Appropriate fluid management in mechanically ventilated critically ill children remains an important challenge and topic of active discussion in pediatric intensive care medicine. An increasing number of studies show an association between a positive fluid balance or fluid overload and adverse outcomes. However, to date, no international consensus regarding fluid management or removal strategies exists. The aim of this study was to obtain more insight into the current clinical practice of fluid therapy in mechanically ventilated critically ill children. On behalf of the section of cardiovascular dynamics of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) we conducted an anonymous survey among pediatric intensive care unit (PICU) specialists in Europe regarding fluid overload and management. A total of 107 study participants responded to the survey. The vast majority of respondents considers fluid overload to be a common phenomenon in mechanically ventilated children and believes this complication is associated with adverse outcomes, such as mortality and duration of respiratory support. Yet, only 75% of the respondents administers a lower volume of fluids  to mechanically ventilated critically ill children on admission. During PICU stay, a cumulative fluid balance of more than 5% is considered to be an indication to reduce fluid intake and start diuretic treatment in most respondents. Next to fluid balance calculation, the occurrence of peripheral and/or pulmonary edema (as assessed including by chest radiograph and lung ultrasound) was considered an important clinical sign of fluid overload entailing further therapeutic action. In conclusion, fluid overload in mechanically ventilated critically ill children is considered an important problem among PICU specialists, but there is great heterogeneity in the current clinical practice to avoid this complication. We identify a great need for further prospective and randomized investigation of the effects of (restrictive) fluid strategies in the PICU. Increasing evidence shows that overzealous use of (intravenous) fluids in critically ill patients beyond the resuscitation phase is associated with adverse outcome –3. A recRestricting the amount of fluids is a daily clinical challenge, particularly in critically ill children undergoing invasive mechanical ventilation. Specifically, because the administration of fluid is necessary to provide hemodynamic support and to ensure appropriate caloric/protein intake while at the same time it functions as a vehicle for drug delivery (fluid creep) , 6. As aThe main goal of this study was to gain insight into the current clinical practice and attitudes of PICU clinicians regarding fluid maintenance and replacement therapy in mechanically ventilated critically ill children.®. The survey was composed using the contribution of all authors. In the process, besides email contact, we organized two discussion sessions and multiple dry runs. The conceptual survey questions were sent to an independent colleague with expertise regarding the subject, for review concerning clarity, relevance and topic coverage.This web-based, anonymous survey was designed using SurveymonkeyThe survey was written in English and comprised of a total of 47 questions divided over eight sections . As stated in the survey  the quesParticipants were asked for consent at the start of the survey and were given the opportunity to leave comments and demographic information on a voluntary basis. A waiver from the local ethical committee for the distribution of the survey was obtained (W21-388). The survey was created and distributed following current available recommendations where possible and appropriate .Only (fellow-) pediatric-intensivists and PICU nurse practitioners were asked to fill in the survey. Furthermore, it was also required for the participants to work in a European country. The survey invitation was distributed through the European Society of Pediatric Neonatal Intensive Care (ESPNIC) newsletter and by email personally directed to all members of the section of cardiovascular dynamics of ESPNIC. In the Netherlands, the survey was also distributed via email to the members of the Dutch Society of Pediatric Intensive Care. Finally, in order to increase the response rate, the survey was also distributed to other colleagues using the authors' personal contact list. Official email reminders were sent twice, at 1 and 3 months after the initial distribution of the survey. In addition, monthly reminders were sent out through social media platforms of ESPNIC .Data from the online survey were collected from November 2020 until April of 2021.Statistical analysis was performed using IBM statistics SPSS v26.0. Data were analyzed with descriptive measures and presented as proportion, percentage and median . For each question, the total number of respondents may due to an incomplete survey response leading to missing answers. Therefore, we present the number of respondents per survey question throughout the paper. Data from Likert scales were enumerated as ordinal data ranging from 1 to 5, with 1 = strongly disagree and 5 = strongly agree.After exclusion of those respondents that were not eligible to participate, a total of 107 respondents were included in the final analysis . 82/107 N = 65/107, 60.7%) of clinical experience working in a PICU. The respondents stated to work in a general-, cardiac-, or mixed PICU in 49/107 (45.7%), 1/107 (0.9%), and 45/107 (42.1%) of the cases, respectively. 12/107 (11.2%) reported to work in a combined PICU-neonatology (N)ICU.As depicted in Respondents were asked to give their view on several statements concerning the topic fluid overload and management. As shown in In the survey, fluid maintenance was defined as all fluids administered during the course of mechanical ventilation, including medication, nutrition, fluid challenges. 57/86 (66.3%) of the respondents reported the presence of a local written protocol concerning total fluid management in invasive mechanically ventilated patients. In 55/86 (63.9%) of cases, the existing protocol was intended for all admitted patients, while in the other cases the protocol was primarily intended for a specific PICU population .55/86 (63.9%) of the respondents reported that they use the Holiday-Segar formula (4 ml/kg/h for the first 10 kg + 2 ml/kg/u for the second 10 kg + 1 ml/kg/u>20 kg) to determine the normal daily total fluid volume requirement in healthy children . For PICU patients at the start of invasive mechanical ventilation, 64/86 (74.4%) of the respondents reported to give less fluids (median (IQR) 20% (20–30)] based on the calculated normal daily total fluid volume. The remainder of the respondents 21/86 (24.4 %) stated to give the full 100% of calculated normal maintenance fluid.Balanced crystalloid solutions were the preferred choice during intravenous fluid therapy followed by crystalloid solutions. A small minority [3/82 (3.7%)] preferred colloid solutions, such as albumin and hydroxyethyl starch.When administering a fluid bolus, 59/82 (72.0%) of the participants preferred a fluid bolus of 10 ml/kg in invasive mechanically children without signs of cardiac failure. 11/82 (13.4%) of the respondents reported the use of a fluid bolus of 20 ml/kg.N = 21/82, 25.6%) or eight  hours.The choice of fluid overload monitoring in invasively mechanically ventilated children was divided between the respondents of the survey. More than one third of the respondents claimed that NET or cumulative fluid balance was monitored hourly, followed by every six  of the survey respondents (strongly) agreed that energy requirements of the patients can be decreased. On the other hand, 32/82 (39.0%) (strongly) disagreed with this statement. Enteral administration of fluid by feeding (non-resuscitation) was considered the preferred method in 75/82 (91.5%) of the cases.When asked whether future research in fluid management is essential to improve our understanding and tailoring medical care in invasive mechanically ventilated patients in the PICU, 78/82 (95.1%) respondents agreed or strongly agreed with the statement. None of the respondents disagreed or strongly disagreed .N = 71/82, 86.6%) among participants to include patients in a future clinical trial investigating possible benefits of a conservative fluid approach. Some respondents who answered “no” believe there is already enough evidence to justify a conservative fluid management approach in invasive mechanically ventilated children. The other respondents argued allocating to a “liberal fluid management” arm would not be ethical, as a conservative approach has already been integrated in their current fluid management protocol.There is also a high willingness  of the respondents preferred a pragmatic clinical trial, whereas 32/82 (39.0%) preferred patient allocation to strict, detailed intervention protocols .N = 59/75, 78.7%). Other possible important primary outcomes, reported by respondents, were: PICU length of stay , mortality  and renal failure/ need for renal replacement therapy .The duration of mechanical ventilation was often reported as an important primary outcome of a future clinical study ICU care. During critical illness, the blood circulation can be compromised due to several factors, including a (widespread) pro-inflammatory response. Inflammation may cause capillary leakage, with subsequent hypovolemia, and a reduced cardiac function, both leading to circulatory insufficiency. Invasive mechanical ventilation itself can also reduce the cardiac output by increasing the afterload, while also decreasing the preload of the right ventricle. In these circumstances fluid loading can be lifesaving, and is therefore recommended in the acute phase of severe disease states like septic shock , 11. In The theoretical concept mentioned above, has clearly been embraced by the critical care community, fueling a large number of studies on fluid management over the last years. In our survey, the vast majority of respondents indeed considered fluid overload to be a common problem in the PICU, associated with a poor outcome . This isConsidering fluid replacement, the majority of respondents used a volume of 10 ml/kg as a fluid bolus. This is in conjunction with current guidelines and studies , 21 althThe majority of respondents monitor the fluid balance and possible signs of fluid overload regularly. However, there was large variability in the clinical practice regarding the threshold of a positive cumulative fluid balance at which adjustments to the fluid management strategy were applied. A close majority considered an increase of more than 5% in cumulative fluid balance a reason for intervention. Advanced diagnostics, when used, were diverse, ranging from chest x-ray to laboratory tests. A recent systemic review showed that positive cumulative fluid balance is indeed a risk factor for increased mortality in adult ICU patients . The incAlthough several studies have shown that a positive cumulative fluid balance is associated with a worse outcome as early as day 1 of PICU admission, in a recent study among children with pediatric ARDS this association was only apparent after day 4 of disease progression , 14. AlsLoop diuretics were mentioned in our survey as the predominant first line drug intervention. However, there was no uniform strategy to counteract pending fluid overload. Lowering maintenance fluids, diuretics or avoidance of maintenance fluid and minimizing drug diluents were all mentioned almost equally. Unlike to the adult ICU literature, no guidelines for de-resuscitation or protocols for diuresis after the resuscitation phase in critically ill children have been published to our knowledge , 27. WheThe current lack of randomized clinical trials hampers the development of widely accepted international guidelines. In terms of future research regarding fluid overload in the PICU, some problems have to be overcome.First, current fluid strategies among participating centers will likely vary to a great extent and should thus be aligned. In particular, determining the volume of fluids in the liberal treatment arm might pose a difficulty, considering that centers, in which restriction of maintenance fluids is already common practice, may raise ethical concerns.Second, there are questions related to timing, type and aggressiveness of interventions  in a conservative fluid treatment arm complicating trial design . The abiThird, obtaining an appropriate sample size may be challenging. The adult ARDS FACTT-study enrolled 1,000 patients and had enough power to detect a 10% absolute reduction (from 31 to 21%) in mortality . This saFinally, the results of this survey show a high willingness among PICU clinicians to participate in a clinical trial in which children are to be randomized into a liberal vs. a conservative fluid strategy. Without such a trial, an evidenced based guideline cannot be accomplished.There are several limitations to this study. First, the response did not follow an even distribution from the various European countries. There could be a bias as the majority of the respondents originated from the Netherlands, Germany and the UK. Second, the number of respondents was not very high and poses the question if the results reflect the opinion of the majority of European pediatric intensivists. Third, the results reflect the individual opinion of clinicians and not institutional or departmental policy. Fourth, intensivists that consider fluid overload a problem may have been more motivated to participate in the survey causing bias.Pediatric intensivists consider fluid overload an important problem and a possible threat to invasive mechanically ventilated critically ill children. However, currently there seems to be no agreement on fluid-sparing strategies and interventions to avoid this complication. Therefore, clinical trials that address prevention and treatment of fluid overload in mechanically ventilated children in the PICU are highly needed.