Also, it found that high-income cities have a higher technology gap than upper middle–income cities, and media reports efficiency have a high correlation with respiratory diseases and CO2.Over the past few decades, China’s rapid economic, energy, and industrial developments have caused serious environmental damage. However, as there are large resource, energy use, economic, and environmental damage differences across Chinese regions, the Chinese government is seeking to reduce city pollution across the country. Most previous analyses have only looked at these issues on a single level; for example, the impact of environmental pollution on health, or energy and environmental efficiency analyses, but there have been few studies that have conducted overall analyses. Further, many of the methods that have been used in previous research have employed one-stage radial or non-radial analyses without considering regional differences. Therefore, this paper developed a meta undesirable two-stage EBM DEA model to analyze the energy, environment, health, and media communication efficiencies in 31 Chinese cities, from which it was found that the productivity efficiency in most cities was better than the health treatment efficiencies, the GDP and fixed asset efficiency improvements were small, the air quality index (AQI) and CO The World Health Organization  claims tPast studies have focused on the relationship between economic growth and air pollution ,5, the c2 and air quality index (AQI) to the environment. The undesirable output CO2 and AQI—intermediate output from the production stage (first stage)—can be seen in second stage—input resources—to the production of new values in the health treatment stage (second stage). The government provides health expenditures to reduce diseases caused by environmental pollution. Media reports can objectively present air pollution information, identify the causes of pollution in a timely manner, and identify protective measures so as to prevent or control the risk of physical injury and reduce the incidence of diseases. Media reports can reduce the incidence of public diseases, improve the public’s physical and mental health, and improve the health and ethics of the entire population. So, government health expenditures and media reports can reduce disease. Therefore, energy, environmental pollution, health, and media can be constructed by the two-stage model.However, in general, few studies have linked these energy, air pollution, health discussions and media discourse. This article will therefore discuss economics, environmental pollution, health, and media together. The relationship is shown in While several past studies have employed network data envelopment analysis (DEA) to examine production and pollution controls ,42,43,442 emissions and AQI. Health treatment was taken as the second stage based on health expenditure and media report inputs and birth rate and respiratory disease prevalence outputs.As this model not only includes existing production efficiencies but also considers the sustainability of human health, it has two main contributions. First, to avoid under- or over-estimation, the economic, environmental, media communication, and health efficiencies are jointly analyzed. Second, a meta undesirable two stage EBM DEA model is used to avoid the radial and non-radial biases. Sometimes, decision making units (DMUs) are not homogeneous and have different resource endowments, such as income and location, which affects the inputs and outputs of DMUs, so the concept of meta should therefore be adopted to avoid large regional difference by grouping DMUs. Data from 2013–2016 for 31 Chinese cities were extracted and analyzed, with production taken as the first stage based on labor, fixed assets, and energy consumption inputs and GDP output, with the link between the production stage and the health treatment stage variables being COPast research can be divided into discussions on the relationships between economic growth and air pollution and between air pollution and human health, examinations of preventative measures to reduce the effects of air pollution on societal health, and the effect of public awareness raising by the media on air pollution and environmental issues.3 over a 24-h average particulate matter PM2.5 increased the risk for wheezing bronchitis by 5%. In related studies, Chen et al. [2, PM10, and O3. In examinations on the effects of long-term exposure to air pollutants on human health, Loomis et al. [3 increase in PM10 and NO2 was significantly associated with non-accidental mortality. In other studies, Kelly and Fussel [With a focus on economic growth and air pollution, Georgiev and Mihaylo  found thn et al.  used GLMn et al.  examineds et al.  found a s et al.  revieweds et al.  studied d Fussel  analyzedd Fussel  found th3, the cardiovascular mortality increased by 0.47% and the respiratory mortality increased by 0.57%, when PM10 increased by 10μg/m3, cardiovascular mortality increases by 0.27% and respiratory mortality increased by 0.56%, and that short-term exposure to a particulate environment was associated with an increased incidence of cardiopulmonary disease and an increased mortality in low- and middle-income countries. Zigler et al. [Khafaie et al.  used resr et al.  exploredr et al.  found thTo reduce the effects of air pollution on societal health, Torretta et al.  proposedNew York Times, the Los Angeles Times, and the Washington Post over 20 years and found that air pollution was generally explained as being related to asthma. However, the newspapers avoid connecting respiratory disease with environmental problems that reduced the government’s control on air pollution due to low public concern. Elliot et al. [In a study on the relationship between media promotion and air pollution, Dworkin and Pijwaka  exploredt et al.  studied t et al.  investigt et al.  studied t et al.  studied t et al.  examinedt et al.  studied The theoretical framework for this study is based on previous study results and the following assumptions: public media reports positively impact public awareness of air pollution and its impact on the environment and human health.Based on the above literature analysis, this paper makes the following research hypotheses:H1: Public media reports have a correlation with CO2 and AQI.H2: Public media reports have a correlation with respiratory diseases.As can be seen from this brief literature review, much of the previous research has only been on a single level using radial and non-radial methods with little consideration for regional differences. Therefore, to overcome these issues, this paper used a meta undesirable two-stage EBM DEA model to explore the energy, environment, health, and media communication efficiencies in 31 mainland Chinese cities. Due to the difference in income between regions, this paper compares the 31 Chinese cities divided into high- and upper middle–income cities. The hypotheses are as follows:H3: In the efficiencies, high-income cities are higher than upper middle–income cities.H4: In the Technology gap, high-income cities are higher than upper middle–income cities.After Farrell  proposedIn 2007, Färe et al  proposedWhile the EBM DEA resolved the radial and non-radial issues, it failed to deal with the two-stage problem, and while the NDEA model solved the multi-stage problems, it failed to deal with the radial and non-radial problems. As different countries have different social and cultural backgrounds, economic environments, management models, and production efficiencies, and as manufacturers from different countries have different production technologies, if a traditional DEA assumes that all DMUs have the same technical level in the efficiency evaluation, it may be inappropriate to analyze efficiencies using traditional efficiency evaluation models. This paper, therefore, proposes a model based on Tone and Tsutsui , O’Donne2 emissions and AQI. In the second stage, health expenditure and media reports were the input, with the output being birth rate and respiratory diseases. As respiratory diseases were seen as undesirable output, Tone and Tsutsui’s [This study collected data from 31 Chinese cities. In the first stage, labor, fixed assets, and energy consumption were the inputs, and GDP was the output, with the one-stage and two-stage links being COsutsui’s  EBM modeIn a traditional DEA efficiency evaluation, it is usually assumed that all producers have the same level of production technology; however, in reality, most decision-making units have different production technologies because of different geographical locations, national policies, or social and economic conditions. Battese and Rao  and Battn DMU and K division, jDMU = , m input jX = , s output, jY = , DMU efficiency: Due to management, resource, regulatory, and environmental differences, all firms (N) are made up of DMU groups (1 + N2 +…+ NGN = N), with Xij and Yrj denoting the input  and with the final output being r  for unit j . Under the meta-frontier, DMU k then chooses an optimal final output weight  to attain the highest efficiency; therefore, under a non-oriented EBM, the efficiency of DMU k using the meta undesirable two stage EBM DEA can be determined using the following linear programming.Subject toY: DMU output,X: DMU input,From the above equations, the overall technological efficiency of the cities can be determined under the meta-frontier, and using Equation (1)–(5), the overall technological efficiency of all high-income and upper middle–income cities can be determined under the meta-frontier undesirable two-stage EBM group frontier modelThe high- and upper middle–income cities were divided into g decision-making units, each of which was assigned an optimal output weight; therefore, the DMU efficiency under the group frontier was solved using the following equations.Subject toAs the production frontier for the g groups were included in the meta-frontier, the technical efficiency under the meta-frontier needed to be less than the technical efficiency under the group frontier. The ratio of the two frontiers is called the technology gap ratio (TGR):The Hu and Wang  total-faIf the target fixed assets, labor, energy consumption, and health expenditure inputs equaled the actual inputs, then the fixed assets, labor, energy consumption, health expenditure, and media efficiencies equaled 1, indicating overall efficiency. If the target fixed assets, labor, energy consumption, health expenditure, and media inputs were less than the actual inputs, then the fixed assets, labor, energy consumption, health expenditure, and media efficiencies were less than 1, indicating overall inefficiency.If the target GDP and birth rate desirable outputs were equal to the actual GDP and birth rate desirable outputs, then the GDP and birth rate efficiencies equaled 1, indicating overall efficiency. If the actual GDP and birth rate desirable outputs were less than the target GDP and birth rate desirable outputs, then the GDP and birth rate efficiencies were less than 1, indicating overall inefficiency.2, and AQI undesirable outputs were equal to the actual respiratory disease, CO2, and AQI undesirable outputs, then the respiratory diseases, CO2 and AQI efficiencies equaled 1, indicating efficiency. If the target respiratory disease, CO2, and AQI undesirable outputs were less than the actual respiratory disease, CO2, and AQI undesirable outputs, then respiratory diseases, CO2, and AQI efficiencies were less than 1, indicating inefficiency.If the target respiratory diseases, COBased on the World Bank’s classification for rich and poor countries, the 31 Chinese cities