo‐Alnot: Resources ; supervision ; validation . Marie José Gross: Resources ; validation . Ludovic Mansuy: Resources ; validation . Pascal Chastagner: Funding acquisition (lead); resources ; validation . Isabelle Koscinski: Conceptualization (lead); formal analysis ; investigation ; project administration ; supervision (lead); validation ; visualization ; writing – original draft ; writing – review and editing (lead).Institut National du Cancer .The authors have no conflicts of interest to declare.Ethics approval was not required for this systematic literature review.Informed consent was not required for this systematic literature review.Table S1Click here for additional data file.Table S2Click here for additional data file.Table S3Click here for additional data file.Table S4Click here for additional data file.Table S5Click here for additional data file.


Background Flexibility is crucial to the harmonious execution of joint movements. While skeletal muscle dysfunction in patients with HTLV-1 can interfere with mobility, it is unclear whether these patients experience reduced flexibility.Objective To evaluate the differences in flexibility between HTLV-1-infected individuals with and without myelopathy compared with uninfected controls. We also investigated whether age, sex, body mass index (BMI), physical activity level, or lower back pain influence flexibility in HTLV-1-infected individuals.Methods The sample consisted of 56 adults, of which 15 did not have HTLV-1, 15 had HTLV-1 without myelopathy, and 26 had TSP/HAM. Their flexibility was assessed using the sit-and-reach test and a pendulum fleximeter.Results No differences in flexibility were observed between the groups with and without myelopathy and controls without HTLV-1 infection using the sit-and-reach test. The pendulum fleximeter results of individuals with TSP/HAM presented the lowest flexibility among the groups with respect to trunk flexion, hip flexion and extension, knee flexion, and ankle dorsiflexion, even after adjusting for age, sex, BMI, level of physical activity, and lower back pain using multiple linear regression models. Additionally, HTLV-1-infected individuals without myelopathy demonstrated reduced flexibility in movements: knee flexion, dorsiflexion, and ankle plantar flexion.Conclusions Individuals with TSP/HAM demonstrated reduced flexibility in most of the movements evaluated by the pendulum fleximeter. Additionally, HTLV-1-infected individuals without myelopathy demonstrated reduced knee and ankle flexibility, potentially representing a marker of myelopathic development. The adult T cell leukemia virus-1 (HTLV-1), a delta retrovirus also known as Human T-lymphotropic virus type 1, was the first retrovirus to be isolated in humans.The HTLV-1 is etiologically linked to adult T cell leukemia-lymphoma (ATLL), tropical spastic paraparesis/HTLV-1-associated myelopathy (TSP/HAM), uveitis and infective dermatitis.Manifestations associated with TSP/HAM, a chronic, progressive demyelinating disease that mainly affects the thoracic region of the spinal cord, generally appear after 40 years of age.A previous study provided preliminary evidence indicating that patients with TSP/HAM present reduced joint flexibility and, consequently, mobility, resulting in decreased functional capacity compared with uninfected individuals.Joint flexibility is the range of motion (ROM) in a joint or group of joints, or the ability of joints to move effectively through a complete range of motion.In addition to endogenous factors , exogenous factors  may also influence joint flexibility.It is well known that changes in joint flexibility can affect mobility and increase the risk of falls. Therefore, it is important to investigate the changes in flexibility in patients with TSP/HAM. The current study aimed to more accurately evaluate differences in flexibility between infected individuals with and without myelopathy, comparing measurements obtained via pendulum fleximeter to a control group without the HTLV-1 infection. Additionally, we investigated whether the confounding variables of age, sex, BMI, level of physical activity, and lower back pain influence flexibility in HTLV-1-infected individuals.The present exploratory, analytical, cross-sectional controlled study was conducted between April 2018 and December 2019 in a non-probabilistic sample at the Integrated Multidisciplinary HTLV/Neurosciences Center (CHTLV) at the Bahiana School of Medicine and Public Health (EBMSP). This outpatient clinic provides comprehensive biopsychosocial care to the public, with support provided by the National Unified Health Care System (SUS), including general medical treatment, laboratory diagnosis, psychological counseling, and physical therapy.The patients were recruited sequentially during routine neurological evaluations by a single trained neurologist. All HTLV-1-infected patients, with or without myelopathy, aged between 18 and 65 years were invited to participate, as well as individuals without HTLV infection, who served as controls for comparison purposes. Individuals with TSP/HAM were diagnosed as ‘definite’, according to the criteria