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Amsterdam University Medical Center. The Ethics Committee waived the requirement of written informed consent for participation.IA: study inception, survey design and conduction, analysis, and report writing. SI and JW: survey design and revision of the report. RB and JL: study inception, survey design, analysis, and report writing. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Paulownia hybrid leaves, a wood industry by-product, have been recognized not only as a valuable dietary ingredient for ruminants but also as a rich source of bioactive components such as polyphenolic compounds. Hence, this study was carried out to assess the effects of different concentrations of Paulownia hybrid leaves rich in polyphenols or their particular part on in vitro ruminal fermentation, methane production and microbial populations. Paulownia leaves with high (PLH), medium (PLM), and low levels of polyphenols (PLL) were used from different plantation areas. Lamina (PLLA) and twigs (PLT) of the leaves were also collected from the PLM plantation. Most of the basic nutrient content was similar to dehydrated alfalfa. The use of Paulownia leaves with high content of total polyphenols (PLH and PLLA) or high content of fiber (PLT) lowered ruminal methane production. Reduction of methane production was attributed to the lowering of methanogen populations in PLH and PLLA without affecting substrate degradability and volatile fatty acid concentrations, but in PLT, it was due to decreased in vitro degradability causing decreases in some ruminal parameters, mainly total volatile fatty acids.Paulownia Clon In Vitro 112® leaves or their particular parts on in vitro ruminal fermentation, methane production and microbial population. Paulownia leaves with high ), medium , and low level of polyphenols  were used from three plantation areas. Lamina  and twigs  of leaves were also collected from the PLM plantation. The chemical analyses of Paulownia leaves indicated that the content of the most basic nutrients  were similar to dehydrated alfalfa. The in vitro results showed that the use of Paulownia leaves with the highest content of total polyphenols (PLH and PLLA) decreased methane production, methanogens numbers, and acetate to propionate ratio. In PLT, lowered methane production was followed by reduced substrate degradability and volatile fatty acid (VFA) concentration along with higher acetate to propionate ratio. Therefore, reduction of methane production in PLH and PLLA was attributed to the lowered methanogen population, whereas in PLT it was caused by decreased substrate degradability with the resultant of limited hydrogen availability to the methanogens.This experiment was conducted to study the effects of different concentrations of polyphenols of  Dairy cow production results in a great deal of threats to environments. Increased greenhouse gas emission into the atmosphere, alterations of biological diversification of the ecosystems, and some nutrient pollutions are only some of them . GeneralPaulownia, a tree originating from China [Paulownia hybrid leaves, a wood by-product, have been recognized as a potential dietary ingredient for dairy cows as well as a rich source of bioactive components such as phenolic compounds, saponins, and flavones [Paulownia leaves and Paulownia leaves silage, differing in polyphenolic content (25 vs. 47 mg/g dry matter (DM)), may have different effects on rumen fermentation, including methanogenesis. Thus, it seems interesting to verify how Paulownia leaves from plants grown at different plantations containing the same bioactive components but different concentration will affect the rumen microbial environment.One of the plants with a great potential to be implemented as an alternative dairy cattle dietary ingredient is om China . Paulownflavones ,9. Recenflavones ,11. Howeflavones . ResearcPaulownia hybrid leaves from different plantation areas or their particular parts could influence in vitro ruminal fermentation, methane production and microbial populations.We hypothesized that the higher concentration of total polyphenols may limit the production of methane due to a decrease in the methanogen populations. The main aim of the study was to assess whether different concentrations of polyphenols from Paulownia Clon In Vitro 112 leaves were collected from three different plantations in Poland: 1st in Tuchola , 2nd in Szczecinek , and 3rd in Trzcianka . Over the period March, April, and May 2019 , the average temperature of 14 °C in all plantations, and average rainfall of 44 mm in Tuchola and Trzcianka, and 39 mm in Szczecinek were recorded. These plantation areas were selected on the basis of the previous research where different concentrations of total polyphenols in Paulownia leaves were detected (unpublished data). This study showed that leaves from plantation 1 were characterized with high content of polyphenols (PLH), leaves from plantation 2 were characterized with medium content of polyphenols (PLM), and leaves from the 3rd plantation area contained the lowest level of polyphenols (PLL). Lamina of leaves (PLLA) and twigs (PLT) were also collected from the second plantation with PLM. Plant samples were lyophilized using a freeze-drier , ground using a ZM 200 mill  and kept in dark until analysis.Fresh Paulownia leaves [g for 5 min before undergoing the spectrometric analysis. All analyses were performed in triplicate for three independent samples and stored in a freezer at −20 °C.The phytochemical analysis was focused on polyphenols content, since they were previously marked as the predominant bioactive compounds in a leaves . Before v/v) formic acid in water and mobile phase B consisting of 0.1% (v/v) FA in acetonitrile. A linear gradient from 7% to 50% phase B in phase A over 20 min was used to separate phenolic compounds with a short of 0.3 min calibration segment from 0 to 0.5 min. The flow rate was 0.3 mL/min and the column was held at 25 °C. Spectra were acquired in negative-ion mode over a mass range from m/z 100 to 1500 with 5 Hz frequency. Operating conditions of the electrospray ionization (ESI) ion source were as follows: capillary voltage 3 kV, dry gas flow 6 L/min, dry gas temperature 200 °C, nebulizer pressure 0.7 bar, collision radio frequency 700.0 Vpp, transfer time 100.0 μs, and pre pulse storage 7.0 μs. Ultrapure nitrogen was used as drying and nebulizing gas, and argon was used as collision gas. Collision energy was set automatically from 15 to 75 eV depending on the mass to charge number (m/z) of the fragmented ion. Acquired data were calibrated internally with sodium formate introduced to the ion source at the beginning of each separation via a 20 μL loop.Concentrations of polyphenols in plants materials were analyzed by Ultra-high-resolution mass spectrometry on a Dionex UltiMate 3000RS  system with a charged aerosol detector interfaced with a high-resolution quadrupole time-of-flight mass spectrometer . Phenolic compounds were chromatographed on an Kinetex C18 column , with mobile phase A consisting of 0.1% . The concentrations of the phenolic derivatives in all plant samples were calculated as equivalents of chlorogenic acid . Stock solutions of chlorogenic acid were prepared in 80% methanol at concentrations of 3.1, and 4.1 mg/mL, respectively, and kept frozen until used. Calibration curves for these two compounds were constructed based on seven concentration points (from 3.9 to 500 µg/mL). Hyperoside was used to calculate the amount of flavonoids identified in the extract, as well as chlorogenic acid for phenolic acids. The sum of polyphenols was calculated based on concentration of both: flavonoids and phenolic acids. Bruker QuantAnalysis 4.3 software  was used for this purpose. All analyses were performed in triplicate.All plant samples were also analyzed based on AOAC methods  using th2HPO4, 240 mg KH2PO4, 480 mg (NH4)2SO4, 480 mg NaCl, 100 mg MgSO4.7H2O, 64 mg CaCl2.2H2O, 4 mg Na2CO3, and 600 mg cysteine hydrochloride per liter of double distilled water in the 1:4 ratio. Buffered rumen fluid (40 mL) was added to prewarmed serum flasks (125 mL) and incubated under CO2 at 39 °C. Finally, two batch culture sets were carried out: in the first set, PLH and PLL were tested, and in the second set, PLM, PLT, and PLLA were studied. In both experiments, the plant materials  were incubated as a sole substrate (400 mg in DM) to rule out other factors related to the diets and to obtain ruminal fermentation responses based on the substrate used. The experimental design used in the present study was established on the data published by Huang et al. [Paulownia leaves parts on ruminal fermentation. The incubation flasks (five flasks for each substrate and each run) sealed with aluminum caps and rubber stoppers were placed in an incubator for 24 h and recurrently mixed. Additionally, five bottles in each run containing buffered ruminal fluid only were also included as a blank control. Each experiment was repeated in three runs in three consecutive days. Finally, 35 bottles in the first batch culture and 50 bottles in the in second batch culture were analyzed.Batch culture procedure was used following the method described by Huang et al. . Briefly−1. Oven temperature was pre-programmed: 180 °C for 1.5 min at the beginning, then 20 °C min−1 to 220 °C. Afterwards, the gas samples were injected. Methane concentration was calculated by comparison of retention times with appropriate gases standards  containing 1210 ppm of methane in nitrogen gas (99.99%). After termination of incubation, pH was measured immediately after opening bottles, using a pH meter type CP-104 . The ammonia concentration was analyzed by the colorimetric Nessler method previously described by Cieslak et al. [The gas production, after 24 h of incubation, was determined by the displacement of syringe piston, which was previously attached to the serum flasks. Total gas production was calculated by subtracting gas produced in blank control from the test materials. Methane production was determined by sampling the headspace gas of the flasks by using a gastight syringe into gas chromatograph  that was supplied with a thermal conductivity detector and Carboxen—1000 column . Nitrogen was used as a carrier gas at a constant flow rate of 30.0 mL mink et al. . The volk et al. .Methanogens and total bacterial populations were quantified by fluorescence in situ hybridization (FISH). Briefly, 50 μL of the ruminal fluid was diluted in phosphate-buffered saline (PBS) and pipetted onto 0.22 μm polycarbonate filters  and vacuumed . After vacuuming, the filters were transferred onto cellulose discs for dehydration in an ethanol series . For each sample, a series of identical filters were prepared to allow the determination