were divided into high- and upper middle–income cities, with the upper middle–income economies having a GNI  per capita between $3896 and $12,055, and the high-income economies having a GNI per capita of $12,056 or more .Therefore, the 31 sample cities were divided into 14 high-income cities  and 17 upper middle–income cities .2 and AQI are undesirable outputs . In theh et al. , input ig et al. . The twoThe variables used in the study are explained in the following:First stage: production stageLabor input: Employees; this study used the number of employed people in each city at the end of each year; unit: person.Energy consumption was calculated from the total energy consumption in each city; unit: 100 million Tonnes.Fixed assets: the capital stock in each city was calculated using the fixed assets investment in each city; unit: 100 million CNY.Input variables:Output variables:Desirable output (GDP): the GDP in each city was used as each city’s output; unit: 100 million CNY;2, a common greenhouse gas;Carbon dioxide: CO2), and nitrogen.AQI: the air quality index, which is a measured concentration of the pollutants such as PM2.5, PM10, sulfur dioxide , with the number of statistics being the total amount in the year. The official news websites were selected because of the amount of news published and their wide influence.Input variables:2. Karimi et al. [3, PM2.5, PM10, NO2, NOx, SO2, and CO) were associated with increased mortality and hospitalization rates, but PM2.5 and PM10 were more strongly affected.Respiratory Diseases: referring to the prevalence of respiratory diseases. In order to examine the effects of medical health inputs on diseases in various regions, only respiratory disease data can be collected, and data on specific respiratory diseases cannot be obtained. Therefore, in this study, the respiratory disease rate was used to measure the adverse effects of air pollutants and the effects of health management, mainly because a large amount of literature research has been proved. Some researchers had found that respiratory disease is significantly affected by air pollutants as PM10 . In some model specifications, ozone, another measure of pollution, is also found to affect respiratory illness. Furong et al.  studied i et al.  collecte2, had significant effects on female fertility and infant birth rate.Birth rate: this study used the infant birth rate as the second output indicator for medical input. Carré  exploredOutput variables:The average value of the undesirable carbon dioxide emissions fell in 2016, the maximum dropped in 2015, and then rose again in 2016. The maximum and average AQI reached its highest point in 2013 and then continuously declined. The minimum value decreased in 2016 but was slightly smaller compared with the maximum.The maximum respiratory disease efficiency continued to rise, and the average value decreased in 2015 and increased slightly in 2016. The birth rate efficiency was the highest, with both the minimum and average showing a continuous slow rise. The standard deviation reached a high in 2015 and declined slightly in 2016.After reaching a peak in 2013, the maximum, minimum, and average news report efficiencies continued to decline and dropped significantly to the lowest point in 2014. From 2013, when mainland China began to disclose the annual AQI data in each region, the media attention on air pollution began to decline, and the reports decreased.In Chengdu and Shijiazhuang had efficiency fluctuations, with Chengdu’s fluctuating below 0.6 for all four years, and with Shijiazhuang’s being below 0.5 and having a downward trend.Five cities had efficiencies above 0.8 for three years, and four cities had efficiencies between 0.5 and 0.8 for four years. Nanning’s efficiency was 1 in three years, which fell slightly in 2016 to around 0.9. Beijing achieved an efficiency of 1 in 2013, after which it began to decline, reaching its lowest value in 2015 at 0.8.In the production stage, there were annual efficiencies of 1 only in Guangzhou, Lhasa, and Shanghai in all four years, and in the treatment stage, there were annual efficiencies of 1 in Fuzhou, Guangzhou, Haikou, Lhasa, Nanning, and Shanghai.Beijing, Changchun, Changsha, Chengdu, Harbin, Hangzhou, Hefei, Hohhot, Jinan, Nanchang, Nanjing, Shenyang, Tianjin, Wuhan, and Zhengzhou had higher efficiency scores in the production stage than the treatment stage, and Chongqing, Guiyang, Haikou, Kunming, Lanzhou, Nanning, Shijiazhuang, Taiyuan, Urumqi, Xi’an, Xining, and Yinchuan had higher efficiency scores in the treatment stage than the production stage.Chongqing, Guiyang, Kunming, Lanzhou, Shijiazhuang, Taiyuan, Xining, and Yinchuan had four-year production stage efficiencies below 0.6, with the poorest being in Shijiazhuang, with four-year efficiencies of around 0.4. All other cities had efficiencies between 0.4 and 0.6.The worst performing cities in the treatment stage were Chengdu and Tianjin, with Chengdu having an efficiency of less than 0.4 in three years; therefore, there was a significant need for improvement.The declines in the production stage were much smaller than in the treatment stage, with the largest being in Nanchang, which fell from 0.85 in 2013 to 0.66 in 2016. Efficiency changes in the treatment stage were more volatile, with Beijing and Wuhan having the largest declines, from 1 in 2013 to 0.6 in 2016.The efficiency increases in both the production and treatment stages were much the same. Changsha, Hefei, Jinan had the largest increases, with Jinan rising from 0.47 in 2013 to 1 in 2016 and Hefei rising from 0.48 in 2013 to 1 in 2016.In In production stage, according to the Wilcoxon Test, the efficiency of the high-income and upper middle–income countries from 2013 and 2015 is strong significant. The efficiency of the 2014 and 2016 production stages is not significant, but the efficiency of the 2013 and 2015 production stages is strongly significant. The efficiency values of high-income countries are higher than those of upper middle–income countries, consistent with the H3 hypothesis in 2013 and 2015.In treatment stage, Wilcoxon Test shows that the efficiency of high-income and upper middle–income countries from 2013 and 2015 is strongly significant. The efficiency of the treatment stage in 2014 and 2016 is not significant, but the efficiency of the treatment stage in 2013 and 2015 is strongly significant. The efficiency values of high-income countries are higher than those of upper middle–income countries, consistant with the H3 hypothesis in 2013 and 2015.Only Guangzhou, Lhasa, and Shanghai had fixed assets efficiencies of 1 in all four years; however, Beijing, Haikou, Nanning, and Urumqi all had annual efficiencies higher than 0.8. The other 24 cities had a significant need for improvement. For example, Changsha, Chongqing, Guiyang, Hefei, Kunming, Nanchang, Nanning, Shijiazhuang, Tianjin, Xi’an, and Yinchuan all had efficiencies under or around 0.6, with Tianjin requiring the most improvements at only 0.45 in 2013.Guangzhou, Lhasa, Nanning, and Shanghai had energy consumption efficiencies of 1 in all four years, and Beijing, Changchun, Fuzhou, Harbin, Haikou, Hefei, Nanchang, Urumqi, and Zhengzhou all had efficiencies higher than 0.8. However, Guiyang, Lanzhou, Shijiazhuang, Taiyuan, Xining, and Yinchuan had efficiencies lower that 0.6, with the worst performance being in Taiyuan, at below 0.2, followed by Shijiazhuang, Lanzhou, and Yinchuan at around 0.4.Only Guangzhou, Lhasa, and Shanghai had labor efficiencies of 1 for all four years, and the worst performing cities were Chongqing, Guiyang, Kunming, Lanzhou, Shijiazhuang, Taiyuan, and Xining at below 0.7 in most years. All other cities had labor efficiencies between 0.8 and 0.9.Fuzhou, Guangzhou, Haikou, Lhasa, Nanning, and Shanghai had carbon dioxide emissions efficiencies of 1 in all four years. However, Lanzhou, Taiyuan, and Yinchuan all scored less than 0.4, with all of Taiyuan’s results below 0.2. Changchun, Harbin, Hefei, Nanchang, Urumqi, and Zhengzhou had carbon dioxide emissions efficiencies higher than 0.8, and the other cities had carbon dioxide emissions efficiencies between 0.6 and 0.8.There were also large differences in the AQI efficiencies. Beijing. Chongqing, Fuzhou, Guangzhou, Haikou, Kunming, Lhasa, Nanjing, Nanning, Shanghai, and Urumqi had AQI efficiencies of 1 in all four years, and many cities had two- or three-year efficiencies of 1, with the other years being above 0.9. However, the AQI efficiencies in Lanzhou, Taiyuan, Xining, and Yinchuan began to decline from 2013 and, by 2016, had fallen to around 0.4. The largest declines were in Lanzhou, Nanchang, Shijiazhuang, Taiyuan, Wuhan, Xi’an, Xining, Yinchuan, and Zhengzhou, but there were AQI efficiency increases in Changchun, Chengdu, Harbin, Hefei, Jinan, Urumqi, and Shenyang.2 emissions and AQI efficiencies in most cities. Guangzhou, Lhasa, and Shanghai had GDP efficiencies of 1, and the GDP efficiencies in Beijing and Nanning in the first three years were all 1, but both declined slightly in 2016. Guiyang, Kunming, Lanzhou, Shijiazhuang, Taiyuan, and Xining had comparatively poor efficiencies at lower than 0.8, and all other cities had GDP efficiencies between 0.8 and 1.The GDP efficiencies were better than the COFuzhou, Guangzhou, Haikou, Lhasa, Nanning, Shanghai. Beijing, Changsha, Urumqi, Xining, and Yinchuan had health expenditure efficiencies of 1 or at least two years above 0.9. However, Zhengzhou’s health expenditure efficiency in all four years was below 0.5, and Tianjin had a health expenditure efficiency less than 0.2 for three years. There were noticeable health expenditure efficiency volatilities. However, 13 cities had reduced efficiencies and needed improvements.Fuzhou, Guangzhou, Haikou, Lhasa, Nanjing, and Shanghai had birth rate and respiratory diseases efficiencies of 1, but Chengdu, Harbin, Shijiazhuang, and Tianjin had four-year efficiencies just above 0.7.Compared with the birth rate efficiency, the respiratory diseases efficiencies required significant improvements. Fuzhou, Guangzhou, Haikou, Lhasa, Nanning, and Shanghai had respiratory disease efficiencies of 1, Chengdu and Tianjin had respiratory disease efficiencies of around 0.6, and Harbin and Shenyang had three-year efficiencies between 0.7 and 0.8. Nine cities had reduced efficiencies, and 17 cities had rising efficiencies.2 and AQI efficiency exceeded 0.4 , and there is a high correlation, which is consistent with the H1 hypothesis. The correlation coefficient between Media efficiency and Respiratory Diseases efficiency is 0.5932 , which is correlated and conforms to the H2 hypothesis.According to 2 and AQI efficiency are 0.4275 and 0.3387 , and there is a high correlation, which is consistent with the H1 hypothesis. The correlation coefficient between Media efficiency and respiratory diseases efficiency is 0.4252 , which is correlated to and conforms to the H2 hypothesis.In 2014, the correlation coefficient between media efficiency and CO2 and AQI efficiency exceeded 0.4 , and there is a high correlation, which is consistent with the H1 hypothesis. The correlation coefficient between media efficiency and respiratory diseases efficiency is 0.5751 , which is correlated to and conforms to the H2 hypothesis.In 2015, the correlation coefficient between media efficiency and CO2 and AQI efficiency exceeded 0.4 , and there is a high correlation, which is consistent with the H1 hypothesis. The correlation coefficient between media efficiency and respiratory diseases efficiency is 0.3697 , which is correlated and conforms to the H2 hypothesis.In 2016, the correlation coefficient between media efficiency and