established by De Castro-Costa et al. (2006).Briefly, definite TSP/HAM is considered when non-remitting progressive spastic paraparesis sufficiently impairs a patient's gait to the point of being perceptible. The presence of HTLV-1 antibodies in serum and cerebrospinal fluid (CSF) must be confirmed by Western blot and/or C-reactive protein (CRP) positivity for HTLV-1 in blood and/or CSF. While sensory symptoms or signs may or may not be present, when present they remain subtle, lacking a clear-cut level of sensory perception. Urinary and anal sphincter signs or symptoms may or may not be present. Any other disorders that resemble TSP/HAM should be excluded through appropriate laboratory and clinical evaluations. To calculate the sample size, we used the data of Santos et al.,The following parameters were used: mean (SD) of flexibility between uninfected and asymptomatic subjects of 29.2 (7.5) and 23.4 (7.9) cm, respectively, power of 80%, and α-error of 0.05, resulting in a sample of 29 subjects in each group, with an increase of 20% due to possible losses and adjustments for multivariate analysis. Calculations were performed with the OpenEpi program , version 3.All included patients signed a term of informed consent. This study was approved the Institutional Review Board of EBMSP (protocol number 2.480.700/2018).Exclusion criteria consisted of any other causes of motor deficiency , wheelchair use, evidence of coinfection, e.g., syphilis, hepatitis B and C, human immunodeficiency virus (HIV), or any other diseases that could lead to neurological impairment . The HTLV-1-positive individuals who did not meet the criteria for definite TSP/HAM  were also excluded.All HTLV-1 patients without myelopathy were submitted to two neurological scales to confirm the absence of neurological abnormalities: 1) expanded disability status scale (EDSS)A semi-structured questionnaire was applied to collect information on the following variables: sex, age, weight, height, BMI, marital status, self-reported skin color, education, family income (recorded in multiples of minimum monthly wage). The BMI was categorized as obese (BMI ≥ 25 kg/m2) or non-obese (BMI < 25 kg/m2). The brief pain inventory (BPI), validated in Portuguese (Brazilian), was applied to assess the frequency and location of pain experienced by individuals over the previous 24 hours.To measure each participant's flexibility, the sit and reach test was employed to measure, in centimeters, the degree of elongation of the posterior part of the trunk and lower limbs.thpercentiles) were used for non-normal distributions. Absolute and relative frequencies were described for categorical variables. Comparisons among sociodemographic and clinical characteristics were performed using the χ2 test or the Fisher exact test where indicated . Analysis of variance (ANOVA) was performed using the Bonferroni post hoc or the non-parametric Kruskal-Wallis tests, with the Dunn-Bonferroni post-test correction where indicated (continuous variables).Quantitative variables were assessed for normal distribution using the Shapiro-Wilk test. Results were expressed as means ( ±  SD) when normal distributions were verified, while medians (with 25–75(−)group as a reference. Pseudo r2 values and β coefficients with respective 95% confidence intervals (95% CI) are shown in each adjusted model. Thep-values < 0.05 were considered statistically significant. All statistical analyses were performed using the Stata  software, version 13.0, for Mac, and graphs were constructed using Prism , version 9.1.2, for Mac.Individual sit and reach test values, as well as group medians of the HTLV infection status, were plotted via dot-plot graphs. Multivariate linear regression analysis was employed on datasets containing the angles measured using a pendulum fleximeter, while adjusting for confounding factors , considering the HTLV-1(+)), and 15 individuals without infection (HTLV-1(−)) , 15 HTLV-1-positive individuals without myelopathy (HTLV-11(−)) .(+)and HTLV-1(−)groups ((+)group was composed of younger individuals, with a median age of 39 (range: 30–52) years; all individuals reported income below the minimum wage, and 73% were considered overweight. The HTLV-1(−)group reported significantly higher family income than the HTLV-1(+)and TSP/HAM groups.Sociodemographic and anthropometric data are shown ingroups . The HTp = 0.232). However, the data shown inthpercentile) values across the three groups: the median value obtained for the HTLV-1(−)group was 23.0 (17.5–28.5) cm, higher than the HTLV-1(+)group  and the definite TSP/HAM group  cm). Most participants (76.8%) reported pain within the last 24 hours. The most frequent site of pain in all groups was the lumbar region (69.64%): 9/15 (60.0%) in the HTLV-1(−)group, 8/15 (53.33%) in the HTLV-1(+)group, and 22/26 (84.62%) in the HAM/TSP group.When analyzing flexibility using the sit and reach test, no statistically significant differences were observed between the three groups ((+)and HTLV-1(−)groups. Regarding right and left hip flexion and right and left hip extension, the definite TSP/HAM group presented less flexibility compared with the HTLV-1(+)and HTLV-1(−)groups.p < 0.001). Surprisingly, HTLV-1(+)individuals presented higher median trunk extension values than HTLV-1(−)individuals in all models (p < 0.01)  .