of optimal hybridization. Hybridizations were carried out in 50 μL of hybridization buffer  containing the oligonucleotides probes (S-D-Arch-0915-a-A-20). After hybridization, the filters were washed with a washing buffer  for 20 min at 48 °C. The filters were rinsed gently in distilled water, air-dried, and mounted on object glasses with VectaShield  anti fading agent containing DAPI . To distinguish total count of bacteria (DAPI) from other methanogens in the rumen fluid, filters were left in 4 °C for 1 hour in the dark until visualized using a Microscope Axio Imager M2 .Paulownia leaves were tested by one-way analysis of variance (ANOVA), followed by Tukey’s post-hoc test. Batch culture experiments (24 h incubation) were performed in three repetitions and five replications (5 incubation vessels) for each of plant materials. Data were analyzed by ANOVA using the General Linear Model (GLM) procedures of SAS. No statistical influence of day was observed; therefore, this factor was deleted from the final model. Differences between treatments in experiment 1 and experiment 2 were tested using Tukey’s post-hoc test. Data were taken as statistically different when p < 0.05. All values are shown as group means with pooled standard errors of means.All data were analyzed using SAS statistical software . Chemical composition and contents of the main bioactive compounds of p ≤ 0.013; p ≤ 0.001). Crude fat and NFC dominated in PLLA with values of 32 and 294 g/kg DM, respectively.The content of DM, OM, CF, and NDF was greater in PLT in comparison to the other plant materials (p < 0.001) of total polyphenols was recorded in PLLA, PLH, and PLM , while the lowest concentration was noted in PLL and PLT  compared to other groups. Among all investigated Paulownia leaves samples, majority of biologically active substances (only except apigenin 7) were significantly different (p ≤ 0.015). The 7- hydroxytomentoside, campneoside isomer and luteolin 4′,7-O-diglucuronide were dominant after acetoside.The higher content (Paulownia leaves with higher concentration of bioactive compounds (both PLH in the first experiment and PLLA in the second one) affected the analyzed parameters of ruminal fluid and the microbial populations. The pH value was higher (p = 0.02) in PLH compared to PLL (p ≤ 0.029) in ammonia concentration, total gas production, CH4 production, CH4 mmol/g DM, CH4/total gas, CH4/IVDDM (in vitro degraded dry matter), acetate to propionate (A/P) ratio, Entodiniomorpha population, total protozoa, and total methanogens. PLH significantly (p ≤ 0.006) increased the propionate, iso-valerate, and valerate proportions. PLT significantly increased (p ≤ 0.049) the pH value, acetate concentration and total methanogen numbers in the buffered ruminal fluid , a significant decrease (p < 0.001) was noticed in PLT compared with the PLLA. In comparison to PLM, PLLA with higher concentration of polyphenols (33.63 mg/g DM) reduced total gas production, CH4 production, CH4 mmol/g DM, CH4/total gas, CH4/IVDDM. The methanogens content was the lowest in PLLA 1.86 × 107/mL) in relation to PLM and PLT.Paulownia leaves are not only a valuable source of basic nutrients but may also reduce the methanogenesis in dairy cows’ rumen [Paulownia leaves on the ruminal environment’s parameters and its mechanisms. To our knowledge, this is the first complete report on the relationship between different polyphenols concentrations in Paulownia Clon In Vitro 112 leaves and ruminal fermentation, methanogens population and methane production.A recent study demonstrated that s’ rumen . These fPaulownia leaves are a good source of nutrients, especially CP, the most expensive nutrient in animal feeding. The average value of CP was 185 g/kg of DM that was relatively higher compared to the previous results—175 g/kg of DM [Paulownia Clon In Vitro 112 is a Paulownia fortunei and Paulownia elongata hybrid, while the materials used in Huang et al. study [Paulownia tomentosa and Paulownia fortunei hybrid. In Huang et al. study [Paulownia leaves was close to the nutrient value of alfalfa the widely used in cattle feeding, rather than grass. This feature enforces Paulownia as an alternative feed component since there is an ongoing shortage of feeds of dairy cows not competing with human foods [The kg of DM —however,l. study  was a Pal. study , the CP Paulownia leaves was 432 g/kg DM), difference was noted in the NFC content (average 232 g/kg DM). Concentration of NDF was slightly higher in Paulownia leaves than in dehydrated alfalfa (378 g/kg DM), but lower than in dehydrated grass  which cd intake .Paulownia leaves materials , as it was previously hypothesized. The concentration of polyphenols ranged from 11.90 mg/DM to 31.35 g/mg DM. Polyphenol concentration in PLM was comparable to the finding of Huang et al., [Paulownia leaves. The differences in Paulownia leaves materials may be a cause of divergent agronomic management [4 per gram of DM (by 7%). These observations may indicate that the higher concentrations of polyphenols inhibit growth effect to a greater extent to some class of methanogens, while the activity of other types of methanogens may be increased reducing the efficiency of methane inhibition. In the present study, also the lack of changes in the number of total rumen’s bacteria that provide hydrogen for the methanogenesis process should be considered for final CH4 production. Another compound present in higher concentrations in PLL, PLH, and PLM was 7- hydroxytomentoside, and its concentration was within the range of 3.66 to 14.01 mg/g DM. Additionally, in other studies on Paulownia Clon In Vitro 112, 7- hydroxytomentoside was found as one of the dominant biologically active compounds [Differences in concentration of total polyphenols were observed among nagement  than soinagement  researchnagement  which waompounds . 7- hydrompounds , which mompounds . Due to ompounds , which wompounds ,27.Increased pH and reduced ammonia concentration were observed in the PLH group. As a consequence, more suitable ruminal fluid environment was obtained. Increased pH by PLH may be a result of higher concentration of total polyphenols that could favor lactate-utilizing bacteria. For example, according to Balcells et al. , phenoliPaulownia leaves have high soluble fractions , which Paulownia leaves with medium concentration of phenolic compounds , lamina of leaves (33.63 mg/g DM), and its twigs (2.53 mg/g DM). We showed that higher concentrations of polyphenolic compounds in PLLA have a similar impact on ruminal fermentation characteristics and microorganism populations. PLLA mitigated methane production by 16% compared with the PLM. Additionally, in PLT  a decrease in methane concentration was also observed (25 %), which was the resultant of increased NDF content in this part of leaves. Consequently, decreased methane production was a result of reduced digestibility of dry matter (by 15%) limiting hydrogen availability to methanogens. Increased NDF concentration induced a pH increase and IVDMD reduction with a direct impact on the content and VFA profile. Thereby, methane production reduction in the second experiment in PLLA and PLT groups was caused by different mechanisms. Moreover, PLT containing high fiber content decreased propionate proportion and acetate to propionate ratio, which are normally observed in high fiber forage diets compared with concentrate diets due to stimulation of fiber degrading bacteria that predominantly produce more acetate in comparison to propionate [The second experiment was focused on using Paulownia leaves with high total polyphenols or NDF content into the ruminants’ diet could improve the sustainability of ruminant production system, since it lowered methane production. Reduction of methanogenesis was obtained by lowering methanogens populations in PLH and PLLA whereas decreasing IVDMD caused a decreased efficiency in ruminal fermentation, mainly total VFA and reduced propionate proportion in PLT. This study also demonstrated that plantation areas affect polyphenolic compounds in Paulownia leaves, which subsequently exert ruminal fermentation and methanogenesis differently.PLH, PLLA , and PLT  affected methane and VFA profile. Incorporating


N = 20 pairs of pianists as they performed a melody first in Solo performance (at their spontaneous rate of performance), and then in Duet performances at each partner’s spontaneous rate. Influences of partners’ spontaneous rates on interpersonal synchrony were assessed by correlating differences in partners’ spontaneous rates of Solo performance with Duet tone onset asynchronies. Coupling between partners’ neural oscillations was assessed by correlating amplitude envelope fluctuations of cortical oscillations at the Duet performance frequency between observed partners and between surrogate (re-paired) partners, who performed the same melody but at different times. Duet synchronization was influenced by partners’ spontaneous rates in Solo performance. The size and direction of the difference in partners’ spontaneous rates were mirrored in the size and direction of the Duet asynchronies. Moreover, observed Duet partners showed greater inter-brain correlations of oscillatory amplitude fluctuations than did surrogate partners, suggesting that performing in synchrony with a musical partner is reflected in coupled cortical dynamics at the performance frequency. The current study provides evidence that dynamics of oscillator coupling are reflected in both behavioral and neural measures of temporal coordination during musical joint action.Interpersonal synchrony refers to the temporal coordination of actions between individuals and is a common feature of social behaviors, from team sport to ensemble music performance. Interpersonal synchrony of many rhythmic (periodic) behaviors displays dynamics of coupled biological oscillators. The current study addresses oscillatory dynamics on the levels of brain and behavior between music duet partners performing at spontaneous (uncued) rates. Wireless EEG was measured from  Many joint actions, from ensemble music performance to team rowing, require that partners synchronize the timing of rhythmic (oscillatory) movements. There is growing evidence that interpersonal synchrony of rhythmic movements is influenced by dynamics of entrainment between biological oscillators . An exteEvidence for principles of oscillator entrainment in interpersonal coordination comes from a growing body of behavioral research. Much of this work is based on ‘frequency detuning’ paradigms from studies of intra-limb coordination  in whichspontaneous frequencies—unconstrained frequencies of self-paced spontaneous rhythmic motion during music performance—influence interpersonal entrainment  research has shown that neural oscillations entrain to the frequency of external rhythms . Neural It has been suggested that partners’ neural activity becomes coupled during temporal coordination in joint action . LindenbAmplitude envelopes, defined as the absolute value of the Hilbert transform of a neural oscillation, reflect energy fluctuations over time . CorrelaThe current study investigated oscillator dynamics of interpersonal synchrony in duet music performance by investigating the extent to which partners’ spontaneous performance rates influence interpersonal synchrony during temporally unconstrained performance. We also investigated whether partners display inter-brain coupling of cortical oscillations at the duet performance rate. Duet music performance was used as a model of oscillatory joint action, since music is highly rhythmic and musicians must be able to coordinate production of these rhythms with millisecond precision. We randomly paired pianists and recorded wireless EEG while pianists performed a simple melody in the Solo condition at their spontaneous rate and in Duet performance with their partner. In Duets, partners took turns as Leader to set the pace of performance at their spontaneous rate, in contrast with much of the previous literature on coordinate dynamics of music performance, where musicians produce actions at a cued rate. The use of wireless EEG enabled us to investigate inter-brain synchrony during music performance with minimal artifact , b. MoreWe hypothesized that interpersonal coordination in duet music performance is constrained by the amount of coupling needed to overcome differences in partners’ natural frequencies. Based on previous findings, Duet tone onset synchronization was predicted to decrease as a function of the difference in partners’ spontaneous rates . Larger M = 85.9, SD = 17.2), except one individual who showed a tendency toward left-hand dominance (score = 36.8). The study protocol was reviewed by the local ethics committees at the University of Oldenburg and McGill University, and all participants provided informed consent prior to recording, in accordance with the Declaration of Helsinki. EEG data associated with Solo performances from the current sample have been reported in 40 pianists were randomly assigned to 20 pairs  with six or more years of private piano lessons  were recruited from the Oldenburg community. Pianists were included if they had self-reported normal or corrected to normal vision, no current psychiatric or neurological conditions or use of neuropsychiatric medication, self-reported normal hearing confirmed through a pure-tone audiometric screening test  and right-hand dominance. Handedness was confirmed using the Edinburgh Handedness Inventory . All parBruder Jakob  on the piano with their right hand. Participants were familiar with the melody and rehearsed the melody from stimulus notation sent in advance of their arrival at the laboratory; the melody was notated in C major (treble clef) and the rhythm was in binary (4/4) meter and was 32 tones in duration . To control for possible differences in finger movements across pianists, suggested fingerings were indicated on the melody notation (provided by three skilled pianists not in the study).Participants performed the popular melody via a MIDI-USB merger , and sent to a Linux (Fedora) operating system computer running FTAP MIDI recording software (via an ethernet switch (TP-Lin GmbH). FTAP was adapted to include the Lab Streaming Layer library , which allowed for sending MIDI keystroke triggers to LabRecorder software (v1.1)2) over the LAN.software . The Linary LSL; 1, which 3), attached to separate elastic electrode caps4, were used to record EEG data from participants. Electrode positioning followed the international 10–20 system. FCz served as the reference electrode and AFz served as the ground electrode. Electrode impedances were below 20 kOhms before the recording started. Wireless EEG amplifiers  were strapped to the back of each participant’s electrode cap between O1 and O2 electrode sites. Digitized EEG data from each participant were sent wirelessly from the amplifier to a Bluetooth receiver placed on the wall directly behind their keyboard. Bluetooth receivers sent this information via USB to Windows 7 computers running SmartingLSL, which collected the data using the LSL library and sent the data to LabRecorder over the LAN. LabRecorder synchronized EEG data from both amplifiers with MIDI data by correcting for clock offsets between acquisition computers. For details on synchronizing MIDI and EEG data from a single mobile amplifier, it was confirmed that MIDI and EEG recordings were synchronized with millisecond precision  was not influenced by their partner’s performances. The Solo Task measured each pianist’s spontaneous rate on 3 trials, where 1 trial included 4 continuous performances of the melody (yielding 12 repetitions per pianist). Each pianist completed 1 practice trial and 3 test trials of Solo performance, yielding a total of 12 Solo test performances of the melody.The Duet task measured the pianists’ tone onset asynchrony while one partner played the role of Leader (partner responsible for cueing the pace of the Duet performance) and the other partner played the role of Follower (partner responsible for performing at the Leader’s pace) as they tried to synchronize their performances. Two independent variables were manipulated in a within-subject design. The first independent variable, Musical Role  was coded for analyses that examined each pianist as the random variable. The second independent variable, Leader-Order condition, included 2 levels  and was coded for analyses that examined each pair as the random variable. In the First-Leader condition, the duet partners chose which partner would play the role of Leader. In the Second-Leader condition, the experimenter assigned the role of Leader to the partner who played the role of Follower in the First-Leader condition. Each Leader-Order condition comprised 1 practice trial and 6 test trials of duet performance , yielding a total of 24 Duet test performances of the melody for each of the two conditions .Pianists were sent the melody’s stimulus notation in advance of the study, with the instruction to practice with the notated fingering until memorized. When Duet partners arrived at the lab, they were each given a short practice session and then separately completed a melody memory test, as shown in Partners subsequently completed the Duet performance task, in which partners performed the melody together simultaneously. One partner (the Leader) was instructed to set the pace of each performance at a rate that was natural and comfortable for them just as they did during Solo performance, while their partner (the Follower) was instructed to follow the Leader’s rate and to synchronize their production of tone onsets with the Leader’s. In the First-Leader condition, Duet partners decided amongst themselves who would be the Leader and who would be the Follower. Partners performed 6 test trials of the First-Leader condition. Then, in the Second-Leader condition, partners switched roles and the First Leader became the Follower while their partner became the Leader, and 6 test trials were subsequently performed in this condition. On each trial of the Duet performance, the partner assigned as Leader cued the performance rate by performing the first 8 melody tones alone, allowing the Leader to clearly signal the performance tempo to their partner at the beat level . The Follower joined the Leader on the 9th melody tone, and the rest of the trial was played entirely in unison (the two pianists intended to produce the same pitches at the same time). EEG was recorded during Solo and Duet piano performance tasks. Resting state EEG data was collected from both partners, as was EEG data associated with a second Duet task (after the Second-Leader condition) in which partners performed the melody cued by a metronome and there was no Leader; these data are not reported in the current paper.Since pitch errors in music performance often coincide with timing errors , melody M = 2.6, SD = 0.98). Artifact-corrected data were referenced to the common average across electrode sites. A single bad channel was identified in a single participant, and replaced by means of spherical interpolation as implemented in EEGLAB.EEG data were corrected for artifacts using EEGLAB . First, All behavioral and EEG spectral density measures were computed over a fixed-duration analysis window. The use of a fixed duration window was necessary for spectral density analyses to ensure identical frequency resolution across participants’ spectra; behavioral data were analyzed over the same window to ensure that neural and behavioral comparisons were made across the same data segments.The window duration of 9 s was selected, corresponding to the fastest pair’s mean duration of melody performances across Duet conditions . This window was defined relative to the fastest pair (and not the slowest pair) so that padding was not necessary to achieve equivalent window duration across performances. Neural oscillations at the duet frequency were assumed to show slow (low-frequency) changes over time; therefore for this analysis only we assessed amplitude envelope measures over the full melody performance instead of the shorter 9-second window to allow sufficient time for capturing their temporal dynamics.t(38) = 0.015, p = 0.99; Second-Leader: t(38) = 0.016, p = 0.99. Therefore, Leaders’ and Followers’ mean Duet performance IOIs were averaged to yield a single mean Duet IOI for each pair in each Duet condition. To facilitate comparison with EEG frequency spectra, mean Solo and Duet IOIs were converted to Hertz . Whereas Mean Solo and Duet Performance rates were defined as the mean inter-tone onset interval  at the quarter-note level across each participant’s melody performances . PSD was computed separately for each melody repetition and then averaged to obtain a single value per partner, per Leader-Order condition.Neural entrainment during Duet performance was defined within each duet condition by the EEG Power Spectral Density (PSD) of each partner, computed at the pair’s mean Duet Performance Rate (section “Performance Rates”). This definition is consistent with previous work defining stimulus entrainment by enhanced spectral amplitude of oscillations at the stimulus frequency , 2013. Tpwelch function in MATLAB; frequency resolution = 0.061 Hz). Resulting power spectra were log-transformed to compensate for 1/f power distribution characteristic of EEG data, and then separately averaged across epochs on each channel for each participant.To compute PSD, artifact-corrected EEG data were low-pass filtered , high-pass filtered , and epoched into 9 s segments . To reduce edge effects, epochs were multiplied with a 4,500-point (9 s) Hanning window, and the PSD was computed for each epoch and channel using Welch’s method  bins . This prAmplitude envelopes of EEG oscillations at the Duet performance rate were computed to assess the dynamics of the Duet partners’ neural responses over time using methods described in detail in Because musicians do not perform the same melody with identical timing across the tone sequence , the numz transform to ensure normality, and averaged across melody repetitions, within-pair and within-condition.To quantify correspondences in the amplitude dynamics of partners’ neural oscillations at the Duet performance rate, inter-brain correlations of EEG amplitude envelopes  were assessed for each pair, using the method described in To test whether observed inter-brain AECs reflected amplitude correspondences specific to each Duet pair, AECs from observed Duet pairs were compared with AECs of surrogate pairs. Surrogate pairs were created within each condition by pairing each Leader with all Followers except their true partner: This procedure yielded 19 surrogate Duet pairs per Leader and per condition. For each surrogate pairing, amplitude envelopes were resampled within Duet condition such that the number of samples between corresponding tone events was constant across melody repetitions, using the same procedure described above. Resampling was necessary because surrogate partners’ performances occurred at different rates, and their data could not be compared without resampling relative to the musical event structure. After resampling, amplitude envelopes of corresponding melody repetitions in the trial structure were correlated (24 repetitions per condition), and averaged using the same procedure as for observed pairs. Amplitude envelope correlations were averaged within each surrogate pair across conditions.The distribution of individual pianists’ Solo performance rates (mean IOI in ms) is shown in SD = 62.07 ms). The First and Second Leaders’ Solo rates did not differ significantly, t(19) = −1.29, p = 0.21 , ensuring that any subsequently observed differences between First-Leader and Second-Leader conditions were not simply a function of their random assignment to Duet pairs.The differences between Duet partners’ Solo performance rates were examined in terms of the Leader-Order Duet conditions, to determine whether one Leader-Order condition differed from the other for the randomly paired partners. The mean difference in partners’ Solo performance rates was 74.26 ms  = 0.015, p = 0.99; Second-Leader means: t(38) = 0.016, p = 0.99]. Therefore, the mean Duet performance rates within condition were defined for each Duet pair as the mean IOI averaged across the two duet partners. The distribution of mean Duet performance rates by Leader-Order condition is shown in r (18)First–Leader = 0.90, r(18)Second–Leader = 0.71, both p’s < 0.001], whereas the correlations with Follower’s Solo performance rate were not .We compared the mean Duet performance rates of Leaders and Followers within Leader-Order conditions. Those mean values indicated that the duet partners were performing at the same rate within condition, as expected . Duet pairs’ mean absolute asynchronies were also computed [abs (Leader − Follower tone onsets) divided by mean Duet IOI], and ranged from 0.033 to 0.124 across Leader conditions. Tests of Leader Order effects on absolute asynchrony indicated no significant differences , suggesting that overall synchronization accuracy was not significantly influenced by whether the partner served as Leader in First or Second Leader conditions.Duet pairs’ mean signed asynchronies  across Leader conditions ranged from negative to positive values (range = −0.056 to 0.113). Tests of Leader Order effects on signed asynchronies yielded no significant differences , consistent with dynamical systems predictions that coupling between oscillators is a function of the difference in their natural frequencies.Dynamical systems hypotheses predict that the signed asynchrony, which is the degree to which Leaders’ tone onsets preceded Follower’s tone onsets, is related to how much faster the Leader’s Solo rate is relative to the Follower’s . We testEEG spectral power at the Duet Performance Rate was defined for each pianist as mean PSD at the frequency bin closest to the mean Duet Performance Rate, averaged across electrode sites (channel mean PSD). F = 1.256, p = 0.269, and at the auditory-motor ROI, F = 0.287, p = 0.595, indicating stability of spectral power within individual pianists across musical Roles.To assess whether each individual pianist’s spectral power at the Duet performance rate changed as a function of their musical role (Leader/Follower), a one-way repeated-measures ANOVA on mean noise-normalized PSD at their Duet performance rate was conducted with Role (Leader/Follower) as a fixed factor and Subject as the random variable. Individual pianists’ spectral power did not change as a function of musical Role, both across channels, zFirst–Leader = 4.50, p < 0.001; zSecond–Leader = 4.31, p < 0.001), confirming the prediction of increased power of neural oscillations at the Duet performance frequency in both Duet conditions.zFirst–Leader = 4.31, p < 0.001; zSecond–Leader = 5.15, p < 0.001), confirming the presence of a spectral peak at the Duet rate. A Wilcoxon signed-rank test indicated that ROI spectral power at the Duet rate did not differ between conditions . rFirst–Leader (18) = −0.569, p = 0.009; rSecond–Leader (18) = −0.571, p = 0.009], and less strongly correlated for Followers . As shown in r(17) = −0.4601, p = 0.0845. Due to the small sample size and the fact this pair’s overall synchronization accuracy was still quite high, this pair was retained in subsequent analyses.Next, the Duet pairs’ synchronization accuracy (mean absolute asynchrony divided by the mean performance beat IOI) in each condition was compared directly with mean PSD at the Duet performance rate. Synchronization accuracy and mean PSD were negatively correlated for Leaders [R2 = 0.33, p = 0.036: The Leader’s PSD was a significant predictor of Duet asynchrony, standardized β = −0.578, t(17) = 2.47, p = 0.025, whereas the Follower’s PSD was not, standardized β = 0.02, t (17) = 0.08, p = 0.94. For the Second-Leader condition, this model was also significant, R2 = 0.34, p = 0.03: The Leader’ PSD was a marginally significant predictor of Duet PSD, standardized β = −0.480, t(17) = 1.88, p = 0.08, whereas the Follower’s was not, standardized β = −0.14, t(17) = 0.56, p = 0.58. Thus, Leaders’ PSD values increased as the Duet partners’ asynchrony decreased, regardless of which partner served as Leader (First- or Second-Leader).For each Duet condition, a multiple regression model was implemented to predict mean absolute Duet asynchrony, adjusted for Duet performance rate, from Leader and Follower PSD at the Duet performance rate. For the First-Leader condition, this model was significant, r-to-z scores. Because Fisher r-to-z scores did not differ significantly between First-Leader and Second-Leader conditions, F = 1.83, p = 0.19, each Duet pair’s condition-mean Fisher r-to-z scores were averaged across conditions. This procedure yielded a single mean Fisher r-to-z score per Duet pair (N = 20), which was then converted to a Pearson’s r-value. The mean observed AEC across pairs and conditions was r = 0.26 .p = 0.02; median observed r = 0.29, median surrogate r = 0.13).Amplitude envelopes may be correlated across Duet partners because they exhibited inter-brain correspondences, or, alternatively, because they performed the same task (each Duet pair performed the same melody). To test whether the AEC values were pair-specific, the observed values were compared with the chance estimate based on mean AECs of each pair’s surrogate distribution generated from the re-pairing of data from different duet partners (described in section “Inter-Brain Correlations of Duet Partners’ Amplitude Envelopes”). The current study demonstrated that two pianists’ spontaneous performance rates were associated with their ability to synchronize actions when performing duets. Specifically, differences in partners’ spontaneous rates were positively correlated with Duet asynchronies: Partners with larger differences in spontaneous rates showed larger signed tone onset asynchronies. This finding is consistent with dynamical systems accounts that predict period coupling between oscillations as a function of the difference in their natural frequencies . In contThe current findings add to a growing body of work indicating that spontaneous music performance rates reflect oscillatory processes that influence auditory-motor entrainment within and between individuals . WhetherThe observed oscillatory cortical activity in the current study may have been influenced by evoked potentials elicited by the perception of rhythmically occurring tone onsets, as suggested by an ongoing debate in the literature over whether rhythmic brain activity reflects purely oscillatory processes or also stimulus-evoked potentials elicited by rhythmic stimuli see . There iDuet partners also showed temporally correlated fluctuations in amplitude dynamics across the entire performance. Amplitude coupling was observed in the inter-brain correlations of partners’ spectral energy at the Duet frequency (rate of performance). Correlations between observed partners’ amplitude envelopes were higher on average than correlations between duet pianists who performed the same task but with other partners (surrogate pairs), suggesting that inter-brain amplitude coupling is partner-specific and may arise from the temporally distinctive auditory-motor patterns of each performance. It cannot be ruled out that some amount of inter-brain amplitude coupling in the current study arose from partners’ perception of musical sequences with identical rhythmic  properties. Our previous work  indeed swithin individuals’ brain networks (between individuals. Although the current findings are agnostic with respect to the relationship between phase-resetting mechanisms of endogenous neural oscillations and transient ERPs in response to rhythmic auditory stimuli (The current study demonstrates the novel application of amplitude envelope correlations to inter-brain correspondences. Previously used to detect functional connectivity or coupling networks , we appl stimuli , the mea stimuli .A remaining question is how these amplitude-based metrics of inter-brain correspondences compare with alternative measures of inter-brain synchrony, such as phase-based metrics. Some work suggests that amplitude and phase are related ; howeverFinally, the current study implements what is to our knowledge the first simultaneous recording of wireless EEG from performing ensemble musicians. Wireless EEG with head-mounted amplifiers enables individual to walk freely, with modest motion artifact , b. HoweThe raw data and code supporting the conclusions of this article will be made available by the authors upon reasonable request, without undue reservation.The studies involving human participants were reviewed and approved by Kommission für Forschungsfolgenabschätzung und Ethik. The participants provided their written informed consent to participate in this study.AZ designed the experiment in collaboration with co-authors, conducted the experiment, implemented and interpreted analyses, wrote drafts of the manuscript and incorporated the revisions. CP contributed to and provided supervision in experiment design, supervised implementation of data analysis, contributed to interpreting results and assisted in writing and revising the manuscript for publication. A-KRB contributed to experiment design, gave input on implementation of EEG data analyses, and assisted with data interpretation and manuscript revision. MGB contributed to experiment design and technical set-up, gave input on implementation of EEG data analyses, and assisted with data interpretation and manuscript revision. APD gave input on statistical analyses of data, and assisted with manuscript revision. SD supervised and contributed to experiment design and implementation, provided laboratory space and mobile EEG equipment for data collection, supervised implementation of data analysis, and contributed to interpreting results, assisted in writing and revising the manuscript for publication. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This case describes a 51-year-old male who presented to the emergency department with a complaint of two weeks of progressively worsening dysphagia as well as the emergence of superficial fluid collections on the anterior chest and leg during the same period. Computed tomography showed retropharyngeal and paratracheal fluid collections with adjacent vertebral osteitis; however, biopsies were negative for any infectious or mycobacterial source, and instead showed chronic inflammatory changes.Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome is a rare rheumatic disorder that presents with multifocal osteitis and sterile neutrophilia. SAPHO syndrome may be easily mistaken for a diffuse infectious process on initial evaluation and imaging; however, it is treated with anti-inflammatory medications, including non-steroidal anti-inflammatory drugs and corticosteroids. Although most patients achieve remission of symptoms with treatment, the location of the fluid collections and resultant bony destruction may be life-threatening if undiagnosed. A 51-year-old male with a history of human immunodeficiency virus presented to the emergency department (ED) with two weeks of progressively worsening hoarseness and dysphagia. During the same period of time, he noted the development of two superficial fluctuant areas on the anterior chest and right leg. The patient denied any associated symptoms, including fever. He was born in Brazil and had a negative tuberculosis (TB) test in the United States. During the interview, he was notably hoarse but otherwise non-toxic in appearance. On examination, he had an area of fullness adjacent to the trachea, and a tender, fluctuant mass on the anterior chest. His lungs were clear to auscultation, no stridor was appreciated, and he had no pharyngeal erythema on inspection. He was afebrile, with oxygen saturation of 99% on room air with normal work of breathing and otherwise unremarkable vital signs. Laboratory workup was unremarkable, and computed tomography of the neck and thorax were obtained .Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome. Computed tomography showed multiple fluid collections in the soft tissues of the neck, chest, and lung, with bony destruction of the sternum and vertebrae. Magnetic resonance imaging showed retropharyngeal fluid collection with vertebral osteitis –3. OtolaWhat do we already know about this clinical entity?Synovitis, acne, pustulosis, hyperostosis, osteitis syndrome is a rare sterile neutrophilic disorder producing fluid-filled collections which may invade local structures.What is the major impact of the image(s)?Although the fluid collections may be benign, their location may result in airway compromise and destruction of local bony structures.How might this improve emergency medicine practice?The presence of a superficial fluid collection in conjunction with ‘red-flag’ symptoms such as dysphagia warrants imaging to identify lesions in high risk areas.Propionibacterium acnes bacteria.This syndrome is a rare, sterile neutrophilic disorder that can be characterized by multifocal sterile osteitis, most often involving the anterior chest.


