We present a case of a rare complication of negative-pressure wound therapy (NPWT) wherein there was fixation of a meshed split-thickness skin graft (STSG), suspected as a failure by hypergranulation. However, the meshed STSG was integrated within 5 days of NPWT cessation.A 22-year-old Asian man sustained 25% total-body-surface-area flame burns. After multiple operations, an ulcer was present on the proximal left thigh. On day 37 after admission, the ulcer was debrided, and an 11/1000-inch (0.28 mm) skin graft was taken from the ipsilateral thigh and meshed, using a 1:1.5 ratio. NPWT was applied to the donor and recipient sites with a continuous negative pressure of 125 mmHg. On day 43, NPWT was discontinued. The skin grafts were not identified on the surface of the granulation tissue. With topical ointment therapy, rapid epithelialization of the ulcer was observed as the granulation tissue regressed. On day 48, the recipient site had completely epithelialized.The hypergranulation tissue rarely covered the meshed STSGs when the grafts were fixed by NPWT. In that case, immediate debridement should be avoided, and conservative treatment should be initiated. Several studies have reported the use of negative-pressure wound therapy (NPWT) for the fixation of split-thickness skin grafts (STSGs) , 2 and i® Ag BURN: ConvaTec, Princeton, NJ, USA) for 6 days, petroleum gel  for 6 days, a hydrocortisone-bacterial culture suspension mixture ointment  for 3 days, and silicone-faced wound dressing mesh  for 3 days, the ulcer was covered with healthy granulation tissue  skin graft was taken from the ipsilateral thigh and meshed, using a 1:1.5 ratio. A slightly larger skin graft was taken, and the excess skin graft was immediately regrafted to the donor site. The regrafted skin was meshed using a 1:1.5 ratio, the same as the recipient site. NPWT  was then applied to both the donor and recipient sites with a continuous negative pressure of 125 mmHg. A silicone-faced wound dressing mesh (SI-mesh) was inserted between the skin graft and polyurethane foam dressing  to avoid damage to the skin graft (Fig. On day 43 after admission, the polyurethane foam dressing was removed from both the donor and recipient sites. Although the regrafted skin at the donor site was taken completely, the skin graft was not found at the recipient site, and the entire area was covered with granulation tissue Fig. : day 48.In this case, the meshed STSG was not found on the wound surface and was suspected to have failed. On the day of NPWT cessation, the granulation tissue had firmly covered the wound surface and could not be removed. Conservative treatment with ointment reduced the size of the granulation tissue, and the epithelized areas expanded rapidly. These findings suggest that the hypergranulation tissue had overgrown and covered the meshed skin graft. Although protrusion of the hypergranulation tissue through the mesh interstices of the skin graft is not uncommon when NPWT is used for the fixation of meshed skin grafts , to the The possible reason that the skin graft was covered by the hypergranulation tissue is that the rate of granulation stimulated by NPWT was faster than the rate of closure of the meshed STSG interstices Fig. . The graIn this case, on the day of NPWT cessation, the hypergranulation tissue was raised and covered almost the entire wound surface. It was difficult to scrape the granulation tissue, and there was no evidence of the skin graft under the granulation tissue at that time. Debridement in this condition is highly invasive and involves a high risk of skin graft damage. Rapid epithelialization was completed 5 days after NPWT cessation without any surgical interventions. If immediate debridement and skin grafting had been performed in this case, it would have resulted in the loss of the initially taken skin graft, which would have caused an unnecessary complication for this patient. Once surgeons determine that the appearance of the wound is due to the hypergranulation tissue over the integrated grafts, topical steroid dressings would be a good treatment choice ; a hydroIn conclusion, hypergranulation over a meshed STSG is a rare complication when the graft is fixed by NPWT. It is important to note that immediate debridement should be avoided, and conservative treatment should be initiated because the graft may be integrated under the granulation tissue.


Quantitative calculation and evaluation of seismic damage are very important for structural safety, performance-based structural analysis, and seismic reinforcement. However, the relevant research results for precast concrete structures are extremely limited. In this paper, the seismic damage evaluation of beam-column joints in monolithic precast concrete frames was studied through cyclic loading tests and damage index calculation. The seismic damage process, load-displacement relationship, stiffness degradation, and the influence of axial compression ratio were analyzed, then the damage indexes were calculated and analyzed, and the quantitative evaluation of joint damage was conducted last. The results show that the connection seams can significantly affect the mechanical properties of precast joints, easily causing damage concentration, resulting in a lower bearing capacity and faster stiffness degradation compared with a cast-in-situ joint. A larger axial compression ratio can bring higher bearing capacity for the precast joints, and the peak load can be increased by 42.9% when the axial compression ratio is increased from 0.2 to 0.4. In contrast, the stiffness degradation will be accelerated with the increase in the axial compression ratio. From yield load to peak load, the stiffness of the precast joint with the largest axial compression ratio decreases by 46.0%, while the joint with the smallest axial compression ratio is only 36.4%. The damage index model adopted in this paper can accurately reflect the damage characteristics of the precast joints. The presented damage states based on the damage index calculation can accurately reflect the joint’s damage characteristics according to different stages. The paper realizes the quantitative damage evaluation for this kind of joint and provides a theoretical basis and method for further studies. Structures are prone to damage under seismic action. Accurate evaluation of seismic damage can provide a reliable basis for structural identification and repair and has important research value. The damage process of the structure under an earthquake is essentially cumulative damage. Many scholars have studied the damage to concrete structures. According to the actual seismic damage results, the seismic damage forms are divided into the first-passage failure and the cumulative damage failure, and a single-parameter model and a two-parameter model are proposed to evaluate the damage degree of structural members. Among them, the single parameter model mainly adopts one parameter index, such as deformation ,2, ductiA precast concrete structure is a concrete structure assembled by precast concrete members through a reliable connection such as post-cast concrete, sleeve connection, bolt connection, etc. Compared with the traditional cast-in-place concrete structure, it mainly has the advantages of high production efficiency, short construction period, good product quality, small environmental impact, sustainable development, and less labor consumption . The monMuch