(+)individuals revealed lower values  with borderline significance in the former group, which were not significant after adjusting for confounders . Regarding trunk extension, TSP/HAM individuals presented significantly lower median values compared with the HTLV-1(+)group across all models (data not shown).A separate comparison of trunk flexion between the TSP/HAM group and HTLV-1(+)and TSP/HAM groups to HTLV-1(−)individuals, statistical significance was consistently observed across the adjusted models for right and left hip flexion, right and left hip extension, as well as right hip external rotation in the TSP/HAM group. With regard to left hip extension, significance was observed in the HTLV-1(+)group across all four multivariate models. Furthermore, considering left hip abduction, significantly lower results were found in TSP/HAM group only in Model 1 (p = 0.04). Moreover, significance was also observed across Models 2 to 4 in the TSP/HAM group when left hip external rotation values were analyzed groups revealed significantly worse values across all models with regard to the flexion, extension, and abduction movements of both hips, as well as the external rotation of the right hip (data not shown).A subcomparison of differences in hip movement between TSP/HAM and HTLV-1(+)group only in Models 2 and 3 groups revealed significantly worse values in all models with respect to left knee flexion movement (data not shown).A subcomparison of the differences in knee and ankle movement between the TSP/HAM and HTLV-1(−)subjects. After adjusting for confounding variables, such as age, sex, BMI, level of physical activity, and lower back pain, multivariate analysis confirmed that individuals with TSP/HAM presented significantly reduced flexibility in approximately 50% of the joint movements studied, when compared with the HTLV-1(−)reference group. Some causal factors underlying the reduction in flexibility observed in these patients could include neurological disorders associated with TSP/HAM, such as spasticity, muscle shortening, and weakness, postural changes, and reduced mobility.Flexibility is significantly reduced in individuals with TSP/HAM as assessed by the pendular fleximeter. Significantly lower flexibility was noted in the trunk extension and flexion, and bilateral hip extension movements compared with individuals without myelopathy and HTLV-1(-)group. These types of motor alterations may be explained by the clinical picture of TSP/HAM, as it is already known that the region proximal to the lower limb muscles is mainly affected in patients with spastic paraparesis, generally characterized by muscle shortening and stiffness.(+)individuals with TSP/HAM in a prospective cohort.In patients with TSP/HAM, decreased mobility was observed in the hip joint in terms of flexion, extension, external rotation, and abduction movements, when compared with the HTLV-1TSP/HAM patients present pelvic instability due to muscle shortening and the inability to resist gravity due to muscle weakness.Pelvic instability can also lead to a loss of knee flexion in patients with TSP/HAM, as biomechanical compensatory mechanisms change the center of the knee.Among patients living with HTLV-1 who did not demonstrate clinical signs of myelopathy presented decreased plantar flexion compared with uninfected individuals after adjusting for sex, age, and physical activity. This finding suggests that some degree of impairment in plantar flexion may already be occurring in patients living with HTLV-1, despite the absence of other myelopathic signs or symptoms. Indeed, previous reports have shown clinical manifestations occurring in HTLV-1-infected patients without myelopathy, and it has been postulated that even asymptomatic HTLV-1 carriers may harbor other neurological signs and symptoms that potentially constitute early indicators of myelopathy development, such as subcortical cognitive deficits.Lower back pain is the most frequently reported pain in patients with HTLV-1.(-)group presented inferior results compared with the TSP/HAM group. It is possible that the TSP/HAM group exhibited superior performance as a result of the regular physical therapy  provided to these patients.