COChengdu, Chongqing, Nanchang, Shijiazhuang, and Taiyuan had technology frontiers of 0.7, which fell in Nanchang, Shijiazhuang, and Taiyuan. However, the technology frontier in the other cities was mostly between 0.8 and 0.9.Changsha, Chengdu, Chongqing, Fuzhou, Hangzhou, Hefei, Jinan, Kunming, Nanjing, Shenyang, Wuhan, Urumqi, and Zhengzhou had rising technology frontiers, but they fell in the other 15 cities, indicating that the technology gap between the cities was expanding, which is in line with the economic development and technical level characteristics in mainland China.Fuzhou, Hefei, Jinan, Kunming, Shenyang, Wuhan, Urumqi, and Zhengzhou had rising technology frontiers during the production stage, but those of the other cities fell, further indicating that the technology gap between the regions was expanding. For example, while Harbin, Hohhot, Jinan, Nanchang, Shenyang, and Zhengzhou had higher technology gaps compared to cities in their regions, there was still a large gap compared with other cities in the country. Only Beijing and Shijiazhuang had declining technology gaps; however, the scores in the other 23 cities all rose, indicating that the technology gap between the regional cities in the treatment stage in most cities shrank.According to the Wilcoxon Test in In production stage, Wilcoxon Test shows that the technology gap of strong-income and upper middle–income countries from 2013 to 2016 is strongly significant. In other word, the technology gap of high-income countries is higher than that of upper middle–income countries, consists with the H4 hypothesis.In the treatment stage, the Wilcoxon Test shows that the technology gap of high-income and upper middle–income countries is strongly significant from 2013 to 2016, where the technology gap of the 2014 treatment stage is weakly significant. The treatment stages in 2013, 2015, and 2016, technology gap is strongly significant. The technology gap of high-income countries is higher than that of upper middle–income countries, consistent with the H4 hypothesis.This study used panel data and a meta undesirable two-stage EBM DEA to examine the production and health governance efficiencies in 31 Chinese provincial capital cities from 2013 to 2016 under the influence of media reports and the technology gap between high-income and middle-income cities.Guangzhou, Lhasa, and Shanghai had overall efficiencies of 1. Beijing’s overall efficiency score was only 1 in 2013 but was lower in other years, and the other 20 cities had four-year efficiency scores between 0.5 and 0.8; therefore, most cities needed efficiency improvements.Guangzhou, Lhasa, and Shanghai had annual efficiencies of 1 in the production stage, and Fuzhou, Guangzhou, Haikou, Lhasa Nanning, and Shanghai had annual efficiencies of 1 in the treatment stage. Overall, 15 cities had higher efficiencies in the production stage than in the treatment stage, and 12 cities had higher efficiencies in the treatment stage than in the production stage. Chongqing, Guiyang, Kunming, Lanzhou, Shijiazhuang, Taiyuan, Xining, and Yinchuan had four-year production stage efficiencies below 0.6, with the poorest being Shijiazhuang, with a four-year efficiency of around 0.4. Chengdu and Tianjin had the poorest treatment efficiencies; however, in general, the treatment stage and production stage efficiencies were similar.Guangzhou, Lhasa and Shanghai had fixed assets efficiencies of 1 in all four years, but 11 cities had four-year fixed assets efficiencies of only about 0.6, with Tianjin, which had a four-year efficiency of below 0.45, requiring the most improvement. Guangzhou, Lhasa, Nanning, and Shanghai had energy consumption efficiencies of 1 in all four years, nine cities had efficiencies higher than 0.8, and the lowest efficiency was in Taiyuan, at below 0.2. Guangzhou, Lhasa, and Shanghai had labor efficiencies of 1, and only seven other cities had labor efficiencies below 0.7 in most years.Fuzhou, Guangzhou, Haikou, Lhasa, Nanning, and Shanghai had carbon dioxide emissions efficiencies of 1 in all four production stage years, but the other 25 cities had carbon dioxide emissions efficiencies of less than 0.4 in all four years, of which Taiyuan had the lowest, at less than 0.2. Only Beijing had an AQI efficiency of 1 in all four years, and Chongqing, Fuzhou, Guangzhou, Haikou, Kunming, Lhasa, Nanjing, Nanning, Shanghai, and Urumqi had two- or three-year efficiencies of 1, with the other years being higher than 0.9. However, in most cities, the AQI efficiencies had large fluctuations, with eight cities fluctuating upward. Even though only three cities achieved GDP efficiencies, the efficiencies were relatively good in most cities, at close to 0.8.Fuzhou, Guangzhou, Haikou, Lhasa, Nanning, and Shanghai had media report efficiencies of 1 in all four years, and the efficiencies in 17 cities ranged from 0.5 to 0.9 in most years. However, Lanzhou and Xining’s highest annual efficiencies were only about 0.4. The media report efficiencies fluctuated significantly, and many cities experienced large declines, with the largest being in Beijing.Fuzhou, Guangzhou, Haikou, Lhasa, Nanning, and Shanghai had four-year health expenditure efficiencies of 1. However, Tianjin had the worst performance, with its health expenditure efficiency in three-years being below 0.2. The health expenditure efficiencies in the other cities fluctuated significantly, and many cities experienced large declines, with the largest being in Beijing. The urban birth rate efficiency improvements were small; however, Chengdu, Harbin, Shijiazhuang, and Tianjin had the lowest four-year efficiencies at above 0.7.The respiratory disease efficiencies required in most cities needed significant improvements, and the efficiency differences between the cities was wide. Fuzhou, Guangzhou, Haikou, Lhasa, Nanning, and Shanghai had four-year respiratory disease efficiencies of 1. Chengdu and Tianjin had low efficiencies of around 0.6 in most years. Nine cities had four-year efficiency fluctuations or declines, and the other 17 cities had upward fluctuations or continuous upward trends. Overall, the respiratory disease efficiencies improved.respiratory diseases, AQI, and CO2 efficiency.The media reports efficiency has a high correlation with Guangzhou, Lhasa, and Shanghai had technology frontiers of 1, but Chengdu, Chongqing, Nanchang, Shijiazhuang, and Taiyuan had large technology gaps. Changsha, Chengdu, Chongqing, Fuzhou, Hangzhou, Hefei, Jinan, Kunming, Nanjing, Shenyang, Wuhan, Urumqi, and Zhengzhou had rising technology frontiers, but the technology frontiers in the other 15 cities fell.Fuzhou, Guangzhou, Guiyang, Haikou, Lhasa, Nanjing, and Shanghai had treatment stage technology frontiers of 1. However, Harbin, Hohhot, Jinan, Nanchang, Shenyang, and Zhengzhou had backward technology frontiers. Beijing and Shijiazhuang had sustained fluctuating technology frontiers, and the technology frontiers in the other 23 cities all rose, indicating that the technological differences in the treatment stage shrank. Also, we found that high-income cities are higher technology gap than upper middle–income cities.The main conclusions from this study were as follows:From these results, the following policy recommendations are given.As there were obvious differences between the cities, cooperation between regions should be actively promoted. The technology gap of high-income countries is higher than that of upper middle–income countries. So, high-income cities have technological advantages and rich experience in air pollution and health management. High-income cities can use advanced technologies for air pollution treatment by combining regional characteristics, economic and social development levels, geographical characteristics of cities, and meteorological conditions.Industrial structure and energy structure adjustments need to be more rapidly implemented to improve the production and environmental efficiencies in the Beijing-Tianjin region. The Beijing-centered Beijing-Tianjin region had lower production and treatment stage efficiencies than the Pearl River Delta area with Guangzhou at the center and the Yangtze River Delta area with Shanghai at the center. Therefore, the energy consumption, fixed assets investment, human resource input, and environmental efficiencies need to be improved in Beijing. The economic and energy structures in the Beijing-Tianjin region are closely related, and the economic growth in the region has relied heavily on coal for its energy production. Therefore, there needs to be a greater focus on energy structure adjustments and clean energy and clean coal–use technological developments to replace coal and maintain production. Developing and maintaining normal economic and social development is also an important treatment measure.The media is an important “link” and “bridge” for the dissemination of health information. It plays an irreplaceable role in reporting health knowledge, changing health concepts, and promoting healthy behavior. The media has strengthened coverage of air pollution, energy conservation and emission reduction, green development, and environmental protection in terms of content and channels. By continuously improving the scientific and professional reporting of the media, this can guide the public to rationally think about and interpret information and improve the accumulation of public health knowledge. On the other hand, it eliminates public fears and threats of air pollution and promotes public health awareness. Therefore, it is important to enhance the strategy of media coverage. In order to increase the effect of media reporting on public health, media organizations need to constantly improve and strengthen reporting strategies. The media needs to strengthen reports on air pollution, energy conservation, green development, and environmental protection in terms of content, channels, and forms of communication and needs to improve the science and professionalism of the reporting that guides the public to think about and interpret information rationally.Drawing on the advanced health management efficiency in the Pearl River Delta and the Yangtze River Delta, the government can enhance the health management efficiency in the Beijing-Tianjin region. Health management investment in the Beijing-Tianjin region needs to continue to increase in line with economic growth and social development. The Beijing-Tianjin region still needs to strengthen its overall management, improve governance, and design more effective systems to improve health management efficiency.The governance in the middle-income cities needs to adopt strategies and measures appropriate to the regional characteristics. Middle-income cities in the west, such as Lanzhou, Xining, and Yinchuan, need to strengthen their industrial and energy structure adjustments. The news reporting efficiencies in these cities also need significant improvement. Therefore, systems need to be developed that are more suitable to the energy, economic, social, environmental and news reporting characteristics in these cities.To improve their production efficiency and environmental efficiencies, middle-income cities in the midwest and some individual middle-income cities in the East  need to learn from the advanced technologies in cities such as Guangzhou and Shanghai.Middle-income cities in the northeast and some central cities  need to improve their news report and health governance efficiencies. Therefore, these cities could learn from the governance measures adopted in other cities to improve the effectiveness of their news reports to increase the environmental awareness of their residents.