work has been performed on the mechanical properties of precast concrete beam-column joints. Liu et al.  studied It can be seen that although there have been a lot of research results on the seismic performance of precast concrete joints, the relevant research results on the quantitative calculation and evaluation of seismic damage of precast concrete structures are extremely limited, while the relevant results of cast-in-situ concrete structures cannot be applied directly due to the different damage characteristics. However, quantitative calculation and evaluation of seismic damage are very important for structural safety, performance-based structural analysis, and seismic reinforcement. Therefore, it is very necessary to carry out seismic damage research on precast concrete structures. In this paper, for beam-column joints of monolithic precast frame structures that are widely used in China, the author attempts to use the damage index model to calculate the damage of such joints and carry out damage evaluation according to the damage index. The seismic damage process, load-displacement relationship, and stiffness degradation of monolithic precast concrete beam-column joints are studied by cyclic loading test, and the effect of axial compression ratio is analyzed as well. This paper carried out a meaningful exploration for the accurate calculation and quantitative evaluation of seismic damage of monolithic precast concrete frame structures.The test materials used in this study are mainly concrete and steel bars. According to the Chinese code GB 50010-2010: Code for design of concrete structures, the strength grade of concrete is C30, and the measured material mechanical properties parameters are shown in 12, and the reinforcement ratio was 1.63%; the longitudinal reinforcements of the beams are all 612, and the reinforcement ratio is 2.14%; the stirrup is 8 mm in diameter, and 100 mm in spacing, but in beam end encryption area is 50 mm in spacing. The size and reinforcement of the precast joint specimens are shown in In order to accurately evaluate the damage to the beam-column joint of the precast concrete frame under the action of earthquake, the damage characteristics and mechanical properties of the beam-column joint specimen under cyclic loading were studied through quasi-static tests. Four 1:2 scale specimens of concrete beam-column joints were designed for the tests according to the Chinese codes JGJ 1-2014: Technical specification for precast concrete structures  and GB 5The fabrication of the precast specimens was carried out through the following steps: firstly, the precast parts, including the left and right beams and the upper and lower columns, were fabricated. In order to strengthen the shear resistance of the seam surface, shear keyways were set on the left and right beam ends, and the upper and lower column ends were chiseled. Then, the reserved steel bars of left and right beam were welded together, and the reserved steel bars of upper and lower column were connected by sleeve connectors. Finally, the post-cast concrete was poured to fill the core area. Taking into account the important influence of curing conditions on the mechanical properties and durability of concrete materials , the maiAccording to different loading points, there are usually two kinds of quasi-static loading modes for beam-column joint; one is loading at beam ends, the other is loading at column top end . In thisy was set to be the increment for each cycle and repeated 3 times after the specimen yielded. When the lateral load decreased to 85% of the peak load, it meant the test joint was destroyed, and the loading process finished. The loading process is shown in Displacement loading was used in this test. Before the lateral loading, the vertical load provided by the oil-pressure jack was applied on the column top and was kept to be constant. When applying lateral loads, the electrohydraulic servo actuator was used to provide the lateral cyclic loads on the column top end, and the loading was controlled by displacement. The loading increment for each cycle was set to be 3 mm before the specimen yielded, and the cycle was repeated only once. Then the yield displacement ΔUnder low cyclic loading, the failure process and damage development mode of the precast joint specimens are basically the same. Specimen ZJ2, with an axial compression ratio of 0.3, is taken as an example and compared with the cast-in-situ specimen ZJ0 to illustrate the seismic damage evolution process of monolithic precast frame joints. According to the test, the seismic damage of monolithic precast frame joints can be roughly divided into five stages. The failure mode of the specimen is shown in (1)y), small cracks appear in the concrete at the beam end of specimen ZJ0 and specimen ZJ2 and tend to be stable. The strain of steel bars in the core area of the beam, column, and the joint is small and in the elastic stage. At this time, the deformation of the beam and column is very small, and the strength and stiffness of the specimens have no obvious change.Non-damage stage: At the initial stage of loading (the displacement is less than Δ(2)y, the fine bending cracks of concrete at the beam end of ZJ0 gradually develop into long oblique cracks. The growth rate of stress and strain of the steel bar in the core area of specimen ZJ2 is accelerated, and the concrete strain in the plastic hinge area of the beams increases sharply, resulting in microcracks, and several equal spacing vertical cracks appear one after another. The cracks of both joints begin at the beam end, which is consistent with the damage characteristics of a strong column and weak beam joints.Initial damage stage: When the cyclic loading displacement is continued to Δ(3)y cyclic loading. Similarly, the stress and strain of the steel bar in the core area of specimen ZJ2 continued to increase, and the cracks in the plastic hinge area of the beams extended to the joint core area and developed from vertical cracks to oblique cracks. When the loading is continued to 3Δy, the diagonal cracks of specimen ZJ0 develop to be the main cracks through the core area, and new diagonal cracks appear at the beam end. As to specimen ZJ2, new cracks began to appear at the far end of the left and right beams, old cracks continued to extend, and the width gradually increased. At the same time, the inclined cross cracks appear in the core area of the joint, and then the inclined cracks divide the concrete in the core area into several diamond blocks and extend to the lower column.Mixed damage development stage: multiple diagonal cracks appeared in the core area of specimen ZJ0 under 2Δ(4)y, the main crack of specimen ZJ0 widens, and the cracks in the core area and beam end increase. As to specimen ZJ2, the longitudinal reinforcement in the core area is close to yielding, the cross diagonal crack in the core area extends to the end of the lower column, and the concrete peels in a large area. Subsequently, there is a separation between the beam end, the column end, and the core area of the joint.Stable damage development stage: When the cyclic loading is continued to 4Δ(5)y and 6Δy cycles, the concrete at the core area and beam end of specimen ZJ0 fall off in a large area, and the bearing capacity decreases suddenly, and finally, the concrete is crushed and destroyed. As to specimen ZJ2, the longitudinal reinforcement in the core area entered