(+)without myelopathy and HTLV-1(-)groups. Another limitation is the lack of associations with specific factors that underline the loss of flexibility in individuals with myelopathy. Nonetheless, it is important to emphasize that some individuals in the HTLV-1(+)group without myelopathy presented a loss of flexibility despite not being classified as TSP/HAM, which may indicate that muscle weakness can more relevantly impact flexibility than spasticity. This warrants further investigation. Finally, while muscle weakness was not investigated herein, we recommend that future studies include this parameter in an attempt to elucidate factors underlying the observed loss in flexibility in patients living with HTLV-1.In contrast to a study conducted by Santos, 2015,Because the number of recruits in these groups was lower than the estimated calculation, the power of the study was reduced by increasing the β error. Therefore, the hypothesis that asymptomatic subjects suffering from myelopathy have limited flexibility cannot be excluded. However, as mentioned above, decreased flexibility was observed in certain joints. New studies should be performed to confirm these differences.It is important to note that no broad consensus exists regarding the most appropriate method of measuring flexibility. However, the pendular fleximeter has been suggested as a more accurate tool to assess flexibility, when compared with the sit-and-reach test. Thus, it is necessary to comprehensively assess the accuracy of instruments designed to assess flexibility.It can be concluded that individuals with TSP/HAM present reduced joint flexibility in most movements evaluated by the pendulum fleximeter. In addition, patients infected with HTLV-1 subjects without myelopathy demonstrated loss of flexibility in some joints, such as the knee and ankle. In view of these results, it is highly recommended that careful evaluations of flexibility to be longitudinal in patients with HTLV-1, to better understand the impacts of myelopathy in reduced mobility and, consequently, in the quality of lives of people living with HTLV-1.


Rupture of the cranial cruciate ligament in dogs is a very common condition in veterinary medicine. Surgical treatment is well established and several procedures provide very good clinical results. However, surgical treatment is associated with a high financial burden for patients’ owners. Veterinarians are bound to charging services according to a mandatory fee schedule, which gives a range in pricing. In this study, we examine the prices for two surgical interventions. We found that one technique is slightly more expensive; however, it also creates greater costs in the veterinary practice setting. Therefore, it is questionable whether the more expensive procedure provides a greater scope for profit. Pricing strategies are identified and may either be based on costs or a promise of quality in terms of a better clinical outcome.In surgical treatment of cranial cruciate ligament disease in dogs, Tibial Plateau Levelling Osteotomy (TPLO) and Tibial Tuberosity Advancement (TTA) are commonly established procedures and have proven effective in restoring limb function. Unlike clinical outcome, economic aspects have not been studied as extensively. However, the surgical intervention poses an enormous financial burden on patients’ owners. In a veterinary practice setting, this study compares prices for TPLO and TTA and examines prices differences as well as potential cost drivers. Charges for veterinary treatments are based on the Gebührenordnung für Tierärztinnen und Tierärzte (GOT), which is mandatory for veterinarians in Germany but allows a certain range in billing. This study found that TPLO is charged at a higher price than TTA; however, this might not cover the additional costs of this procedure. The price is also associated with weight, heavier dogs being more expensive. The underlying strategies for pricing decisions may be based on costs, as efforts for TPLO and heavier dogs are higher in terms of a prolonged surgical time, the number of staff involved and in surgeons’ training. Price setting may also be based on a quality promise, suggesting better clinical outcome in a more expensive procedure. Future investigations should involve economic considerations and consider cost-effectiveness analysis when evaluating surgical treatment options. Cranial cruciate ligament (CCL) disease is one of the most common orthopaedic problems in canines  causing The high incidence of CCL disease  leads toProfit generally is defined by revenue minus expenses . RevenueThere are several instruments to define an ideal pricing structure. Price can be determined by either cost-based or value-based approaches, depending on the pricing objectives. While, in a cost-based approach, the main leverage for the price is the costs in terms of expenses, the pricing in a value-based pricing suggests a certain quality .The aim of this study was to determine the pricing structure of TTA and TPLO and, if possible, to identify drivers or influences on the total price. We hypothesise that there is a difference in price for TTA and TPLO. Furthermore, we will investigate price components and how they influence key economic figures. Finally, we will discuss factors on the decision-making process in pricing TTA and TPLO and how scientific evidence influences this process.Price (P) = revenue of a single surgical procedure = charges billed to the patient owner;Cost (C) = expenses borne by the veterinarian related to the surgical procedure.First of all, we must be careful using the term costs. Costs in terms of the GOT are the price charged to the owner. Therefore, it corresponds to the revenue of each surgical procedure. There are also costs that are direct and indirect expenses for the veterinarian related to the surgical treatment, such as staff, consumables, other materials and medication