EU legislation prohibits clinical trials that modify germ line ‘genetic identity’. ‘Genetic identity’ however, is left undefined. This study aims to identify the use of the term ‘genetic identity’ in academic literature, and investigate its relevance for debates on genetic modification. A total of 616 articles that contained the term were identified. Content analysis revealed that the term was used in various and contradicting ways and a clear understanding of the term is lacking. This review demonstrates that the EU legislation is open to interpretation, because of the diversity of meaning with which ‘genetic identity’ is currently used. Because of the diversity of meaning with which ‘genetic identity’ is used and understood, further reflection is needed. This requires further medical, legal, ethical and social debate and a coordinated response at both a European and a global level. The possibility of modifying a person’s genes is no longer confined to the realms of science fiction. Genetic modification has been a field of interest for decades, however recent developments have caused a revolution in the field of biology . VariousOne of the potential applications is in human reproduction; CRISPR could potentially correct germline mutations and therefore prevent certain hereditary diseases . AlthougAn authoritative international and legally binding (for State Parties) instrument for the protection of human rights in the field of biomedicine is the Oviedo Convention. It states that the identity of all human beings should be protected and it speaks of the need for protection of the human being, both as an individual and as a member of the human species . The ConGiven the developments in both scientific practice and legislation, it is essential to understand the meaning of the term ‘genetic identity’ and the contexts in which it is currently used. Such an understanding is vital in order to clarify the European legislation and its normative consequences. This study aims to explore the use of the term ‘genetic identity’ within different academic discourses, and relate how it is used to potential interpretations of European legislation, particularly in relation to germline genetic modification. This review systematically identifies all uses of the term ‘genetic identity’ within the academic literature. Content analysis is used to code and categorize its use, and the emerging discourses are related to disciplinary perspective, year of publication, and geographical setting.The study is a systematic scoping review. A scoping review is appropriate to map similarities and differences in the key concepts that form the base of a specific research area, in contrast to a conventional systematic review that addresses a more specific research question . The metThe search strategy followed the PRISMA extension for scoping reviews and the guidelines developed by Peters et al –13.Searches were designed to retrieve articles in which the terms ‘genetic identity’ or ‘genetic identities’ were used in relation to humans. A detailed description of the search terms is provided in . In case of disagreements, consensus was reached by discussion. Records were excluded if they were written in a language other than English and if they concerned non-human ‘genetic identity’. Afterwards, full-text articles were assessed for eligibility. During the full-text screening, additional in- and exclusion criteria were formulated  and showed that no articles that met the inclusion criteria had been excluded.After duplicate removal, records were screened independently on title and abstract by two reviewers rmulated . The rem collaboratively developed a coding scheme (([institution anonymised for review]) and the Faculty of Religion and Theology of the ([institution anonymised for review]).Full texts of included articles were examined for the term ‘genetic identity’. Content analysis was used to categorize the definitions and context regarding the term ‘genetic identity’. An emergent (inductive) coding approach was used and coding units were defined: sampling units were articles, context units were paragraphs and the recording units, the areas of text coded, provided insight into the defined or undefined use of the term ‘genetic identity’ . Two revg scheme . The twohttps://doi.org/10.5281/zenodo.2611190available at: ). Location was documented as the place of work of the first author. If this information was not available, the location of the second author was used. Discipline was documented as highest educational degree of the first author. If this information was not available the current department of work was used. When authors had degrees from different disciplines or worked at multidisciplinary departments, the capacity in which it was written was assessed . Explicit definitions of ‘genetic identity’ were recorded.Each article’s authors, year, location, discipline and the recording units were summarized in a data extraction table  were finally included based on eligibility .The disciplinary perspective, location and year of publication of these articles is depicted in https://doi.org/10.5281/zenodo.2611190) and are discussed in the relevant meaning categories below.Few definitions for ‘genetic identity’ were found in literature. Only twenty-five authors defined the term or explained how it was to be understood in the context of their article. These definitions can be found in the ‘defined’ column of the data extraction table  ancestry or heritage, B) personal identity, C) (the beginning of) individuality, D) privacy or property, E) regions of DNA, and F) cells and genes. These categories and the codes from which they are comprised are depicted in Table 2The relationship between these meaning categories and articles’ disciplinary perspective, location, and year of publication is depicted in In this section, the meaning categories that were revealed by content analysis will be discussed, including definitions and relevant quotes found in the reviewed literature.‘Genetic identity’ was most frequently used in the context of ancestry and heritage. This category encompasses the subcategories of: parentage; genetic relatedness or similarity; and use in population genetics.‘Genetic identity’ was used in relation to the need to know one’s parentage and the establishment of legal parentage, most often in the legal literature. The importance of knowing one’s parentage was discussed in relation to adoption or anonymous sperm donation. In these cases the courts tend to focus on ‘genetic identity’  when establishing legal parentage, although situations concerning surrogacy and In Vitro Fertilization (IVF) prove even more complicated due to different actors taking on various roles of a parent. Indeed, ‘genetic identity’ was used exclusively to refer to genetic parenthood in the sub-category of parentage.These cases demonstrate that genetic identity is a key element of the court’s understanding of identity. This is clear from Mikulic and from subsequent cases that deal with the establishment of paternity. The court’s focus was not on the existence of a social relationship between the plaintiffs and the biological father, but simply on the biological truth of the plaintiffs’ paternity and the importance of that to their personal development .Who is the mother? Is it the woman who carried the child for nine months and gave birth, or is it the woman who provided the egg and therefore gave the child its genetic identity? The painful question of genetic identity and its complexity is evidenced by the nomenclature advanced by Snowden and Mitchell. They contend that there are actually seven distinct roles for the female: genetic mother, carrying mother, nurturing mother, genetic-carrying mother, genetic-nurturing mother, carrying-nurturing mother, and complete mother .In this subcategory, ‘genetic identity’ was used to mean ‘genetically identical’ in the case of identical twins (or clones), or the term was used in reference to the sharing of certain biological characteristics between people, families or species. These shared characteristics were, for example, associated with altruistic behaviour, while other articles emphasized the inheritability of these characters. Definitions of ‘genetic identity’ in this subcategory include something that ‘as opposed to genetic uniqueness, has to do with the extent to which our genes are shared with others’ ; ‘the biDeliberately bringing about genetic identity can be ethically reprehensible if and only if, by being made genetically identical, the persons who are thus born are deprived of something that is their right: namely, the right to genetic uniqueness. As has already been indicated, the claim that there is such a right is of dubious validity. .Religion enters into the center of the debate for Burhoe regarding how altruistic behavior is to be understood and accounted for. It is noted that whereas genetically related species exhibit a high degree of cooperation, the less genetic identity obtaining between individuals leads to a diminishment of cooperative activity .Several authors used ‘genetic identity’ in relation to ethnicity or race. Definitions include ‘ancestry’ ; and ‘thCurrent research dealing with population genomics and the origins of human populations raises several challenges to Native American identity based on a blend of scientific and legal attacks. This research places a heightened emphasis upon ‘genetic identity’ in accordance with contemporary scientific analysis, but in reality, this research constitutes a twenty-first century manifestation of a very old phenomenon in American social politics: the construction of race .The legacy of race and ethnic nationalism bleeds into contemporary literature around the genetics of Jews. (…) disinterested sounding terms like ‘genetic identity’ presuppose specific notions of ancestry and racial purity. (…) Indeed, resonating with her discussion about the problems gender poses to ethnicity as a marker of ancient Jewishness, Baker draws attention to the significant presence of European women (at least 80%), incorporated into the community through conversion, marriage, and motherhood, in Ashkenazic Jewish genetics .‘Genetic identity’ was often discussed in relation to personal and social identity. This category includes the subcategories of: personal and social identity; ‘disease’ identity; religious or spiritual identity; gender identity; critiques of genetic determinism or essentialism; external or environmental influences on identity; and human identity.Articles in this subcategory discussed the impact of genetic knowledge, derived through genetic technologies, on one’s self-concept, social position and life. Definitions of ‘genetic identity’ in this subcategory include ‘that dimension of self-concept that develops from the individual’s perception of his or her inherited endowment’ ; and ‘onOne way to engage with genetic knowledge as expressed in these two books is to consider the social and political context in which genetics are enacted as biosocial practices. Both studies illuminate that genetic identities are far from being centered on a stable bounded biological body, but rather concern a biosocial body surrounded by a plurality of genetic practices and discourses that are being reconfigured in social relations .Biosociality recognises a central role for biomedical knowledge in constructing genetic identities and producing and reproducing social relationships. Accordingly, it is often imagined as a new form of social solidarity .The more the study moves out from the individual subject to the family, the more important is the assumption that social identity–who we believe we are–coincides with genetic identity–who genetically we are .