In Japan, six workers handling cross-linked water-soluble acrylic acid polymer (CWAAP) at a chemical plant suffered from lung diseases, including fibrosis, interstitial pneumonia, emphysema, and pneumothorax. We recently demonstrated that inhalation of CWAAP-A, one type of CWAAP, causes pulmonary disorders in rats. It is important to investigate dose–response relationships and recoverability from exposure to CWAAPs for establishing occupational health guidelines, such as setting threshold limit value for CWAAPs in the workplace.3 CWAAP-A for 6 h/day, 5 days/week for 13 weeks using a whole-body inhalation exposure system. At 1 h, 4 weeks, and 13 weeks after the last exposure the rats were euthanized and blood, bronchoalveolar lavage fluid, and all tissues including lungs and mediastinal lymph nodes were collected and subjected to biological and histopathological analyses. In a second experiment, male rats were pre-treated with clodronate liposome or polymorphonuclear leukocyte-neutralizing antibody to deplete macrophages or neutrophils, respectively, and exposed to CWAAP-A for 6 h/day for 2 days.Male and female F344 rats were exposed to 0.3, 1, 3, or 10 mg/m3 and the no observed adverse effect concentration (NOAEC) was 0.3 mg/m3. Rats of both sexes were able to recover from the tissue damage caused by 13 weeks exposure to 1 mg/m3 CWAAP-A. In contrast, tissue damage caused by exposure to 3 and 10 mg/m3 was irreversible due to the development of interstitial lung lesions. There was a gender difference in the recovery from CWAAP-A induced pulmonary disorders, with females recovering less than males. Finally, acute lung effects caused by CWAAP-A were significantly reduced by depletion of alveolar macrophages.CWAAP-A exposure damaged only the alveoli. The lowest observed adverse effect concentration (LOAEC) was 1 mg/m3 CWAAP-A was reversible: recovery in female rats was less than for males. These findings indicate that concentration limits for CWAAPs in the workplace can be determined.Pulmonary damage caused by inhalation exposure to CWAAP-A was dose-dependent, specific to the lung and lymph nodes, and acute lung damage was ameliorated by depleting macrophages in the lungs. CWAAP-A had both a LOAEC and a NOAEC, and tissue damage caused by exposure to 1 mg/mThe online version contains supplementary material available at 10.1186/s12989-022-00468-9. Cross-linked water-soluble acrylic acid polymers (CWAAPs) are used worldwide as a thickening agent to increase viscosity and sol–gel stability. CWAAPs are used in products such as cosmetics and pharmaceuticals owing to their low potential for skin and eye irritation. However, recently in Japan, six workers who were handling CWAAPs at a chemical plant producing these resins suffered from lung diseases, including fibrosis, interstitial pneumonia, emphysema, and pneumothorax . Site inLittle is known about lung disorders caused by inhalation exposure to CWAAPs, Therefore, using a whole-body systemic inhalation system, we recently examined the effects of inhalation exposure to CWAAP aerosol in the rat, from the acute to the chronic phase . The resTo be accepted by many regulatory body, a reliable toxicity test should be conducted with reference to testing guidelines adopted by the Organization for Economic Co-operation and Development (OECD). The OECD guidelines for the testing of chemicals 413 (OECD TG 413) requires an exposure protocol of 6 h per day, 5 days per week, for 90 days at more than 3 concentrations, using both male and female rodents [Our previous research had demonstrated that inhalation of CWAAP-A causes alveolar injury characterized by alveolar collapse with a high degree of neutrophilic infiltration in the acute phase . In addiThe mass concentrations of CWAAP-A aerosol in the inhalation chamber are shown in Additional file 3 group, these changes were still significant after the 13-week recovery period, while in the 3 mg/m3 exposure groups these changes were no longer significant and in the 1 mg/m3 and 0.3 mg/m3 exposure groups these changes were completely resolved. Exposure to CWAAP-A significantly decreased total cholesterol and phospholipid (PL) in the plasma immediately after the 13 week exposure period in a CWAAP-A concentration dependent manner, however, these changes were mostly resolved after the 13 week recovery period , and fibrous thickening of the interstitium. These lesions were not present in any of the rats immediately after the end of the inhalation exposure period  at the 13 week recovery period  and drainage via lymphatic vessels –12. We iels Fig. b, c. TheHistopathological findings in the nasal cavity, trachea, liver, stomach, pancreas, kidney, prostate, pituitary gland, thyroid, mammary gland, uterus, brain, eye, harder gland, and bone marrow are shown in Additional file 3 groups, after the 13 week recovery period, blue particles were found in only 3 of the 8 animals examined, indicating some clearance of CWAAP-A from the lungs of the rats exposed to 0.3 mg/m3 CWAAP-A.As reported previously, our modified alcian blue staining method stains CWAAPs . The resCurrently, there is no established method to quantify the deposition of CWAAPs in the lung. Therefore, the Multiple-Path Particle Dosimetry (MPPD) model ver. 3.04 was used to estimate local mass depositions of CWAAP. The results suggest a concentration-dependent increase in deposition in the alveolar and airway regions immediately after 13 weeks of exposure, with a trend towards higher deposition in the upper and peripheral regions  Fig. . Howeverods Fig. : CWAAP-AP-A Fig. a, b. Tot3 exposure groups, and LDH activity had returned to normal in the 0.3 and 1 mg/m3 groups. In female rats, LDH activity, ALP activity, and PL levels had returned to normal after the 13 week recovery period in the 0.3, 1, and 3 mg/m3 exposure groups, and γ-GTP activity had returned to normal in the 0.3 and 1 mg/m3 groups. In both males and females exposed to 10 mg/m3 CWAAP-A, the activities of LDH, ALP, and γ-GTP and the PL levels remained significantly elevated after the 13-week recovery period. In agreement with these lung lesion markers, the plasma and BALF levels of surfactant protein D (SP-D), a marker for interstitial pneumonia, were increased by CWAAP exposure in an exposure concentration-dependent manner , alkaline phosphatase (ALP), and γ-glutamyl transpeptidase (γ-GTP) and the levels of phospholipid (PL) in the BALF were all increased in an exposure concentration-dependent manner Fig. a–h. ALP ner Fig. a–d. Afte3 CWAAP-A exposed groups after the 13 week recovery period and TGFβ2 was significantly increased only in the 10 mg/m3 CWAAP-A exposed groups after the 4 week and 13 week recovery periods.To quantify the fibrotic changes in the lungs, we measured the levels of transforming growth factor TGFβ1 and TGFβ2, the major signaling molecules for fibrosis , 15, in 3 CWAAP-A hydroxyproline content was significantly increased  for CWAAP-A in this study was 1 mg/m3 for both sexes, and 0.3 mg/m3 was the no observed adverse effect concentration (NOAEC)  Fig. . Further3 group and after a 13-week recovery period in the 3 mg/m3 group  in the BALF, and an increase in neutrophils in the BALF [In contrast to untreated normal lungs, in CWAAP-A exposed lungs, clodronate liposome pretreatment resulted in a moderate but significant reduction of the increase in neutrophil count in the BALF caused by CWAAP-A exposure. Cytokine-induced neutrophil chemoattractant-1 (CINC-1) in rats is a key neutrophil chemoattractant . Previouthe BALF . Thus, ePMN antibody pretreatment dramatically reduced the number of neutrophils found in the blood. However, the decrease in neutrophils in the BALF while significant was moderate. PMN antibody and clodronate liposome pretreated rats had similar numbers of neutrophils in the BALF; however, in contrast to clodronate liposome pretreated rats, PMN pretreatment did not reduce the levels of SP-D in the plasma, but rather the levels of SP-D in the plasma of PMN antibody treated rats exposed to CWAAP-A were increased. This suggests that while it is likely that neutrophils in the lung contributed to CWAAP-A induced acute injury, other macrophage associated factors also contributed to lung injury.It is notable that while PMN antibody pretreatment reduced the number of neutrophils in the blood by more than 90%, there was no significant reduction of neutrophils in the lungs of unexposed rats and only a mild decrease in neutrophils in the lungs of CWAAP-A exposed rats. Since PMN antibodies administered intravenously are mostly present in the blood, they are not easily accessible in the alveolar air spaces, and the alveolar spaces are considered to be a "safe haven" for neutrophils. Therefore, once the neutrophils escape into the alveolar air space, they will escape from cell death. This suggests that the increase in neutrophil counts in the CWAAP-A exposed lung in rats pretreated with PMN antibodies depend more on proliferation of tissue resident neutrophils in the lung  that suc3 and the NOAEC was 0.3 mg/m3. In addition, rats of both sexes were able to recover from the tissue damage caused by 13 weeks exposure to 1 mg/m3 CWAAP-A, however, tissue damage caused by exposure to 3 and 10 mg/m3 was irreversible due to the development of interstitial lung lesions. There was a gender difference in the recovery of lung lesions, with females showing less recovery than males. Comparison of CWAAP-A, MWCNT-7, and titanium dioxide revealed that LDH activity in rat BALF after inhalation exposure to CWAAP-A (this study) was higher than that of MWCNT-7 and titanium dioxide [Inhalation exposure to CWAAP-A had harmful effects only in the alveoli. In this study, the LOAEC for pulmonary disorders in male and female F344 rats was 1 mg/m dioxide , 44 (AddCWAAP was purchased from a company which produces acrylic acid polymers. This product is the same as the one we used in our previous study (defined as CWAAP-A) . A list Male and female F344 rats at 6–7 weeks old were purchased from Charles River Laboratories Japan, Inc. . The rats were housed in an air-conditioned room under a 12 h light/12 h dark  photoperiod, and fed a general diet  and tap water ad libitum. After approximately 1–2 weeks of quarantine and acclimation, they were exposed to CWAAP-A. All animal experiments were approved by the Animal Experiment Committee of the Japan Bioassay Research Center.3 for 6 h per day, 5 days per week, for 13 weeks. Histopathological analysis of the tissues and biochemical analysis of lung