and general costs for running the veterinary practice. To differentiate the term cost, we will hereafter define the following terms:To determine the price of TPLO and TTA, we collected clinical and billing records from a veterinary hospital in Germany. The veterinary clinic regularly and alternatingly performs TPLO and TTA in dogs. The collected invoices from 2018 and 2019 were retrospectively reviewed alongside the clients’ records.Clinical diagnosis of cranial cruciate ligament rupture as recommended by current standards ;Surgical treatment of the CCL disease by either TPLO or TTA.Inclusion criteria for billing records are:Any comorbidities treated concurrently with CCL disease;Bilateral CCL disease, if surgical treatment is performed at the same time.Exclusion criteria:Patient data were blinded and included age at time of treatment, sex, castration status, breed and weight. Billing data include all charges billed on the date of surgical treatment. The price is calculated for both surgical treatments individually and compared between TPLO and TTA. All prices were net prices . Patients were then divided into groups by weight : <15 kg; medium dogs (group M): 15–40 kg; large dogs (group L): >40 kg) and prices for all three groups were determined. In order to compare pricing for the different weight groups, we differentiated the population into small, medium and large dogs.n = 30), Labrador Retrievers (n = 20), Bernese Mountain Dogs (n = 12), Boxers (n = 9), Beagles (n = 8), Old English Bulldogs (n = 6), Rottweilers (n = 5), Golden Retrievers (n = 5), Entlebucher Mountain Dogs (n = 4) and Australian Shepherds (n = 4). There were 28 males (17%), 48 neutered males (30%), 22 females (14%) and 64 neutered females (39%). Details on weight, age and sex at the time of surgery are given in The most common breeds were mixed breeds , which is mandatory for billing veterinary services. The services were differentiated into fees for veterinary services (“Gebühren für Leistungen”), compensation such as wayfare (“Entschädigungen”), expenses for postage or external services (“Barauslagen”) and the charges for medication and materials  and multiplication factor (1–3). We set up an exemplary invoice for TPLO and TTA each to compare price components and we calculated the median price that is charged, respectively, for TPLO- and TTA-specific implants/materials. The invoices considered in our study were based on the version of the GOT that was valid in the period of investigation . As a mup < 0.05.A Mann–Whitney U-Test was calculated to determine if there were differences in net prices between TPLO and TTA. Associations were considered to be statistically significant at The search identified a total of 178 clinical records with diagnosis and treatment of CCL disease with TPLO (TPLO group) or TTA (TTA group). Surgeries were performed between 1 January 2018 and 31 December 2019.p < 0.05). The price for TTA is significantly lower than the price for TPLO.Of the 178 records, we excluded 16 cases due to incomplete data (n = 10) or comorbidities that were treated at the same time as CCL disease (n = 6), which leaves 162 cases that met the inclusion criteria. A total of 75 stifles were treated with TPLO and 87 stifles with TTA. The net price for TPLO was EUR 1525.97 . The mean net price for TTA was EUR 1475.60  see . The netComparing the price for both TPLO and TTA between groups based on weight, we could see that price is higher when the dog’s weight is higher see .Price components are based on fees for veterinary services (“Gebühren für Leistungen”) and charges for materials and medication. Compensation such as wayfare (“Entschädigungen”) and expenses for postage or external services (“Barauslagen”) were not applicable in these invoices. The price components of the invoices are similar for TPLO and TTA and can be categorised into fees for veterinary services, materials and medication see . The feeOur results show that the price does differ significantly between TPLO and TTA when comparing records from both procedures within one veterinary hospital. The price for TPLO is by around EUR 50 higher than for TTA, which might not be sufficient to offset the additional staffing costs required for TPLO, even if the material costs for TTA is more cost-intensive.Possible reasons for the different pricing in the same surgical procedure may occur due to varying application of the GOT and cost structures. Therefore, it is important to take a closer look at how prices are designed in a veterinary practice setting.How price is set using the GOT. The price can be set by altering the factor between one and three multiplied by the basic fee for veterinary services. For example, the fee for surgery of the rupture of the cranial cruciate ligament without meniscal resection (No. B 3.12 a) can be charged between EUR 288.61 and EUR 865.83 . Figure The mean factor that veterinarians applied (except for emergency services) in 2019 was 1.44 . We concHow price is influenced by costs. Costs can be differentiated between general costs for running a veterinary practice and specific costs for a certain surgical procedure. The general