the strengthening stage, and the stirrup gradually yielded. The cracks at the connection seams between the left and right beams and the upper column continue to extend, but the crack width is small, the crack width at the seams with the lower column gradually increases, and the concrete continues to peel off, and the damage continues to grow. Finally, a through-and-wide crack is formed Before the specimen yields, the initial horizontal load is small, the hysteresis loop is a spike-type, the enclosure area is small, and the skeleton curve changes linearly. At this time, the specimen damage is small. With the increase in the hysteretic curve bending, the hysteretic loop area also increases. The specimen enters the elastoplastic stage, and the concrete cracks appear in the closure and the opening phenomenon and gradually appear obvious damage. The skeleton curves show that specimen ZJ1 , specimen ZJ2 , and specimen ZJ3  yield 25.71 kN, 42.33 kN, and 46.64 kN, and the corresponding yielding displacements are 10.2 mm, 10.53 mm and 10.84 mm separately. The yielding load increases with the axial compression ratio, and the yielding displacement is similar.(2)After the specimen yields, as the cyclic load increases continuously, both the slopes of the hysteresis curve and skeleton curve decrease. Due to the slip of the steel bar, the stiffness of the specimen degenerates, and the hysteresis curve appears to be a pinching phenomenon, and there is an obvious yield point on the skeleton curve. As concrete cracks continue to expand, the specimen damage begins to increase. The larger the axial compression ratio is, the larger the initial secant modulus and the more saturated the hysteresis loop. The skeleton curves show that the peak loads of specimen ZJ1 , specimen ZJ2 , and specimen ZJ3  reach 50.04 kN, 65.11 kN, and 71.50 kN, respectively, and the corresponding peak displacements are 54.21 mm, 43.83 mm and 36.10 mm. Compared with specimen ZJ1, the ultimate bearing capacity of specimen ZJ2 and specimen ZJ3 are increased by 30.1% and 42.9%. This is because the pressure applied to the core area of the joint can improve the strength of the concrete in the core area and can also provide a good constraint on the longitudinal reinforcement, thereby improving the bearing capacity of the joint . Thus, t(3)After the specimen reaches the peak load, the hysteretic loop area increases continuously with the increase in the loading displacement, showing a good capacity for dissipating energy. Under the same cyclic load, the hysteresis loop of the previous loading is larger than that of the latter, and the maximum load in the latter loading is also reduced, indicating that the specimen has strength degradation and energy dissipation capacity reduction. The sliding section of the skeletal curve is steeper due to the reduced deformation capacity. The damage to the specimen continues to accumulate until the specimen is destroyed.From the above pictures, it can be concluded that the load-displacement curve of a precast monolithic joint has the following characteristics:jK is commonly used to characterize the stiffness degradation of components, and its expression is shown in Equation (1) [jiP means the maximum load applied on the column top in the ith  cycle under the jth loading step; Δji means the displacement corresponding to jiP.Stiffness degradation refers to the characteristic that the stiffness of a structure or component decreases with the increase in cycle number under the condition of constant displacement amplitude. This is because, with the increasing times of load cycles, the damage to the structure continues to accumulate, resulting in the continuous degradation of structural stiffness. Excessive stiffness degradation can significantly reduce the mechanical properties of the structure, which can cause great structure deformation under even a small load. Loop stiffness tion (1) .(1)Kj=∑y (Displacement corresponding to the peak load of ZJ2), the stiffness degradation rate of ZJ2 is significantly faster than that of ZJ0, which is due to the existence of seam surfaces between the precast components, and the damage of the seam surfaces has accumulated to a certain extent, resulting in a faster decrease in the overall stiffness of the precast specimens than the cast-in-situ specimen.(1)The larger the axial compression ratio, the greater the initial stiffness of the specimen. When loading displacement reaches the yield displacement, the stiffness of specimens ZJ1, ZJ2, and ZJ3 are 2.54 kN/mm, 3.90 kN/mm, and 4.83 kN/mm, respectively, and the stiffness of ZJ3  is about 1.9 times higher than that of ZJ1. This is also due to the beneficial effect of axial pressure on the strength of concrete in the core area and longitudinal reinforcement constraints.(2)After the precast specimens yield, the stiffness decreases rapidly, and the larger the axial compression ratio, the faster the stiffness degradation rate. As the loading displacement continues to increase, the stiffness degradation tends to be gentle, but the specimen with a larger axial compression ratio still has higher stiffness. For specimens with faster stiffness degradation, the load increases more slowly under the same loading displacement.(3)When the stiffness of specimens ZJ1, ZJ2, and ZJ3 is 0.92 kN/mm, 1.49 kN/mm, and 1.98 kN/mm, respectively, the load reaches the peak value, and the corresponding stiffness of the specimens at this time decreases 36.4%, 37.1% and 46.0% of the yield stiffness, respectively. Afterward, the stiffness degradation of the three specimens tends to be gentle, and the stiffness of specimen ZJ1 decreases more slowly than that of specimens ZJ2 and ZJ3. The above phenomenon shows that the increase in the axial compression ratio will aggravate the development of damage in the core area and the connection surfaces, resulting in a more rapid decrease in the stiffness of the joint specimen.Comparing the stiffness degradation of the three precast joints ZJ1, ZJ2, and ZJ3 with different axial compression ratios, we can see that:D can be calculated as Equation (2):δm,i is the maximum displacement of the ith loading cycle, and δy and δf mean the yield displacement and the ultimate displacement under monotonic load. Moreover, hE is accumulated hysteretic energy under cyclic load, and yF is the yield force. The value of β is the hysteretic energy factor; when β = 0.05, the modified Park–Ang model can better reflect the damage process of beam-column joints [Based on the damage test results, Kunnath  proposedn joints .y, 2Δy, 3Δy … are taken as the abscissa, and the corresponding damage index D1, D2, D3, … are taken as the ordinate. Through the stiffness degradation analysis, it can be seen that the damage development of the cast-in-situ specimen KJ0 and the precast specimen KJ2 are basically the same. Therefore, only the damage of the three precast joint specimens is calculated and analyzed here. Based on Equation (2), the calculated damage index values of the precast specimens are shown in The hysteretic energy can be taken as the hysteresis loop area of each loading step, and the lateral displacement of the top column corresponding to the applied load decreasing to 85% peak load is assumed to be the ultimate displacement for the joint specimen. Based on the test results, the loading displacement of each step 1Δy, the damage indexes of ZJ1, ZJ2, and ZJ3 are very small, which are only 0.016, 0.021, and 