tissue, BALF, and plasma was carried out to assess the pulmonary toxicity of CWAAP. In a separate set of experiments, the contribution of alveolar macrophage or neutrophil depletion to the initial inflammation caused by CWAAP-A inhalation was examined. Alveolar macrophages and neutrophils were depleted using intratracheal instillation of clodronate liposome and intravenous injection of PMN-neutralizing antibody and the rats were exposed to CWAAP aerosols at 10 mg/m3 for 6 h per day, for 2 days. Histopathological analysis of the tissues and biochemical analysis of lung tissue, BALF, and plasma was carried out to assess pulmonary toxicity.In the primary experiment, rats were exposed to CWAAP-A aerosols at 0.3, 1, 3 and 10 mg/mThe generation of CWAAP-A aerosol into the inhalation chamber was performed using our established method (cyclone sieve method) , 45 with3) and the particle concentration data (particles/m3) obtained from the OPC, the particle concentration for each group during the exposure period was converted to a mass concentration  were weighed for each target concentration at 1, 3, and 5 h after the start of the exposure. Using the mass per particle  calculated using the measured mass results  . The sod13 weeks . Also, aweeks [3 . Based o3 . The s3 would cause only weak lung damage. Male F344 rats (8 weeks old) were divided into 6 groups of 4 rats each. Rats (8 weeks old) were administered a single intratracheal dose of clodronate liposome or control liposome  at a dose of 1 ml/kg. The next day, PMN-neutralizing antibody  or normal rabbit serum  was administered intravenously at a dose of 0.5 ml/kg .To investigate the contribution of alveolar macrophage or neutrophil depletion to the initial inflammation caused by CWAAP-A inhalation, we examined whether prior depletion of alveolar macrophages or neutrophils can suppress the CWAAP-induced lung inflammation. Alveolar macrophages and neutrophils were depleted using intratracheal instillation of clodronate liposome  and intrg) for 10 min at 4 °C, and the activity of LDH, ALP and γ-GTP and the phospholipid level in the supernatant was measured using an automatic analyzer .For the 13-week inhalation study, the right bronchus was tied with a thread, and the left lung was lavaged. 4–7 ml of saline was injected into the lung through the trachea, in and out twice, and collected as BALF. In the macrophage or neutrophil depletion experiment, 6.2 ml of saline was injected into all lungs through the trachea, in and out twice, and collected as BALF. The total cell numbers in the BALF were counted using an automatic cell analyzer . Thin-layer cell populations on glass slides were prepared using Cytospin 4 . After May-Grunwald-Giemsa staining, differential white blood cell count was conducted by visual observation. BALF was centrifuged at 1960 rpm (800×g) for 20 min, and the supernatant was analyzed with an automated analyzer (Hitachi High-Tech).For hematological examination, blood samples were analyzed with an automated hematology analyzer (Sysmex). For biochemical tests, the blood was centrifuged at 3000 rpm . In this assay, the BALF was diluted 500- or 1000-fold, and plasma was diluted 25-fold with the assay diluent included in the kit. BALF concentrations of TGFβ1 and TGFβ2 were measured by Human/Mouse/Rat/Porcine/Canine TGF-beta 1 Quantikine ELISA Kit (R&D Systems) and Mouse/Rat/Canine/Porcine TGF-beta 2 Quantikine ELISA Kit (R&D Systems). For the TGFβ2 assay, BALF was diluted threefold with the sample diluent included in the kit. The absorbance at 450 nm was measured using a microplate reader . For TGFβ1 and TGFβ2 assays, the absorbance at 570 nm was also measured and subtracted as a background signal.g for 5 min. 10 μl of the supernatant was transferred to a 96-well plate and dried at 65 °C in a hybridization incubator . The hydroxyproline signal (absorbance at 560 nm) was measured using a microplate reader  according to the kit instructions.The lung content of hydroxyproline, a major component of collagen fibers, was determined using a hydroxyproline assay kit (Perchlorate-Free) . Small pieces of lung (approximately 30 mg) were homogenized in 10 volumes of distilled water using a portable power homogenizer . The resulting homogenates were mixed with an equal volume of 10 M NaOH, and incubated at 120 °C for 1 h. After neutralization by addition of 10 M HCl, the mixture was centrifuged at 10,000×Serial tissue sections were cut from paraffin-embedded lung specimens, and the first Section (2-μm thick) was stained with H&E for histological examination and the remaining sections were used for immunohistochemcal analysis. The histopathological findings for lung and mediastinal lymph node in this study were determined after multifaceted discussions between certified pathologists from the Japanese Society of Toxicologic Pathology and certified medical pathologists from the Japanese Society of Pathology, based on the definitions of terms adopted by International Harmonization of Nomenclature and Diagnostic Criteria for Lesions in Rats and Mice (INHAND) . PatholoDetails of the method have been described previously . Briefly2O after color detection, the sections were treated with citrate buffer at 98 °C for 30 min before reacting with the next primary antibody to denature the antibodies bound on the sections used. The second antibody was then reacted in the same way as for the initial staining procedure. Histogreen chromogen  was used for the second coloration, followed by hematoxylin staining for 30–45 s as a contrast stain. The sections were dehydrated and sealed. For immunofluorescence staining, all primary antibodies used were made into a cocktail for the staining step and used simultaneously. The sections were then incubated with secondary antibodies conjugated with Alexa Fluor 594. Sections were then thoroughly washed and incubated with secondary antibody conjugated with Alexa Fluor 488. After the fluorescence-labeled secondary antibody reactions, the sections were shielded with DAPI-containing encapsulant and used for imaging. The sections were observed under an optical microscope ECLIPSE Ni  or BZ-X810 .Details of the multiple staining method have been described previously . Brieflyp < 0.025 for William's test and p < 0.05 in the other cases.Except in the case of incidence and integrity of histopathological lesions, the data comparisons among multiple groups were performed by one-way analysis of variance with a post-hoc test of William’s test or Tukey’s multiple comparison test using Pharmaco Basic Ver. 16.1  or GraphPad Prism 5 , respectively. The incidences and integrity of lesions were analyzed by chi-square test using GraphPad Prism 5 . Statistical significance was set at Additional file 1: Fig. S1. The whole body inhalation exposure system using in this study. The whole body inhalation exposure system (A), the averaged CWAAP-A concentration in the chamber per each exposure day (B), cumulative frequency distribution graphs with logarithmic probability (C) and representative scanning electron microscope (SEM) images of the CWAAP-A particles in the chambers (D). Scale bar: 20 μm (panel D).Additional file 2: Fig. S2. Representative macroscopic photographs of cross-sections of rat lungs. The left and right sides represent males and females, respectively. conc concentration, expo exposure, rec recovery.Additional file 3: Fig. S3. Visualization of normal lymphatic vessels in the rat lung using Prospero homeobox protein-1 (Prox1)-enhanced green fluorescent protein (EGFP) transgenic rats [A) Lung sections from Prox1-EGFP transgenic rats were double-stained with GFP and α-smooth muscle actin (αSMA) and counterstained with hematoxylin. Lymphatic vessels (red arrows) run around the veins and arteries. Blue arrows represent neuroendocrine cells. (B) A graphical image of lymphatic vessels running (green lines) through the lungs.nic rats . (A) LunAdditional file 4: Fig. S4. Co-localization of vascular endothelial growth factor receptor 3 (VEGFR3) with lymphatic vessels in rat lungs. Lung sections from Prox1-EGFP transgenic rats were stained with three commercially available lymphatic markers, VEGFR3, lymphatic vessel endothelial hyaluronan receptor 1 (Lyve-1), and podoplanin (RT1-40), with co-staining of GFP and 4',6-diamidino-2-phenylindole . Only VEGFR3 co-localized almost completely with GFP in the rat lungs, including in the peripheral regions. Br Bronchus and Vn Venule.Additional file 5: Fig. S5. The effect of pretreatment of the CWAAP-A-exposed rats with clodronate liposomes (to deplete macrophages) or polymorphonuclear leukocytes (PMN)-neutralizing antibodies (to deplete neutrophils) on BALF markers and cell populations. The lactate dehydrogenase (LDH) activity (A) and surfactant protein-D (SP-D) in the BALF B, and the number of lymphocytes (C), eosinophils (D) and basophils € in the plasma are shown. Tukey’s multiple comparison test: *p < 0.05, **p < 0.01, and ***p < 0.001, pairs indicated.Additional file 6: Fig. S6. Design of animal experimental protocols in this research. 13-week inhalation exposure study (A), and macrophages or neutrophils depletion study (B).Additional file 7: Table S1. Retention and deposition of CWAAP-A in the lungs after 13-week inhalation exposure.Additional file 8: Table S2. Benchmark doses (BMD) for histopathological findings calculated using EPA's Benchmark Dose Software (BMDS 3.2). The model was chosen to have the lowest Akaike information criteria (AIC) score. The goodness of fit between the dose-response curve based on the statistical model and the measured data is Chi-square test . BMDL benchmark dose lower confidence limit.Additional file 9: Table S3. The summary of the effect of inhalation exposure to CWAAP-A, multi-walled carbon nanotube (MWCNT)-7, and titanium dioxide (TiO2) on LDH activity. NP nanoparticles.Additional file 10: Table S4. List of primary antibodies used in this study.Additional file 11: Extended file 1. Blood-hematologic data observed in the 13-week inhalation exposure study.Additional file 12: Extended file 2. Blood-biochemistry data observed in the 13-week inhalation exposure study.Additional file 13: Extended file 3. Absolute/relative organ weights observed in the 13-week inhalation exposure study.Additional file 14: Extended file 4. Histopathological findings excluding lung and mediastinal lymph node observed in the 13-week inhalation exposure study.Additional file 15: Extended file 5. All summary data of Williams test results observed in the 13-week inhalation exposure study.