‘Genetic identity’ was also used in reference to genetic defects. Articles in this subcategory considered the significant consequences that (knowledge of) a genetic disease or predisposition can have on people’s sense of identity. These consequences were usually described in the context of genetic testing. Definitions of ‘genetic identity’ include ‘a shattered self-adequacy syndrome caused by the knowledge that one possesses a defective gene’ ; and ‘a Individuals have to decide not only whether to incorporate their condition into their sense of themselves, but also how—with what moral valence . They wrestle to gauge whether to view this genetic identity as negative or neutral—and to what degree to do so. A few saw themselves as “mutants,” “evolutionary errors,” “mistakes,” or “freaks of nature.” They felt that they had a ‘bad gene’ or ‘flaw,’ and struggled to understand it, stumbling at times in seeking appropriate terms. The fact that a mutation can be viewed as tainted can impede construction or embrace of a genetic identity .The subcategory frequently overlaps with the population genetics subcategory described above, since ‘genetic identity’ was often discussed in regard to certain ethnic groups, due to a high prevalence of deleterious mutations in some populations, for example mutations in BRCA genes and Ashkenazi Jews. A perceived responsibility for genetic disorders was described in other articles and is particularly relevant in the context of prenatal testing and reproductive choices. Articles in this subcategory illustrated the use of ‘genetic identity’ concerning genetic disorders or predispositions and demonstrated their impact on one’s sense of identity, choices, and options in life.Genetic accountability and genetic identity are now expanding beyond prenatal testing. Jewish women may perceive a ‘social obligation to do anything they [can] to advance’ research on BRCA1 testing. Accordingly, at least one researcher has warned that 'those obtaining consent for Jewish women [for BRCA1 testing] should be aware of the “slippery slope” from perceived social responsibility to coercion’ .In this subcategory the term ‘genetic identity’ was used to describe the relation between religion and ancestry. This subcategory illustrates the complex relationship between ‘genetic identity’, religious and ethnic identity and shows ‘genetic identity’ and religious or spiritual identity are both described as related and distinct concepts.That is, blood relationship is part of the glory and mercy of God’s creation; genetic identity is a God-given principle, not a man-made one. (…) In particular, verses 5–6 create a complicated relationship between genetic identity and religious identity, and they seem to affirm an Islamic social structure based not just on faith but also on blood relationships .‘This “half-Sikh identity”’, Wilson J concludes, ‘is a “genetic identity” which the mother was attempting to ‘re-write’. So, like Ward LJ’s judgment in Re P, the child in Re S is seemingly racially or ethnically Sikh through carrying his father’s ‘Sikh genes’ (as N was a Jew in Re P), but he can and should become a Muslim by faith, like his mother .‘Genetic identity’ was sometimes used in relation to sex and gender identity and concerned the male (XY) or female (XX) chromosome pairs. This subcategory includes articles that discussed transsexuality or inter-sex disorders and ‘genetic identity’ in this context was used to indicate the ‘biological’ gender. This subcategory relates ‘genetic identity’ to the male or female identity.In its sentencing judgment, the court set a requirement for Alkobi and others like him to declare at a certain point their ‘biological-genetic identity’ and to reveal the fact that they are ‘male’ or ‘female’ in the narrow sense currently accepted in society .Explicit criticism of the term ‘genetic identity’ and value judgments associated with the term were also encountered in the reviewed literature. This subcategory includes terms like genetic determinism, genetic essentialism, genism and ‘true’ identity. Articles in this subcategory described the dangers of overemphasizing one’s ‘genetic identity’  and stress a person is more than the sum of his or her genes. Authors often referred to differences between identical twins to illustrate their point and most expressed concern about the ease with which complex traits are increasingly attributed to genetics. Some authors described the dangers of overemphasizing one’s ‘genetic identity’ by referring to Gattaca, a 1997 film portraying a dystopic society driven by eugenics –48.These are all illusions of genetic identity, based on extreme genetic determinism, and indeed should be a priori condemned and never permitted. First, because it is not true that two individuals with the same genetic make-up (twins) would have identical lives and behavior .The interest in genetic identity includes a preoccupation with biological determinism. Among the traits attributed to genetics are mental illness, homosexuality, aggressive personality, dangerousness, job and educational success, exhibitionism, the tendency to commit arson, stress, risk-taking, shyness, social potency, traditionalism, and even zest for life. These complex conditions frequently are described as directly inherited, as if they were single-gene disorders .Closely related to the above subcategory is the relation between ‘genetic identity’ and environmental contributions to one’s identity and phenotype. Some articles in this subcategory described (phenotypic) differences in genetically identical twins that could not be explained by their ‘genetic identity’. Also included in this subcategory were articles that described contributions by epigenetics, heritable phenotype changes that do not involve changes in DNA sequence . This suFrom the moment the organism's growth begins, differences in environmental factors will cause phenotypic divergence. (…) Further, even copies which received relatively similar intrauterine treatment may be subjected to different environmental conditions  after birth. Thus, initially identical genetic identity may nonetheless result in different phenotypic development .Epigenetics does not displace the chromosome as the primary mechanism of biological inheritance. It does, however, challenge genetic determinism and the dichotomy between genes and environment. In the context of pregnancy and gestation, it challenges the dichotomy between form and matter, between genetic identity and the supportive environment of the womb .The last subcategory within the personal identity category concerns ‘genetic identity’ in relation to human species membership, often in discussion of the start of life and personhood (further discussed in category C), gene patenting (further discussed in category D) or possible effects on future human ‘genetic identity’ . The relation between ‘genetic identity’ and human identity was described in somewhat different ways; definitions of ‘genetic identity’ in this subcategory include ‘determining one’s status as a member of the human family’ ; and somThough human identity is not equivalent to genetic identity (some sociobiologists might differ on this point), the entire human genome encroaches far enough on fundamental human identity to make it unethical to patent, Brody contends. Patenting parts of the genome (genes or shorter DNA sequences) would remain under consideration, though. .This category concerns the right to a unique or own ‘genetic identity’ or autonomy over one’s ‘genetic identity’. It further includes articles that described the start of life, which includes discussions about embryo development and the start of ‘genetic identity’ and modification or selection of ‘genetic identity’.know your ‘genetic identity’ in relation to parentage has already been discussed in the ancestry and heritage category (category A). Autonomy and freedom were most frequently discussed in relation to cloning and genetic modification. Authors usually asserted that one should be in control over one’s own ‘genetic identity’ and discussed the threats of cloning to autonomy and freedom. Some authors claimed that a unique ‘genetic identity’ is a right, whereas others refer to identical twins to deny this right exists and claim genetic uniqueness and individuality are two distinct concepts that should not be equated. Some authors argued that one has a right to a non-manipulated ‘genetic identity’ whereas others stated autonomy over ‘genetic identity’ includes a right to modification. In this subcategory, the various uses of ‘genetic identity’ in reference to autonomy and freedom contained many different rights and freedoms, both including the right to a non-manipulated ‘genetic identity’ and the right to genetic modification, particularly in relation to severe genetic disorders.This subcategory includes articles describing certain rights; the right to genetic uniqueness (a unique ‘genetic identity’), the right to a random ‘genetic identity’ (instead of something predetermined), the right to a non-manipulated ‘genetic identity’ and the right to individual modification. The right to In addition, cloning is viewed as illicit because it ‘would impose on the resulting individual a predetermined genetic identity, subjecting him—as has been stated—to a form of biological slavery, from which it would be difficult to free himself’ .Genetic identity is often confused with genetic uniqueness (the right to an exclusive genome). Genetic uniqueness cannot be a fundamental or basic human right because of the frequency with which it is violated without any harmful effects by the existence of monozygotic twins .Years ago, the European Community appropriately included the right to a non-manipulated genetic identity in the list of civil rights .The right to genetic identity, therefore, should both foresee the integrity but also the changeability of one’s genetic architecture: the right to personal identity may perfectly encompass the right to individual genetic modification .Articles in this subcategory discussed the significance of ‘genetic identity’ in determining when life  begins, and whether this was relevant for the protection of the embryo, often in the context of abortion or embryo research. A frequently quoted legal case from the USA is the Supreme Court landmark decision in Roe v. Wade from 1973. In this decision ‘genetic identity’ was not deemed sufficient to  recognize the embryo as person. Some authors also mentioned German Constitutional Court abortion decisions. In these decisions, the first determination of ‘genetic identity’ was not discussed. However, the term was used as one criteria, in combination with others, to judge when an embryo was  considered a person and therefore deemed protectable. They placed an emphasis on implantation and the formation of the primitive streak as the beginning of a life capable of protection, as opposed to the construction of ‘genetic identity’ at conception, which is also reflected in several moral-religious judgments on the subject. Most authors agreed that ‘genetic identity’ was first established at conception, although some stress that this is a process rather than a fixed moment. The articles in this subgroup used the term ‘genetic identity’ to refer to the combination of a sperm and ovum into stable chromosomes forming a new and distinct genome and they show a more or less uniform view of when ‘genetic identity’ is first established (at conception). However, this subcategory shows varied importance given to the term in relation to the beginning of life and the protectability of the unborn.In Roe, the Court espoused the view that the unborn offspring of human parents, a human fetus, must be capable of ‘meaningful life’ outside the womb before he or she can be can be considered as having anything more than the ‘potential’ for human life. Genetic identity is, under this formulation, irrelevant, except to determine ‘potential’ for human life .In its abortion decisions the Bundesverfassungsgericht skillfully avoided the question