costs for running a veterinary practice include staff costs, costs for medication and materials, rent and leases, energy, insurance, depreciation, interest and other operating expenses . The cosHow to decide which price to set for TPLO and TTA. The decision-making-process on pricing a surgical procedure can be based on a cost-based or value-based strategy. Therefore, we defined the following decision tree :In a cost-based pricing strategy, price will be determined by the costs that come with a service or product . Costs iProfitability. We found that the price for TPLO is around EUR 50 higher than for TTA, direct costs for TPLO-specific materials/implants are lower than for TTA and the cost structure for other materials and medication, as well as the number of staff needed, is similar, which may evoke the assumption that there is a higher scope for profit for TPLO. However, there is a striking impact of the surgical time on costs, as the duration for TPLO is much longer than for TTA given that the performing surgeons have a similar level of experience. The costs for staff needed for the procedure and the share of general costs for running a veterinary practice increase with extended surgical time. This increased effort must be reflected in price setting by applying a higher multiplication factor and/or adding a time factor, when possible. Furthermore, TPLO requires specific training and is supposed to be more difficult to learn, which leads to higher indirect costs for the surgeon’s education. Altogether, we believe that the price difference between TPLO and TTA must be significantly higher than EUR 50 in order to ensure TPLO’s profitability. In brief, TPLO is associated with higher costs due to the surgery’s duration and binding staff during this time, as well as the surgeon’s training.We previously investigated on the clinical outcome of TTA and TPLO but were not able to clearly prefer one over the other. Both techniques provide a good functional outcome in terms of subjective and objective gait analysis, thigh circumference measurements, goniometry, joint stability and postoperative pain. TTA appears to have slower progression of osteoarthritis within six months after surgery, while TPLO results in lower complication rates, especially surgical site infections . In a vaIn order to evaluate the relationship between the outcome of the treatment option and its cost, there are various empirical methods of health economics. In human medicine, cost-effectiveness analysis is a successfully used technique to examine the cost of orthopaedic treatment in relation to the quality of treatment outcomes ,39. The There are several limitations to our study. We only compared data from one veterinary hospital because we wanted to rule out pricing differences that are accounted to a different pricing policy between two veterinary hospitals. However, we believe that the differences in prices become even more apparent when comparing prices between veterinary hospitals. Further research is needed to compare pricing structures between a large number of veterinary hospitals in order to confirm our results. With the rising importance of pet insurances in Germany, billing data from insurance companies may provide a valuable basis for this comparison. Moreover, prices do not represent the overall treatment cost in treating CCL disease. Additional treatment due to postoperative complications or the need for physical therapy and rehabilitation pose another financial burden on dogs’ owners. Further research may also focus on the overall treatment cost, which takes into account all costs related to the disease. Another limitation is posed on the retrospective character of our study. We did not discount invoices, as price rises of the GOT are not carried out regularly (yearly) and our study period only covers two years. Nevertheless, veterinary hospitals are able to enforce price rises any time by customising the factor applied to the basic fee. A prospective trial with tracking of possible price rises and corresponding discounts in the evaluation is needed to rule out this limitation.Prices of surgical treatment of CCL disease by TPLO and TTA differ and further research on the underlying reasons for pricing decisions is recommended. Both procedures are an effective treatment option for CCL rupture and deliver excellent clinical results with minor differences in outcome parameters. TPLO is charged at a slightly higher price, which may indicate a higher scope for profit. However, there are differences in expenses for performing both procedures. TPLO is associated with higher expenses in the surgeon’s training, in TPLO-specific instruments, as well as a prolonged anaesthesia and surgery time, which creates costs in terms of binding staff and general costs for running a veterinary practice. Pricing decisions in veterinary medicine should be based on comprehensible profitability calculations and consider direct, as well indirect, costs for a certain procedure. More investigations are needed in order to evaluate cost-effectiveness and economic impact, as these types of studies are sparse in veterinary medicine.