Diet management or caloric restriction for diabetes mellitus patients is essential in order to reduce the disease’s burden. Mathematical programming problems can help in this regard; they have a central role in optimal diet management and in the nutritional balance of food recipes. The present study employed linear optimization models such as linear, pre-emptive, and non-pre-emptive goal programming problems  to minimize the deviations of over and under achievements of specific nutrients for optimal selection of food menus with various energy  levels. Sixty-two food recipes are considered, all selected because of being commonly available for the Indian population and developed dietary intake for meal planning through optimization models. The results suggest that a variety of Indian food recipes with low glycemic values can be chosen to assist the varying glucose levels (>200 mg/dL) of Indian diabetes patients. Nutrition is a critical part of health and development. Obviously, better nutrition enhances a strong immune system, lowers the risk of non-communicable diseases, and increases longevity . As an iAs an undeniable fact, DM is reaching potentially epidemic proportions in India. The level of morbidity and mortality due to diabetes and its complications is enormous. Many factors influence the prevalence of disease throughout a country . The oriA three-fold mechanism of proper diet, insulin intervention and physical activity for management of diabetes and slowing down the prevalence of the disease is need of the hour . The priIn this nutritional framework, linear programming problems play a vital role in preparing optimized diet plans with satisfying nutrient requirements. Many researchers have devised various linear and goal programming problems in order to optimize food recipes for global countries in order to provide adequate nutrients for the population. Beginning with the study, to achieve nutritional balance in selected diets by considering 150 raw food materials to satisfy Thais’ daily nutritional requirements with complex inter-relationships of constraints with GP . An effiIn modern references, some authors proposed a two-stage linear programming model for low-cost healthy diets for Malay households. In Stage-1, the model was formulated to satisfy various nutrient requirements for the pre-determined age-gender groups and Stage-2 focused on optimizing diet plans for the whole household with minimum cost daily diet plans . In addiAnother study proposed a goal programming model for optimal dietary variations for diabetes patients with minimal attainment of sufficient nutrients in Indonesia . Other rAll of the studies cited above have focused on optimizing diet plans for both healthy people and those suffering from specific diseases. Limited works have been done on diet plans for diabetes patients based on glucose levels. In the present study, the motivation is to develop six optimized diet plans for diabetes patients with different energy levels . It mainly focuses on optimizing diet plans with varied energy levels  by satisfying the nutrient requirements of the limited menu recipes for diabetes management in India.The nutritional information and dietary intake allowances of nutrients for recipes are collected from the “Nutrify India Now” application (app) authorized by the National Institute of Nutrition (NIN) under the Indian Council for Medical Research (ICMR), India. The food recipes considered based on dietary reference intakes with low glycemic index ,27,28 arThe initial model is derived from the linear programming problem (LPP), with energy  serving as an objective function and nutrients serving as constraints. Accordingly, to minimize the deviations (over-achievement and under-achievement) of various nutrients from the intended priorities, the preemptive goal programming (PGP) problem was proposed for the achievement of nutrient-oriented goals. Finally, the non-preemptive goal programming (NPGP) model included weights with priorities of nutrient goals to minimize the deviations under the method of weight normalization.The mathematical model of the problem is written as a linear program, with the objective function corresponding to the total number of energy calories. There are constraints that need to be satisfied regarding nutrient amounts as per various diet plans. Decision variables are based on the type of recipes considered for diabetes intake under study. Thus, we consider:jR = energy values for j number of recipes of various menus.Em = number of nutrients considered in the study (m = 14).n = number of recipes as per diabetes diet plans.ith nutrient from jth recipe.ith nutrient intake.ith nutrient intake.Pre-emptive goal programming is a technique which provides a more systematic approach to the problem of balancing the supply of nutrients in a selection of recipes. An objective function is considered to be minimizing deviations from conferring on nutrient priorities. The system and goal constraints (nutrient information in each diet) are equalized to the required limits of nutrient values and the recipes are taken as decision variables. This approach ensures optimum nutritional balance with minimal recipes by satisfying all the constraints.Priority 1 (P1): Optimizing Energy LevelsGoal-1: Minimizing under-achievement and over-achievement of energy .Priority 2 (P2): Optimizing the intake of Carbohydrate, Protein, Fat and Saturated FatGoal-2: Minimizing under-achievement and over-achievement of carbohydrate (g).Goal-3: Minimizing under-achievement and over-achievement of protein (g).Goal-4: Minimizing under-achievement and over-achievement of fat (g).Goal-5: Minimizing under-achievement and over-achievement of saturated fat (g).2 and Vitamin B6Priority 3 (P3): Optimizing the intake of Fiber, Vitamin BGoal-6: Minimizing under-achievement and over-achievement of fiber (g).2 (mg).Goal-7: Minimizing under-achievement and over-achievement of vitamin B6 (mg).Goal-8: Minimizing under-achievement and over-achievement of vitamin BPriority 4 (P4): Optimizing the intake of Iron, Zinc and CalciumGoal-9: Minimizing under-achievement and over-achievement of iron (mg).Goal 10: Minimizing under-achievement and over-achievement of zinc (mg).Goal 11: Minimizing under-achievement and over-achievement of calcium (mg).Priority 5 (P5): Optimizing the intake of Potassium, Sodium and CarotenoidsGoal 12: Minimizing under-achievement and over-achievement of potassium (mg).Goal 13: Minimize under-achievement and over-achievement of sodium (mg).Goal 14: Minimize under-achievement and over-achievement of carotenoids (mg).The mathematical formulation of the PGP is given by:jR = energy values for j number of recipes of various menus.Em = number of nutrients considered in the study (m = 14).n = number of recipes as per diabetes diet plans.ith nutrient from jth recipe.ith nutrient intake.Pi = specified priorities of nutrients.In NPGP, minimizing the ratio of sum of deviations of nutrient goals with priorities and weights of required nutrient levels by percentage normalization method. The coefficients for deviational variables in the objective function reflect the importance and desirability of the deviations from various nutrient goals. The constraints and decision variable information are identical to those found in PGP. Thus, we consider:jR = energy values for j number of recipes of various menus.Em = number of nutrients considered in the study (m = 14).n = number of recipes as per diabetes diet plans.ith nutrient from jth recipe.ith nutrient intake.Pi = specified priorities of nutrients.This section explores the solutions of six optimized diets for satisfying the nutrient requirements through LPP, PGP and NPGP which are represented in Overall, the results show diet plans with optimal food recipes for satisfying the nutritional requirements of Menus 1–6 with five-time intervals  for the total energy levels such as 2199.9, 2310.8, 1785.7, 2606, 2196.2, and 2616.8 calories which are optimized by LPP, PGP and NPGP as shown in Nutritional recommendations for optimal disease management are challenging to implement in reality. Patients with DM are already overweight at diagnosis and gain more weight while taking oral medications and/or insulin. DM individuals may also increase energy intake through possible overtreatment of medication-induced hypoglycemia . When taThe study mainly focused on developing pre-emptive and non-pre-emptive goal programming problems in the optimal selection of menu planning for diabetes patients in India. It has explored various menus with different energy levels that satisfy sufficient nutrient requirements for the glucose levels of individuals (>200 mg/dL). The goal programming methods optimized the energy levels  by considering maximum allocation of food recipe quantities and minimized the overall deviations of over and under-achievements of nutrient goals. Efforts are also made to ensure food recipes that contain a low percentage of carbohydrates, fats, and satisfy all of the other required nutrients for diabetes patients, which plays an important role in menu selection. The computed optimal menus are very helpful for varying glucose levels of diabetes patients as they are within the suggested diabetic intake range. The study helps to select food recipes that are widely available to the extensive public and to reduce the economic burden of the Indian population.The optimal selection of food recipes is limited to normal diabetes patients with varying glucose levels (>200 mg/dL). The study can be extended to select optimal food recipes for specific complications such as gestational diabetes, retinopathy, nephropathy and diabetic foot ulcers, etc., and also other diseases  through the proposed optimization models. Our study is limited to employing pre-emptive and non-pre-emptive goal programming problems, which can be improved by utilizing broader areas in optimization techniques for yielding more accurate results to the disease specific. The future scope of GP models can be extended by incorporating various types of normalization procedures, introducing utility theories and solution analysis to develop precise diet plans for disease specific.