of when life begins, however it did emphasize that at least from the time of implantation there could be an individual, no longer divisible, life with its own genetic identity and that from this point the entity could be protected by both Article1 I GG and Article 2 II GG .Fertilization marks genetic identity. Implantation, however, marks the development of biologic individuality, as well as the first emergence of the rudiments of the nervous system .But it is clear that genetic identity is not necessarily fixed by the mere penetration of a single sperm, because more than one may enter, and because even then some genetic material may be rejected. In fact, it is only at the completion of the process of fertilization with syngamy, that is, when the genetic material of the sperm and the egg have condensed into chromosomes to form a new genotype–a single cell- that genetic uniqueness can possibly be fixed .This sub-category includes topics like cloning, gene therapy, genetic modification and pre-implantation diagnostics. Authors described the risks and consequences of these techniques and sometimes weighted these against possible benefits. As for cloning, risks frequently mentioned included threats to dignity, threats to autonomy and individuality and disturbed familial relationships. Threats to dignity were often described from a religious perspective and were combined with the need for genetic uniqueness and individuality. As for genetic modification, risks most frequently mentioned included effects on future generations, ‘designer children’, commodification of ‘genetic identity’ (further discussed in category D) and new forms of liability. The most often encountered benefit of these techniques was the treatment of serious diseases. This subcategory describes the modification or selection of a ‘genetic identity’ and its effects, both in relation to the individual and of the human population as a whole.The natural genetic identity of the prenatal child may become important in the future. By manipulation of the biological makeup of the prenatal child, it may be possible to increase or decrease intelligence, to correct physical defects, or to produce those characteristics needed for strenuous or unique physical activity such as sports or space travel. While the failure to provide the child with superior biological equipment may not give rise to a new variation of the wrongful life type of litigation, the use of such techniques may create substantial risk of negligence or disastrous injury during the experimental stages .However, the fear that gene therapy may have some impact on the genetic identity of the human species must be weighed against the benefit of providing treatment for common and catastrophic diseases .Category D involves the use of ‘genetic identity’ in the context of privacy and property. This category includes subcategories of: identification and protection of ‘genetic identity’; durability of ‘genetic identity’; and ownership and commercialization of ‘genetic identity’.‘Genetic identity’ was frequently used as an identifier in combination with the identification of a suspect in forensics or in combination with paternity testing. The term was used in reference to the need for privacy and protection of genetic information, for example in relation to DNA databanks, and protection from discrimination. Definitions of ‘genetic identity’ in this subcategory include something ‘used to identify the relevant person’ ; and somInstead, as a symptom of biology, relatives and future generations risk being stigmatized for their mere genetic similarity to a previously convicted defendant. Assuming possible criminality based on genetic identity replaces the wrongdoing requirement with what might be described as wrongbeing .Even with the present technology, however, the donor has an interest in the content of the DNA analysis because DNA test results provide evidence of identity .The proposed legislation seems to be based on the assumption that the ‘gene is the person’, that is, constitutive of genetic integrity while legislation on DNA forensics by the state relies on the myth that ‘gene denotes genetic identity’ .In a few articles, emphasis was placed on the durability of ‘genetic identity’. Articles in this subcategory all included the use of ‘genetic identity’ in DNA analysis, however some warned that the durability of genetic material might provide a false sense of reliability if little is known about the processing and storage of DNA in forensic cases.DNA, for example, appears to be everlasting and immutable. But the durability of genetic identity supplies no confirmation that any particular DNA introduced at trial has been appropriately collected, analyzed, and preserved, nor whether the testimony regarding the DNA ‘match’ will be truthful or accurate .This subcategory mostly comprises articles describing the risks of ‘genetic identity’ theft and articles discussing the patenting of genes and ‘genetic identity’. Other articles discussed the commodification or commercialization of genetic information. All articles in this subcategory discussed ‘genetic identity’ in reference to property rights, however the desirability of property rights of genetic material and identity is valued differently in the reviewed literature.If a person does not own his genetic material, he can neither own nor protect his genetic identity, thus leaving it in peril indefinitely. If no one owns something, then, by legal definition, no one can be guilty of stealing it. How can we best protect our genetic identity? The only way to protect genetic identity from theft is to create a legal property right in the genetic information that secures this identity .In her construction of genetic identity, ownership is resisted not only in the name of the human subjects who supply the genetic material but also in the name of all generations, past and future, who are implicated, and hence somehow present in the germline .Judge Sweet’s trepidations mirror the public’s concerns about the gene-patent debate. The plaintiffs’ legal challenges to the BRCA patents raise a difficult legal and ethical dilemma: should information about an individual’s personal genetic identity be protectable as intellectual property for the purpose of promoting scientific innovation ?genomic identity. This subcategory illustrates the use of ‘genetic identity’ as concerning certain genes, parts of DNA or the entire genome and it most strikingly reveals the different and contradictory uses of ‘genetic identity’.Different regions of DNA were used in descriptions of ‘genetic identity’, including DNA base sequence, nuclear or mitochondrial DNA, the Y-chromosome, specific genes and the whole genome. The term was used in different and often contradictory ways, for example in reference to the inclusion or exclusion of mtDNA in determining ‘genetic identity’. Definitions in this subcategory include both the explicit restriction of ‘genetic identity’ ‘to sharing the same nuclear gene set’ ; and twoNotably, the common feature of the definitions for permitted gametes and embryos, even in their extended form, is that deliberate changes to their nuclear DNA are explicitly disallowed. This distinction is not as tenuous as it seems, because mitochondrial DNA contain 37 genes and are passed through the maternal line, whilst nuclear DNA contains 20,000–25,000 genes which are inherited from both parents. Hence, the latter more strongly embodies an individual’s genetic identity and editing nuclear DNA can be considered ‘full-blown’ germline editing .The increased knowledge concerning mtDNA obtained in this study is believed to offer a useful means of determining genetic identity due to increased mitochondrial DNA haplotype diversity, by allowing mtDNAs to be classified into several types of peak patterns .Furthermore, genomic identity needs to be distinguished from genetic identity. In order for someone A to be genomically identical, the total genetic information in her or his cells needs to be the same at time t and time t’. The total genetic information in human cells comprises both the complex nuclear genome and the simple mitochondrial genome. If A is genetically identical, A is the same as regards a certain gene or certain genes (and not necessarily the whole genome) at time t and t’ .[w]e might suggest that genetic identity concerns identification (idem identity), and that genomic identity ultimately connects with our individuality (ipse identity) .In this category ‘genetic identity’ was mentioned in relation to specific human cells, genes or cell lines, mostly in articles from medicine or the life science . This caThis article aimed to systematically identify and review the use of the term ‘genetic identity’. In only twenty-five out of the 616 articles that used the term, ‘genetic identity’ was defined or the use of the term was specified. Within the included articles, the term was used in various ways and with different and even contradicting meanings.Content analysis revealed six categories of meaning: ancestry and heritage; personal identity; (the beginning of) individuality; privacy and property; regions of DNA; and cells and genes. The use of the term varied both between and within the six categories. Overall, the diversity in the use of ‘genetic identity’ in the reviewed literature demonstrates that the term is used differently in different contexts, but also within each context the meaning of the term can vary widely. There is also a lack of consistency within individual disciplinary discourses, as demonstrated by the term’s various use and understanding within the legal literature  and life sciences . These findings support previous assertions that genetic and genomic identity are discussed in vague and contradictory ways in regulatory discourse and that this has important implications related to rights and protections associated with genetic knowledge . How theIn the first place, a distinction can be made between biological and social aspects of ‘genetic identity’. The notion ‘genetic’ refers to a biological basis, whereas ‘identity’ is more frequently understood to have a wider connotation . Authorsgermline ‘genetic identity’, which implies it concerns future generations in particular [A second distinction is that between individual and collective aspects of the term “genetic identity”. Boussard explains how these dimensions could have different interests ; when thrticular , 11.Finally, a distinction can be made on the level of genes. The term ‘genetic identity’ may concern both the whole genome and only certain genes, and it may concern solely nuclear DNA as well as nuclear DNA in combination with mitochondrial DNA. This last distinction is also evident in current policy debate; in the UK for example, mitochondrial replacement techniques are treated more permissively than nuclear genetic modification, because they are deemed ‘unlikely to alter in significant ways the identity of the person created’ . The gloSeveral strengths and limitations of this review need to be addressed. To our knowledge, this is the first systematic (scoping) review on the term ‘genetic identity’, and it comes at a significant time. The Clinical Trials Regulation is set to replace the current Clinical Trials Directive and scheduled to come into application soon, binding in its entirety in all Member States, including the prohibition of clinical trials ‘that result in modifications to the germ line genetic identity’ . FurtherThis review reveals the various and contradicting ways the term ‘genetic identity’ is used and understood. The implication for EU law  is that it is currently open to interpretation. Ambiguity in legal terminology is recognised as creating uncertainty and even potential loopholes. Indeed, S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.S3 Appendix(DOCX)Click here for additional data file.