There is growing interest in improving the quality of life as we get older. The ability to move freely is key for an increased health span. And the health of our joints plays a pivotal role in that. However, joint function tends to decline with age, overuse, or in certain genetic diseases. This happens when cartilage and other tissues within the joint start to deteriorate, and can lead to the most common form of arthritis, osteoarthritis (OA) . CompromThe condition is already a leading cause of work disability in the United States and a major economic burden in an increasingly older human population. There is no effective therapy and for many OA patients the best they can expect is pain management which is also in need for more effective and safer medications for chronic use.Our recent work demonstrates a new and promising approach. Urolithin A, a natural postbiotic molecule showed significant protection against OA associated disease markers . This efMitochondrial dysfunction is a hallmark of aging . This deUrolithin A has been shown to improve mitophagy and mitochondrial function in several tissues affected by aging and age-associated diseases, particularly skeletal muscle . Preclinin vivo, in a preclinical model of knee OA where UA was administered UA for two months. Importantly this was accompanied by significant improvement in the cartilage tissue quality. The untreated controls exhibited standard features of OA joints, such as cartilage erosion and increased cell death. Supplementation with UA improved these pathological aspects, leading to better quality and cellularity of the knee joints.The data showed human primary chondrocytes treated with UA had increased mitophagy flux and higher levels of PINK1-Parkin mediated mitophagy. This increased mitophagy was associated with enhanced mitochondrial respiration, indicative of higher energy production in cartilage cells. An increase in mitophagy and mitochondrial abundance in joint tissue was also shown Another common hallmark of aging is low-grade, chronic inflammation, also known as inflamm-aging. And inflammation is one of the main mechanisms of joint tissue damage and OA-associated pain. There is extensive literature showing UA to have anti-inflammatory activity in several preclinical models .This effect has been translated also in humans. A 4 months administration of UA led to reduced circulating levels of CRP, a well-established marker of inflammation, in subjects that are not diseased but have suboptimal health status , 7. NotaTaken together, the study of the impact of UA in OA models indicates that UA’s beneficial effects could derive from a combined effect on two aging-relevant physiological changes: improved mitochondrial quality and reduced inflammation. Further mechanistic studies should reveal the exact interplay between UA and changes on these two biological pathways.in vivo studies are required, but these initial data suggest UA may support joint health even before the onset of disease.Another key observation is that UA increases mitophagy and mitochondrial not only in cells from OA patients, but also in chondrocytes from healthy subjects. Further Finally, building on the existing literature on Urolithin A, the Aging Cell study supports a combined role for UA in preserving healthy mobility, by acting on both cartilage cells and skeletal muscle . Other rIn summary, UA’s impact on mitochondrial function provides benefits to multiple tissues and their corresponding physiological functions. This suggests regular supplementation of UA may be a useful way to help counter a number of functional and biological changes that occur with aging. This latest data further supports the potential of UA as a nutritional intervention to support joint function and to help people retain better movement and mobility as they grow older.