0.033, respectively. At this time, the corresponding experimental phenomenon is that there are small cracks at the beam end, and the reinforcement strain is small. The specimen is in the elastic stage and is basically intact.It can be seen from y, the damage indexes of ZJ1, ZJ2, and ZJ3 are 0.128, 0.148, and 0.171, respectively. At this time, the corresponding experimental phenomenon is that small cracks appear in the plastic hinge zone of the beam, and the small cracks at the end of the beam develop into long oblique cracks. The stiffness degradation of the specimen is obvious, and the specimen is in a slight damage stage.When the loading displacement reaches 2ΔWhen the loading displacement reaches 3Δy, the damage index of ZJ3 reaches 0.375, which is 1.27 times of ZJ2 and 1.5 times of ZJ1, indicating that the axial pressure has a significant effect on the damage development. At this time, the corresponding experimental phenomenon is that there are many vertical and oblique cracks in the core area of the joint, and the cracks between the beam-column connection interface continue to expand, and the specimen is in the middle damage stage.With the continued increase in loading displacement, the slope of the damage evolution curve becomes larger, and the damage index begins to accelerate growth, especially for specimen ZJ3, with the largest axial compression ratio. The damage index of ZJ3 at 4Δy reaches 1.64 times the index at 3Δy. In addition, ZJ3 and ZJ2 reached the peak load before loading to 4Δy, and the ZJ1 specimen reached its peak load shortly after loading to 5Δy. In the loading displacement stage, from 3Δy to 5Δy, the maximum damage index of the specimen reaches 0.79 (ZJ3). The corresponding experimental phenomenon is that the main cracks of the specimen become wider, the longitudinal reinforcement in the core area is close to yielding, and the concrete is spalling in a large area. The contact between the beam end, column end, and the core area of the joint is separated. The stiffness of the specimen is reduced to less than half of the stiffness when the yield displacement is reached and the specimen is in the severe damage stage.As the loading displacement continues to increase, the damage indexes of the three specimens are all above 0.9. The concrete in the core area is crushed, and the stirrup yields, forming a wide diagonal crack. The beam-column joint loses its bearing capacity, and it is in a complete failure stage.The above studies show that the damage index model adopted in this paper can be used for the damage calculation of the monolithic precast joints and can accurately reflect the damage characteristics.In order to distinguish different degrees of seismic damage, damage states are often used according to the damage index calculation and the damage characteristics. On the basis of the test results and the index calculation results, the damage process of the precast beam-column joints can be divided into five stages: little or no damage, a few damages, damages developing quickly, damages developing stably, serious damages, and the joint is destroyed. Therefore, the corresponding damage states are basically intact, slight damage, moderate damage, severe damage, and complete failure. Referring to the existing literature  and baseIt can be seen from The damage process of precast joints can be divided into five stages, and the connection seam in precast joints can significantly affect damage development. Compared with the shear failure of the core area in the cast-in-situ specimen, the failure mode of the precast joint is mainly the connection seam failure. While for the precast joints, the axial compression ratio has no obvious effect on the failure modes.Compared with the cast-in-situ joint, the pinching phenomenon of the monolithic precast joint is improved a little, but the ultimate displacement is smaller, and the peak load is only 92% of the cast-in-situ one. As for precast joints, a certain amount of axial pressure can effectively improve the bearing capacity. Both the yielding load and peak load of the precast joints increase obviously with the increase in axial compression ratio. Compared with specimen ZJ1, the peak load of specimens ZJ2 and ZJ3 increased by 30.1% and 42.9%, respectively.The stiffness degradation of precast joints is basically consistent with that of cast-in-situ joints, but when the loading reaches a certain degree, the stiffness degradation of precast components will be faster due to the accumulation of damage at the connection seams. As for the precast joints, a larger axial compression ratio can bring higher initial stiffness but faster stiffness degradation. When reaching peak load, the stiffness of ZJ3 with the highest axial compression ratio decreases 46.0% compared with the yielding stiffness, while ZJ1 only decreases 36.4%.The damage index model adopted in this paper can accurately reflect the damage characteristics of the monolithic precast joints. The damage indexes are all smaller than 0.1 before the joints yield, while the indexes are beyond 0.8 when the joints enter the failure stage. The damage states of the precast beam-column joints can be defined as five levels according to a different damage index value. The presented quantitative evaluation table established the corresponding relationship between damage states and damage characteristics, thus realizing the quantitative damage evaluation of this kind of joint.In this paper, the seismic damage evaluation of beam-column joints in monolithic precast concrete frame structures is studied by cyclic loading test and damage analysis. The main conclusions are as follows:


Helicobacter pylori infection, diabetes, liver cirrhosis, alcoholic liver disease (ALD), non-alcoholic fatty liver disease (NAFLD), HBV and HCV infection, liver ischemia and reperfusion injury, inflammatory bowel disease (Crohn’s disease and ulcerative colitis), obesity and overweight, kidney transplantation and ischemic-reperfusion injury, endometriosis and adenomyosis).CXCL1 is a CXC chemokine, CXCR2 ligand and chemotactic factor for neutrophils. In this paper, we present a review of the role of the chemokine CXCL1 in physiology and in selected major non-cancer diseases of the oral cavity and abdominal organs . We focus on the importance of CXCL1 on implantation and placentation as well as on human pluripotent stem cells. We also show the significance of CXCL1 in selected diseases of the abdominal organs, including the gastrointestinal tract and oral cavity (periodontal diseases, periodontitis, Sjögren syndrome,  CXC motif chemokine ligand 1 (CXCL1) is a chemokine that belongs to the CXC chemokines, one of four sub-families of fifty chemotactic cytokines divided according to the N-terminal cysteine motif; the characteristic feature of this subfamily is a conserved CXC motif that forms two disulfide bridges . AlthougCXCL1 is a chemokine that belongs to the CXC sub-family of chemokines ,5 and muBecause of the difficulties described when analyzing the importance of CXCL1 in a given disease, we first showed altered CXCL1 levels in patients. We then assumed that if levels of a chemokine equivalent to human CXCL1 are elevated in laboratory animals with the same disease, then this chemokine has the same role in disease mechanisms as human CXCL1. Nevertheless, in some diseases, animals show elevated levels in the expression of their counterparts of CXCL1, while in humans, we observed no changes. In this case, we indicated that the data cited are from animal studies, and the reported mechanisms may differ in humans with a given disease.Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis . Pr. Pr19]. ngivalis ,21. Thisngivalis . The resngivalis .In humans, CXCL1 causes neutrophil recruitment to inflamed sites in the gingiva . In a moSjögren syndrome is characterized by inflammatory reactions in exocrine glands, particularly salivary glands and lacrimal glands . The incHelicobacter pylori is a Gram-negative bacterium with a spiral morphology and four to six unipolar flagella [H. pylori is approximately 1.67 Mb, with plasmids ranging in size from 1.5 to 23.3 kb. It is estimated that, on average, more than half of the global population carries this microaerophilic bacterium [H. pylori is a pathogen that causes dyspepsia, gastritis and peptic ulcer disease [H. pylori, such as cytotoxin-associated gene A (CagA), which in turn is translocated by the type IV secretion system (T4SS) into host cells [H. pylori-neutrophil activating protein (HP-NAP) [flagella . The bacacterium , from 24 disease . Untreatst cells ,37; vacust cells ,38,39 an(HP-NAP) .H. pylori infection and its pathogenic activity are associated with inflammatory responses, including an increase in CXCL1 expression, as well as other ligands for CXCR2, in particular CXCL2, CXCL3, CXCL5 and CXCL8/IL-8 in gastric epithelial cells in gastric mucosa [H. pylori infection also increases CXCL1 and CXCL8/IL-8 expression in macrophages and neutrophils in the gastric epithelium [+ conventional dendritic cells, H. pylori induces the expression of CXCL1 and CXCL8/IL-8 [+ conventional dendritic cells. H. pylori also increases the expression of CXCR2 ligands in gastric cancer cells, which constitutes a potential therapeutic target in gastric cancer [H. pylori on CXCR2 ligand expression is mediated by  [NF-κB activation by  (Tip-α) . This mec mucosa ,43,44,45ithelium ,47. In CCL8/IL-8 . Toll-lic cancer ,50. The iated by :VirulencH. pylori also increases the expression of CXCR2 in gastric mucosa [H. pylori also increases genomic instability, which leads to mutations in the TP53 gene [c mucosa  through c mucosa . Howeverc mucosa ; that isP53 gene ,59. WithP53 gene , especiaH. pylori can also decrease the expression of ligands for CXCR2. In particular, CagA decreases the expression of IL-17 receptor B (IL-17RB) in gastric mucosa [At the same time, c mucosa , a recepc mucosa ,62. Decrc mucosa .H. pylori infection. H. pylori infection also increases the expression of hepatoma-derived growth factor (HDGF), which causes neutrophil recruitment [H. pylori infection [H. pylori infection. This bacterium causes N1-like subtype differentiation of neutrophils [The increased levels of CXCL1 and other CXCR2 ligands lead to infiltration of gastric mucosa by neutrophils . Howeverruitment , and HP-ruitment  and neutruitment . The latruitment ,66. The nfection . Subsequtrophils . The bactrophils ,68,69. Ttrophils . The actDiabetes is a group of diseases associated with excessively high blood glucose levels. We distinguish type 1 diabetes mellitus (T1DM)  and typeCXCL1 is involved in the pathophysiology of T1DM . PatientThe level of CXCL1 is also elevated in T2DM  and causNeutrophils are also important in pancreatic islet destruction after transplantation ,88. ThisCXCL1 levels are also elevated in the blood of patients with gestational diabetes mellitus and neonates whose mothers had gestational diabetes mellitus . HoweverDiabetes is a multisystem disease, and advanced, untreated diabetes may lead to diabetic ketoacidosis and thus neuroinflammation. Although a study on rats has not shown elevated brain concentrations of the rat equivalent of CXCL1 during diabetic ketoacidosis , the linCXCR2 ligands in the liver play an important physiological role in protecting the body from microbial flora, as demonstrated in a mouse model. Gut microbes contribute to the increased expression of KC in the liver , and allLiver diseases include various liver conditions with different etiologies. In this section, we will discuss the role of CXCL1 in the major liver diseases, namely non-alcoholic fatty liver disease (NAFLD) , alcoholHepadnaviridae family with partially double-stranded circular DNA of 3.2 kb in length [Flaviviridae family, which has a positive-sense, single-stranded RNA of 9.6 kb in length [NAFLD is caused by an abnormal diet with too much fat and simple sugars , which ln length . An estin length , but thin length . An estin length . All then length . It is en length ,93.In mice, high-fat diet-induced NAFLD results in an increased expression of KC and MIP-2 in the liver ,101. ThiPatients with ALD show increased expression of CXCL1 in the liver ,106. ThiTGFB1 gene. TGF-β1 causes activation of HSCs [Increased CXCL1 expression in the liver can also be caused by HBV or HCV infection. HBV infection is associated with chronic inflammation of the liver, which leads to liver fibrosis. Transforming growth factor β1 (TGF-β1) and CXCL1 play an important role in this process. During HBV infection, TGF-β1 expression is increased in hepatocytes  due to t of HSCs , which i of HSCs .HCV infection causes chronic liver inflammation, which leads to liver cirrhosis. An important element in the course of this disease is CXCL1—its expression is elevated in infected hepatocytes . At the CXCL1 plays an important role in liver diseases. It causes increased expression of α-smooth muscle actin (α-SMA) and alpha-1 type I collagen in HSC ,115, whiLiver ischemia and reperfusion injury often result from liver transplantation . This prExperiments in rats have shown that hepatocytes are the main source of the ligands for CXCR2 . IncreasLiver transplantation may also be associated with lung injury. Liver transplantation in mice is associated with an increase in lung expression of KC, MIP-2  and CXCLCXCL1 may be one of the acute-phase proteins (APP). If extensive tissue necrosis occurs in mice, damage-associated molecular pattern molecules (DAMPs) are released into the bloodstream, which leads to an increase in KC expression in many organs such as the spleen, kidney, and heart ; howeverInflammatory bowel disease is any disease resulting from inflammatory reactions in the gastrointestinal tract; the most significant are Crohn’s disease  and ulceCXCL1 has important functions in the course of inflammatory bowel disease. Serum levels of CXCL1 are elevated in patients with Crohn’s disease ,141,142 CXCL1 may be a biomarker for ulcerative colitis . AnalyseCXCL1 expression depends on a variety of factors occurring in the inflamed intestines. For example, elevated expression of IL-17  and TNF-reg) and the activation of pro-inflammatory Th17 cells. Via this axis, neutrophils may also influence inflammatory responses in adult patients with inflammatory bowel disease by producing IL-17 [CXCL1 causes chemotaxis and infiltration of inflammatory response sites by neutrophils in inflammatory bowel disease ,148,162.ng IL-17 . Howeverng IL-17 ,170. Thing IL-17 .CXCL1 is also important in normal bowel function. Various diseases, such as endotoxemia , brain iIn America, an estimated 64% of the population is overweight, with 28% of the population being obese . In EuroOne line of research is to analyze the association of CXCL1 with diabetes in obese individuals. CXCR2 ligands are produced in peri-pancreatic adipose tissue, as shown by experiments in