Ever since the 1960s, transsphenoidal surgery has been the modality of choice for treating Cushing’s disease. Subsequent visualization of the pituitary fossa and sphenoid sinus may be done either with the operating microscope or with the relatively new endoscope. The endoscope due to its panoramic view allows greater visualization as compared to the operating microscope. It confers greater access to the cavernous sinus, sella, suprasellar, and parasellar regions and accommodates higher magnifications. It is bi-dimensional, however as opposed to the operating microscope that provides a three-dimensional view and allows greater depth perception. This article provides a comprehensive review of the advantages and disadvantages of the endoscope and compares it to the operating microscope. We hope this article will prove useful to both clinicians and academicians alike in their approach and management of Cushing’s disease. Cushing syndrome is defined as a state of prolonged hypercortisolism and its accompanying manifestations. When attributable to a pituitary origin, typically a pituitary adenoma or rarely a carcinoma, it is known as Cushing’s disease - named after and first described by Dr. Harvey Cushing in 1932 .Cushing’s disease is the most common cause of endogenous hypercortisolism -8. It isThe first report on the transsphenoidal route to access the pituitary dates back to 1907 by Hermann Schloffer, after which further attempts at exploration were abandoned for nearly half a century -15. It wThis article aims to compare the two techniques by summarizing the findings of recent clinical series published in literature with a special focus on the advantages of the endoscope along with any shortcomings when compared to the operating microscope. We hope this article will prove useful to clinicians and academicians alike in their approach and management of Cushing’s disease.Traditionally the transseptal/translabial approach with the use of the operating microscope is the gold standard transsphenoidal approach ,17,20,24Remission rates, reported in the literature for transsphenoidal surgery for Cushing’s disease vary between 42% and 95% . The majBeing a relatively newer innovation, there are only a few reports that look at the efficiency and prognostics of a purely endoscopic technique for Cushing’s disease. The effectiveness of pituitary surgery is evaluated by normalization of hormone levels and degree of tumor removal . At the Operative techniqueThe procedure is done under general anesthesia. It is conducted in collaboration with an otolaryngologist. The patient is kept supine with the head maintained in a fixed position using a three-pin Mayfield clamp. The head of the bed is elevated. Frameless stereotaxy is used for neuronavigation Figure .Using the binostril, bimanual technique, the endoscope is inserted and the Hadad flap is raised. The sphenoid ostium is identified. The posterior septum is removed to expose the vomer. The sphenoid sinus is identified and the intersinus septum is removed. The anterior part of the sella is then opened using a drill and Kerrison rongeur.After identifying the bony landmarks of the optic nerve, carotid artery, and opticocarotid recess, a disc dissector is used to remove dura from the bone of sella floor. The dura is opened and separated from the gland underneath using a micro dissector. Care should be taken not to coagulate dura as this may lead to white discoloration that may hinder tumor identification . Once thThe sellar defect is repaired using the Hadad flap followed by fibrin adhesive, Surgicell, and Gellfoam.Video In cases of negative magnetic resonance imaging (MRI), inferior petrosal sinus sampling (IPSS) is done to determine the lateralization of the disease. A selective adenectomy is done in cases where the tumor is identified on surgical exploration. Otherwise, subtotal hypophysectomy is done on the side of IPSS lateralization. Refer to Figure Advantages of the endoscopeThe hallmark feature of endoscopic transsphenoidal surgery is the superior view one has of the sphenoid sinus and the pituitary fossa ,30,34,36Another significant advantage of the endoscope is that it allows the surgeon greater access to the cavernous sinus ,35. PrevSince the endoscopic approach does not utilize transseptal dissection, there is less post-operative pain and discomfort -8,17. HoDisadvantages of the endoscopeThe operating microscope resorts to its three-dimensional vision and depth perception, giving the surgeon the ability to operate in three-dimensional space - a feature that is, unfortunately, missing in the endoscope -8,20,30.Concerns have also been raised regarding its lack of maneuverability as surgeons can only manipulate tools with one hand unless a holder is used . The useAnother disadvantage that has been reported is the increased incidence of extracranial manifestations . These iThere is also increased incidences of vascular complications and post-operative cerebrospinal fluid (CSF) leaks with the endoscope . The incSystemic review and meta-analysisIn our review of the literature, we found several systemic reviews and metanalysis that compared microscopic and endoscopic surgical techniques and prognostics in a heterogeneous population of patients with various pituitary adenomas ,20,22,28According to the literature published to date, an endoscope is an effective tool in transsphenoidal surgeries. Its superior view along with better patient prognostics establish it as a superior modality for Cushing’s disease when compared with the microscope. Significant limitations need to be considered, however, as there exists a learning curve for surgeons using the endoscope. Lack of maneuverability and extra-cranial complications need to be addressed as well. In the future, 3D endoscopes may perhaps become a mainstream modality. The operative microscope can till then be utilized upon the surgeon’s discretion.


The Akhal-Teke horse (AKH) is native of the modern Turkmenistan area. It was introduced in Italy from 1991 to 2000 mainly as an endurance horse. This paper characterizes the genetic variability of the whole Italian AKH horse population and evaluates their inbreeding level by analyzing microsatellite markers and mitochondrial D-Loop sequences.o, He, FIS) were compared against the same variables published on other eight AKH populations. In addition, 397 bp of mtDNA D-loop region were sequenced on a sub-group of 22 unrelated AKH out of the 95 sampled ones, and on 11 unrelated Arab horses. The haplotypes identified in the Italian population were aligned to sequences of AKH (56), Arab (five), Caspian Pony (13), Przewalskii (two) and Barb (15) horses available in GenBank. The Median Joining Network (MJN), Principal Component Analysis (PCA) and Neighbor-joining (NJ) tree were calculated on the total 126 sequences.Seventeen microsatellite marker loci were genotyped on 95 DNA samples from almost all the AKH horses bred in Italy in the last 20 years. Standard genetic variability measures  and a low inbreeding level (FIS = 0.016) in Italian horses, compared to other AKH populations (ranged from −0.103 AKH from Estonia to 0.114 AKH from Czech Republic). High variability was also recorded in the D-Loop region. 11 haplotypes were identified with haplotype diversity (hd), nucleotide diversity (π) and average number of nucleotide differences (k) of 0.938, 0.021 and 6.448, respectively. When all the 126 D-Loop sequences were compared, 51 haplotypes were found, and four were here found only in the Italian AKH horses. The 51 haplotypes were conformed to eight recognized mtDNA haplogroups  and confirmed by MJN analysis, Italian horses being assigned to five haplogroups . Using a PCA approach to the same data, the total haplotypes were grouped into two clusters including A+C+M+P and G+F haplogroups, while L and Q haplogroups remained ungrouped. Finally, the NJ algorithm effectively discretizes only the L haplogroup. All the above data univocally indicate good genetic variability and accurate management of the Akhal-Teke population in Italy.Nucleic markers showed a high degree of polymorphism (H In the recent past, several molecular markers and techniques have been used to investigate the genetic origin and variability within and across local endangered populations to disclose biodiversity and to support conservation plans .Mitochondrial DNA (mtDNA) has also been widely used to estimate genetic diversity, phylogenetic relationships and maternal origins among closely related modern populations. Particularly for such purposes, the mtDNA D-loop hypervariable region 1 has been sequenced in equids . The disAkhal-Teke (AKH) is a very ancient horse breed that is native of central Asia, precisely the southern region of modern Turkmenistan, and has adapted well for endurance capacity to cover long distances in harsh climate conditions of Central Asian steppes. The breed during the last 100 years has been selected strongly for speed . As repoThe AKH breed is renowned for the distinguishing metallic shine of its hair. Moreover, natural athleticism makes a well-rounded sports horse of this breed, which is good at dressage, show jumping, eventing, racing, and endurance riding competitions. This ancient breed represents a unique genetic resource that differs from all the other breeds worldwide in terms of type, conformation and use. The pedigree recording started in 1885, and the Studbook was closed in 1932. The AKH was introduced in Italy from 1991 to 2000 mainly as an endurance horse.This paper conducts a genetic variability analysis based on genomic DNA loci (microsatellite markers) and mtDNA D-loop of AKH horses reared in Italy. Furthermore, a meta-analysis was performed using horse mtDNA sequences available in GenBank, besides a comparison with literature data on the genetic variability of AKH horses bred in other countries.The Italian AKH Association’s reference laboratory for genetic testing for parentage control at the Department of Veterinary Medicine (University of Milan) maintains the bio-bank of the biological samples of all AKH horses bred in Italy since they were first imported (107).All applicable international, national and/or institutional guidelines for the care and use of animals were followed. The bio-banked samples were approved by the Ethics Committee of Università degli Studi di Milano Prot. OPBA_56_2016.