obese rats , althougKidney transplantation is associated with renal hypoxia, caused by the disconnection of this organ from the donor’s bloodstream. Following transplantation, blood flow resumes, which oxidizes the transplanted organ, but similar to liver transplant, ischemic-reperfusion injury can occur, associated with increased CXCL1 expression in the kidney . This efCXCL1 is important in human prenatal development. During the peri-implantation period, the trophoblast secretes IL-1β ,187, whiCXCL1 may also be important in the following stages of human prenatal development. CXCL1 levels are higher in cord blood plasma in preterm neonates than in healthy full-term neonates . These CCXCL1 also undergoes increased expression in the myometrium during the period immediately preceding birth , in a prEndometriosis is a disease in which endometrium is found at extrauterine sites . EndometCXCL1 levels in the endometrium are elevated in patients with endometriosis ,202 and Elevated CXCL1 expression in the endometrium is due to pro-inflammatory cytokines  as well Following on from the first part of this paper , the mosThe use of the aforementioned compounds, together with the currently used therapies, may improve the therapeutic methods for the discussed gastrointestinal and abdominal diseases. On the other hand, this approach can be problematic. It is true that CXCL1 causes infiltration by neutrophils, which do cause tissue destruction, and a reduction in neutrophil infiltration can contribute to uncontrollable pathogen infection, which may worsen the patient’s condition. Another limitation associated with the use of CXCL1-reducing drugs is that most diseases are detected at an advanced stage, which means that the affected tissue has already been damaged or irreversibly destroyed, and so the use of CXCL1-reducing drugs will only inhibit the further progression of the disease.Although the significance of CXCL1 in gastrointestinal and abdominal diseases is well-established, little is known about the interplay between CXCL1 and other CXCR2 ligands , whose expression also increases. The vast majority of experimental work examines only one CXCR2 ligand, namely CXCL1 or CXCL8/IL-8, and so the role of the other six CXCR2 ligands remains unknown. There is also a question of why evolution in mammals  has produced such a large number of CXCR2 ligands with identical properties. Some answers may lie in the mechanism of regulation of the expression of individual CXCR2 ligands, where each of their promoters differs slightly from others, which suggests some differences in function. Nevertheless, this is a matter for future experimental studies.


Design expert predicted SMP (70): HAR (30) and CMC (0.8%) as optimum levels for reducing the pGI and maximizing the RS content and other quality characteristics in phirni. RS content of phirni (4.38%) prepared from optimized dry-mix (ODM) was higher while pGI (48.12) and GL (7.50) were lower as compared to phirni prepared from market dry-mix (MDM). The visco-thermal properties of ODM and MDM also showed significant variations. Storage modulus (Gʹ) and loss modulus (Gʹʹ) indicated that ODM phirni was less solid than MDM phirni. Scanning electron micrographs showed fused structures in ODM, while coarse sheet like structures were observed across the surface of MDM. Thus, ODM can be a promising substitute for the available milk desserts for diabetic patients.High amylose rice (HAR) and carboxymethyl cellulose (CMC) are the preferred choices for enhancement of resistant starch content and lowering of glycemic index in dairy desserts. The effects of different levels of skimmed milk powder (SMP): HAR flour (45:55 to 75:25) and CMC (0.1 to 1%) were investigated on physical characteristics of dry-mix and on texture profile parameters, resistant starch (RS), predicted glycemic index (pGI), glycemic load (GL) and overall acceptability of  Phirni—a classic creamy sweet pudding, is one of the most famous traditional dairy based dessert relished in Northern India, especially on festive and social occasions. Phirni is usually prepared from rice flour or semolina and milk with the addition of sugar, and flavoring agents. It is cooked to semi-solid or pasty consistency, by heat desiccation and consumed after brief refrigeration or cooling1. Kheer is used as a synonym for phirni in literature but the principal difference between the two is use of pregelatinized rice grains in former and rice flour in latter2. Dairy based traditional desserts have a very short shelf life without refrigeration, which has prompted researchers to develop technologies for making milk-cereal based pre-mixes with instant reconstitution. Jha et al.2 prepared ready-to reconstitute Kheer pre-mix from milk-rice slurry through spray drying. Different variants of Kheer mix have been prepared by substituting milk with skimmed milk (SMP)/whole milk powders (WMP)/soymilk and rice with other cereals besides addition of various functional ingredients4. Kumar et al.5 formulated phirni mix from pregelatinzed rice flour, sugar, cardamom powder and WMP:SMP in the ratio of 18, 31, 1 and 50:50%. The authors standardized cooking time of 10 min for preparation of phirnion the basis of sensory score and rheological parameters.Traditional dairy based desserts have deep cultural preferences, but their manufacturing has been restricted to non-industrial sector only. 6. Rice serves as the main daily caloric source for more than half of the population worldwide, while its high increases the risk of diabetes mellitusdue to its high GI7. Although various low GI foods have been developed, but the efforts to develop low GI desserts are rare8.Phirni is a rich source of proteins and minerals. Also being semi-solid in nature, it is highly recommended for patients with swallowing difficulties. Rice is categorized as high GI food with GI score ranging from 40 to 100. However, rice starch having high amylose content (> 25%) usually tends to elicit a lower GI9. Gelling polysaccharides and gums are usually added to milk-based puddings for improvement of body and structure11. Zahidi et al.10 studied the effects of soy milk (10–100%) and CMC  on color and rheological properties of soy dessert. Samples containing CMC showed high consistency coefficient. Arancibia et al.11 studied the effect of CMC at concentrations ≤ 0.9 w/w on rheology and microstructure of soy protein desserts and concluded that texture and rheological characteristics of high protein desserts could be altered by adding thickeners. Carboxymethylcellulose (CMC)—a linear chain polymer of D-glucopyranose and anionic carboxylate groups is one such gelling polysaccharide. It has a unique property to limit availability of water which reduces gelatinization of starch12. The gelatinization behaviour of starch is directly influenced by the chemical and morphological structure of the gum present in the starch gel matrix, the swelling power of the granules, and the electrostatic interactions between starch granules and hydrocolloid molecules13. The interaction between starch and hydrocolloids can alter food texture, structure, and viscosity, thereby changing the accessibility of enzymes to starch granules14. Hydrocolloids have the potential effect to increase the viscosity of food products and alter the accessibility of starch granules to the α-amylase. Blending starch with hydrocolloids decreases the rate of starch digestion. Some previous studies have also reported that hydrocolloids decreased starch hydrolysis in rice starch15; corn starch16; maize and wheat starch mixtures17. Srikaeo and Paphonyanyong18 reported that addition of 1% hydrocolloids exhibited lower starch digestion rate in cooked rice samples. Oh et al.19 also reported that addition of 0.4% CMC altered the starch digestibility of dry heat treated high amylose rice.The global demand for low GI foods has increased many-folds due to increased prevalence of diabetes mellitus. The prevalence of diabetes mellitusis high with about 463 M people suffering from diabetes worldwidephirni. Thus, the aim of this study was to a) investigate the effect of different levels of high amylose rice (HAR), skimmed milk powder (SMP) and carboxymethyl cellulose (CMC) on physical attributes of instant phirni dry-mix as well as on the textural parameters, resistant starch, glycemic index, glycemic load and overall acceptability of phirni reconstituted thereof, and b) compare the pasting, thermal, rheological and morphological properties of optimized dry-mix (ODM) and market dry-mix (MDM). The hypothesis postulated in the study was that low GI traditional rice pudding “phirni” with improved quality characteristics can be prepared with ingredient alterations.Despite the increasing demand for low GI foods, no study has been conducted so far on starch digestibility and glycemic response of traditional dairy based dessert like Lalat) were ground in a laboratory mill  to obtain rice flour that passed through 60 mesh sieve size. Moisture, protein, fat, crude fiber, dietary fiber, ash content and amylose content of rice flour were recorded as 11.30%, 10.15%, 1.25%, 1.09%, 3.90% and 0.56%, and 28.31%, respectively. The raw material was procured from the registered seed centers, and all the methods used in this work are in compliance with the institutional guidelines. Food grade CMC was procured from Sigma Aldrich, while SMP , and market dry mix (MDM)were procured from the departmental store in Srinagar, India. In MDM, the ingredients were rice flour, milk powder, sugar, almonds and preservatives.Broken white grains of HAR , predicted glycemic index (pGI), glycemic load (GL) and overall acceptability of phirni re-constituted from dry-mix. The experimental ranges of independent variables and their coded levels are illustrated in Table i , xi2 and xixj are linear, quadratic and interaction effects of the independent variables and bo, bi, bii and bij are regression coefficients for intercept, linear, quadratic and interactive effects, respectively. From ANOVA, the F-values were used to test the adequacy of models, while the model terms having “Prob > F” less than 0.05 were considered as significant terms21.The 5-level-2-factor central composite rotatable design (CCRD) was used to investigate the effects of different levels of SMP: HAR and CMC on physical characteristics of instant 21.All the dry ingredients i.e., HAR flour, SMP and CMC were mixed and homogenized in a planetary mixer  in various proportions as per the experimental design Table . Sucralophirni dry mix samples were mixed with potable boiled water in the ratio of 1:5 (phirni dry mix: water)4 in an open pan and subjected to cooking at low heat (80–85 °C) with constant stirring for 15-20 min till desired consistency was achieved. Reconstituted phirni was poured into plastic cups and kept at 4 ± 2 °C under refrigerated conditions for 12 h prior to analysis.The contents of 22. Porosity was calculated using the standard formula2. The solubility percentage was calculated as per the procedure reported by Seth et al.23.Bulk density . The two-cycle penetration test at a penetration speed of 2 mm s−1, up to a depth of 5 mm was carried out with a 0.05 N load cell and P-20 stainless steel cylindrical probe24. The parameters recorded were hardness, cohesiveness (COH) and adhesiveness (ADH).Texture profile analysis of the phirni samples were freeze dried in a laboratory freeze drier  and subjected to fine grinding. Grinded samples (100 mg) were incubated in a shaking water bath with pepsin , pancreatic alpha-amylase  and amyloglucosidase  for 16 h at 37 °C as per the detailed protocol reported by Naseer et al.21. Resistant starch content was measured using Megazyme Assay Kit 25 and RS was calculated from the formula given in the instruction manual.The reconstituted 21 was followed to determine the in-vitro digestibility of different freeze dried phirni samples. The rate of starch digestion was expressed as the percentage of total starch (TS) hydrolyzed at different time intervals. Hydrolysis index (HI) was calculated using the starch digestion rate curve (glucose release). The area under the curve for the experimental sample divided by the area under the curve of the control sample (white bread) was taken as HI and predicted glycemic index (pGI) was calculated using the standard formula26The procedure reported by Naseer et al.Glycemic load (GL) of the samples was calculated using the following equationphirni samples was carried out on 9-point hedonic scale (9—liked extremely and 1—disliked extremely)27 by a jury of 30 trained judges. Samples were randomly coded and presented to the judges in separate partitioned booths. The judges evaluated the samples for different sensory attributes  according to the rating criteria and overall acceptability (OA) was determined as average of different sensory attributes. The judges used potable water for palate cleaning before evaluating each sample.Sensory evaluation of different reconstituted phirni dry-mix using desirability function approach. Among the physical and textural attributes, BD, TD, hardness, and cohesiveness were minimized; whereas, porosity, solubility, adhesiveness, and OA were maximized. RS content was also maximized, while pGI and GL were minimized. Out of different generated solutions, the solution with highest desirability value was selected for the preparation of instant phirni dry-mix. The actual values of physico-chemical, textural and sensory properties determined after evaluating the instant phirni dry-mix prepared from optimized ingredient levels were compared with the predicted values generated by the software to validate the optimization process. Percentage prediction error was calculated using the equation given by Scheuer et al.28.Specific goals were allocated to all the analyzed parameters to optimize the process for preparation of instant 29. Water activity was measured with the help of water activity meter . Carbohydrate content was estimated by difference method, and caloric value was calculated using Atwater factors. Total solids were estimated by gravimetric and total sugars were estimated using Lane- Eynon method as described by FSSAI30. Standard AACC25 method was followed to measure the total starch content using the total starch assay kit . Standard protocol was followed to determine the amylose content using the Megazyme assay kit (K-AMYL 06/18).Moisture, protein, ash, crude fiber, dietary fiber and fat contents were determined according to the standard methods of AOAC24. The thermal properties were studied with a Differential Scanning Calorimeter . 