® Genotyping Kit (utilized for parentage testing), including 12 from the official ISAG panel (http://www.isag.us/Docs/EquineGenParentage2016.pdf). All PCR products were run on ABI PRISM® 310 Genetic Analyzer, and fragments were analyzed with the Genescan® and Genotyper® software (http://tools.thermofisher.com/content/sfs/brochures/cms_040300.pdf).Ninety-five of the 107 blood samples  were genotyped using 17 microsatellite markers of StockMarks for the Horsesn = 22) were sequenced, and so were 11 additional Arabian horses reared in Italy and bio-banked at the University of Milan. The 379 bp fragment of the mtDNA D-loop region  was amplified and sequenced by classic Sanger methods, using previously published primer pairs (® G-50 (SIGMA) and sequenced for both strands by using the Big Dye® Terminator v.3.1 Cycle Sequencing Kit  according to the manufacturer’s guidelines. The PCR products were processed on an ABI PRISM®310 Genetic Analyzer, and the nucleotide sequence was determined using the ABI PRISM® DNA Sequencing Analysis Software.According to the available pedigrees (first generation/parents), the horses with no common mare and stallion , linkage disequilibrium (LD) and inbreeding coefficient (FIS) were estimated using the GENEPOP software (o) and expected (He) heterozygosity per locus and on the entire population were calculated with POPGENE v.1.32  .Sequences were checked for the presence of ambiguous bases by using the software Chromas v.2.5.1 (X79547 (JN398377 (In order to define the haplotypes (H-) all obtained sequences were aligned with the complete horse mtDNA sequences X79547  and JN39JN398377 , widely JN398377 .π) and the average number of nucleotide differences (k) were estimated using the DnaSP5 v.5.10.01 software , the nucleotide diversity  were considered. All the sequences were trimmed at 254 bp to maximize the number of sequences included. Haplogroup definition was performed according to Three different approaches were used to investigate the haplotype and haplogroup relationship: i)http://www.fluxus-engineering.com); the default setting of Epsilon (0) was applied and the mutational hot spots present in the 254bp fragment were down-weighted as suggested by the Median-Joining Networks (MJN) analysis performed by Network v.5.0 software ( ii)the Neighbor-joining (NJ) tree  based on iii)the Principal Component Analysis (PCA) with a minimum spanning tree based on haplotype sequences was calculated using the PAST v.2.7 software .FST) was calculated by Arlequin v.3.5.2.2 (The pairwise population genetic differentiation (.3.5.2.2  and usedMF580226–MF580244).All the horse mtDNA sequences obtained in this study were deposited , calculated using HW formulae, showed three microsatellites  that were not in genetic equilibrium (P < 0.05). This drift is probably caused by strongly unbalanced allelic frequencies in the small population originally imported to Italy from 1991 to 2000 .The mean number of alleles (NA) calculated on 16 microsatellites was 6.4, whereas the effective mean number of alleles (NE) was 3.1. The analyses of the Hardy–Weinberg genetic equilibrium (According to the position (cM) of the microsatellites as reported by Allelic richness (AR) is a parameter that is used to estimate diversity in the population. It ranges from 4 (HMS1) to 9.8 (ASB2), with a mean value of 6.4, comparable to the AR of 6.09 reported by o and the He values ranged from 0.379 (HTG4) to 0.810 (ASB2), with a mean value of 0.642 and, from 0.410 (HTG4) to 0.816 (ASB2), with a mean value of 0.649, respectively The FIS values per locus that ranged from −0.113 (HTG10) (outbreeding) to 0.174 (HTG6) (inbreeding); the overall FIS value for the population was 0.016.HFIS value that denotes, in the first nucleus, an apparent excess of heterozygosis We estimated the diversity parameters on the AKH horses imported in Italy from 1991 to 2000. The values obtained were compared with those estimated in the AKH population born in Italy (after 2000). The two groups of horses are in HW equilibrium and have similar genetic values, except for the Nucleotide differences compared to reference sequences ranged from 1 (H1) to 11 (H11). The most frequent haplotype found in our samples was H4 (18.2%), while the less frequent haplotypes were H1, H6, H8, H10 and H11 recorded in only one individual each (4.5%).π) and average number of nucleotide differences (k) were 0.938, 0.021 and 6.448, respectively.The values of variability parameter haplotype diversity (hd), nucleotide diversity  were identified by the alignment of the 126 mtDNA D-loop sequences, showing an hd value of 0.971. The detailed sequence variations of haplotypes and the identified haplogroups were reported in Four haplotypes  were found exclusively in Italian AKH and were not reported in GenBank for the same breed. Additionally, our AKH sequences were grouped in five haplogroups A, C, G, L and M, as defined by FST) showed a remarkable similarity between our AKH and other AKH populations, as expected (The MJN  showed texpected .vs H3) and by two mutations 15,650 and 15,728 (H2 vs H50), respectively. The haplotype H42, formally belonging to haplogroups G in the PCA but separated with haplogroup L in NJ tree, will be considered as intermediate among haplogroups G and L as well defined in MNJ  . Haplogrd in MNJ  and 2C.The PCA analysis showing a minimum spanning tree based on sequence haplotypes, is displayed in In Italy, AKH horses are reared by few breeders and are mainly trained for shows and endurance races. The small number of animals and the use of the same stallions for reproduction entail a potential risk of decreasing variability. Hence, we analyzed genetic variability by using both microsatellite DNA nuclear markers and mitochondrial DNA variations.As mentioned above, AKH belong to the clade of Middle Eastern Breeds that involved Arabian horses, Barb horses, Turkoman horses and Caspian pony. The native area of the AKH is considered one of the two hotspots for horse diversity. In fact, the Caspian Area of Western Asia served as refugium for wild horses in the early and mid-Holocene when, due to a lack of suitable habitat as a result of forest expansion, the wild horses migrated to more comfortable areas for this steppe-adapted species . Later, The mean number of alleles (MNA) (6.5) obtained in Italian AKH was comparable to those reported by The NE value indicates the actual impact of alleles on population variability, precisely, a small value reports an unbalanced frequency of the alleles at a certain locus. The NE is associated to the expected heterozygosity. Indeed, heterozygosity is highest when allelic frequencies are balanced, and every allele contributes to the absolute number of alleles detected per locus.(Founders). Particularly, the low number of stallions used in the last twenty years by breeders appears to have strongly influenced allele frequencies, as can be derived by the deviation from HW equilibrium for some microsatellite markers as shown in In the Italian AKH horses we identified a lower effective number of alleles (NE) compared to the other AKH populations. Indeed, in the Italian population the founder effect is still having a strong impact on the population’s genetic composition due to the low number of stallions and dams imported from abroad to constitute the first Italian nucleus in 1991–2000 Several authors reported the influence of inbreeding, founder effect and population subdivision on LD. Nevertheless as pointed out by The MNA value for Italian AKH, comparing with values obtained by FIS values obtained using the 17 microsatellites panel (0.016) and both 12 and 13 microsatellites panels (0.009 and 0.004), revealed a low level of inbreeding, i.e., the Turkmenian population, indicating the fact that Italian breeders are prone to avoid mating between related individuals as much as possible. This trend can be highlighted by comparing the FIS values in Italian horse to other populations , indicating a high level of variability in the Italian population. Many authors report similar results for several horse breeds, specifically, in modern AKH  (π = 0.021 (π = 0.026) (π = 0.019) (π range 0.019–0.024)  and a high nucleotide diversity (= 0.023) , Hungari = 0.021 , Anatoli= 0.026) , Caspian= 0.019)  and in C9–0.024) .http://www.akhal-teke.org/at-lines.html), whereas no information was recorded for the female lines.The high genetic variability of mtDNA is proof of the broad genetic base of founder mares in the AKH population, though only the sire lines were historically documented  among modern AKH, and the 18 Kazakh AKH deposited by FST values found with one of the two Caspian Pony populations (AKH_ITY vs. CAP_a FST = 0) and with the two Arab horse populations   . These s authors .Haplotype H2, which belongs to haplogroup A, both on MJN and on PCA, appears to be the central point, and it is the link among all the haplogroups  and 2C. Haplogroups A, C, M, P and Q are clearly separated on the MJN, but the relationships among these haplogroups are not well defined in the PCA and in the NJ tree. In fact, the PCA is able to separate only the haplogroup Q form others, whereas in the NJ tree they are mixed with the P haplogroup  and 2C. is the most frequent (23.5%) in modern Middle Eastern horse populations as well as in the Western central Eurasia, one of the primary areas of horse domestication event, that comprises the AKH origin area, . Hence, the haplotype H42, which formally belonged to haplogroups G, has to be considered as intermediate among haplogroups G and L  estimated on Italian Akhal-Teke population  (Sheet 2). Linkage disequilibrium P-val (P < 0.005) estimated on Founders Italian Akhal-Teke population (imported 1991–2000) and on New population of Italian Akhal-Teke (born after 2000) (Sheet 3).Chromosome position in cM of the 17 horse microsatellites (Sheet 1). Linkage disequilibrium Click here for additional data file.10.7717/peerj.4889/supp-3Table S3P-val, genetic equilibrium according to HW; Ho, observed heterozygosity; He, expected heterozygosity; FIS, inbreeding coefficient.NSTS, number of microsatellites; NS, number of samples; NA, absolute number of alleles; MNA, Mean number of alleles; NE, effective number of alleles; *Akhal-Teke imported in the years from 1991 to 2000 (Founders).Click here for additional data file.10.7717/peerj.4889/supp-4Table S4X79547 and JN398377, using the ClustalW algorithm implemented in BioEdit. Haplogroup definition was performed according to All the sequences were aligned with the complete horse mtDNA sequences AKH, Akhal-Teke; ARH, Arabian Horse; BRH, Barb Horse; CAP, Caspian Pony; PRZ, Przewalskii horse.* : reference used for alignemet of sequences.bClick here for additional data file.10.7717/peerj.4889/supp-5Table S5FST) was calculated based on mtDNA sequences and was used to evaluate genetic differentiation among Italian AKH, Italian Arabian, and the 93 horse GenBank sequences used.The matrix of pairwise population genetic differentiation . Data are in GENEPOP format (3-Digit Alleles format). The microsatellite LEX03 maps on X chromosome. The females are homozygous or heterozygous at the locus, whereas the males are hemizygous.Click here for additional data file.