10 mg of dry sample was placed in an aluminum pan and 50 µl deionized water was added. An empty aluminum pan was used as a reference. The pans were sealed hermetically and heated at 10 °C/min from 20 to 150 °C heating regime.Pasting properties of different samples  were measured using rapid visco analyzer  as per the procedure described by Pracham and Thaiudom31 with slight modification. The sample was placed on the ram of the rheometer with a spatula, spread uniformly andtrimmed wherever required. Storage modulus (G´), loss modulus (G´´), and loss tangent (tan δ) were analyzed by performing frequency sweep test from 0.1–100 rad/s, with a gap of 1 mm at 25 °C.The strain was kept constant at 2% for all the measurements which were in conformity with the Linear Viscoelastic Range.Dynamic rheological properties were measured by Modular Compact Rheometer , equipped with a parallel-plate geometry (50 mm diameter) using the procedure given by Thaiudomand PrachamMorphology of the samples was analyzed by scanning electron microscope  at 1.50 kX magnification. The samples were fixed on aluminum stubs using double sided adhesive tape. The fixed samples were covered with a thin layer of gold–palladium sputter coating and examined under voltage of 20 kV.p < 0.05 level of significance.Experiments were conducted in triplicate and results presented were average of three replications ± standard deviation. Statistical significance of physico-chemical, textural, pasting, and thermal properties was determined by Students t-test using SPSS software. Mean values were compared by Duncan’s Multiple Range test at 2 values (0.834–0.990) recorded for different parameters indicated fair fit of developed models with the actual values. Models generated for different quality attributes of instant phirni dry mix were highly significant (p ≤ 0.0001). The difference in predicted and adjusted R2 was less than 0.2 in all the models which indicated that they are in reasonable agreement with each other32. F-values obtained (25.29 to 144.12) further demonstrated the validity of the models and there could be 0.01% possibility only that these F-values could be noise based. Range of coefficient of variation (CV = 0.22–10.97%) also confirmed the reproducibility of the developed models. The adequate precision values recorded for different parameters were considered desirable33. Lack of fit (LOF) was non-significant in all the selected parameters, indicating good correlation between second-order polynomial models and the measured data.For bulk density, true density, hardness, cohesiveness, resistant starch, predicted glycemic index, quadratic models were suggested; while for porosity, adhesiveness, glycemic load and overall acceptability linear modelswere suggested by output of fit summary statistics Table . R2 valu34. For different experimental runs, BD, TD and phirni mix ranged from 610 to 685 kg/m3, 710 to 817 kg/m3 and55.64 to 56.82% respectively , true density (TD) and porosity  linear effect on porosity of phirni mix as well. As the concentration of SMP was increased, BD and TD were decreased, while ϕ increased , maximum hardness was recorded highest (0.80 N), which could be attributed to interaction of SMP proteins with leached components of starch in phirni during cooling40. Amylose has an ability to form rigid gel, which may have caused interaction starch and milk causing positive affect on the firmness of puddings41. Figure 42.Regression Eq.  indicate43 while cohesiveness (COH) measures the strength of internal bonds and the degree to which a food can be deformed before it breakdowns44. Both ADH and COH are important factors which govern the acceptability of milk desserts. ADH of different phirni samples ranged between (−) 0.309 to (−) 0.628 N and COH from 0.455 to 0.910, respectively  indicates the ability of the product to adhere to the palate during swallowingphirni samples increased from (−) 0.341 to (−) 0.563 N and (−) 0.309 to (−) 0.628 N, respectively. Higher ADH implies softer texture, which is a desirable trait in milk desserts. Casein—a dominant protein in SMP forms protein gel upon gentle heating and stirring and thus imparts body and texture to phirni45. Higher SMP reduces the consistency of phirni due to formation of liquid bridges, which increases the ADH. Furthermore, lactose act as a plasticizer in the presence of water due to its hygroscopic nature and thus, depresses the glass transition of amorphous sugars46, which also justifies the increase in ADH upon increase in SMP level in phirni. Guimarães et al.47 also reported a significant increase in ADH of instant dessert with the increase in addition of milk powder in relation to rice flour. The positive relationship of CMC and ADH recorded in phirni samples can be attributed to CMC-calcium ion interaction. Coronato et al.48 reported that with increase in gum concentration, the adhesiveness of milk-gum suspension also increased.Both the independent variables (A and B) exhibited positive linear relationships with ADH Eq. . Figure 49 caused by easy dissolution of SMP in water. In contrast, CMC imposed a thickening effect in phirni which may have lead to increase in COH50 due to starch-milk interaction. Zhang et al.51 also reported that addition of gums increased the consistency and cohesiveness of the low-fat fermented skimmed milk.Regression Eq.  indicate52. RS content of different phirni samples ranged from 1.53 to 4.72%  is an important contributor of glycemic response offered by carbohydrate-rich food; hence, lot of research is going on to enhance the RS content in processed foods due to its health benefitsphirni samples respectively. Milk proteins interact with the rice starch granules through adsorption and hydrophobic linkages53. Adsorption of protein aggregates fill the voids inside starch granules which restrict the diffusion of water and thus, limit the starch hydrolysis and digestion. Further, heating induces protein–protein aggregation, and formation of amylose–lipid complexes which may reduce the accessibility to hydrolysis54. CMC exhibited a dominant effect on RS content as compared to SMP due to its thickening effect. A prominent increase in RS content with the increase in CMC concentration is evident in Fig. 55. Elmstahl56 also reported an increase in RS content in semolina porridge due to starch-protein interactions.Both the independent variables exhibited significant positive relationships with RS content Eq. . Interac57. pGI and GL of different phirni samples ranged from 47.15 to 51.78 and 7.15 to 11.18, respectively  ranged from 7.10 to 8.58  0.642 N, 0.724, 4.38%, 48.12, 7.50, 8.39, respectively. The actual values of dependent variables matched the predicted values well with a variation of ≤ 3.66% which confirmed the predicted pattern of the developed models.Design expert predicted high amylose rice flour (70): SMP (30) and CMC 0.85% as optimum ingredient levels for preparation of low GI .70 Fig. l. The BD2 and Vashistha et al.63 in different types of dairy dry-mixes. Protein content was significantly higher, while fat content was significantly lower in ODM as compared to MDM, possible due to ingredient difference. Higher ash content of ODM as compared MDM was presumable due to SMP. Crude and dietary fiber contents were also significantly higher in ODM than MDM, which might be attributed to incorporation of CMC in ODM. However, carbohydrate content was significantly lower in ODM as compared to MDM. Significant reduction in carbohydrate content of ODM was probably due to its higher protein, and fiber content, besides the lower total sugar content. In case of MDM, sucrose is usually added as a taste enhancer, while in case of ODM, lactose was the major sugar present due to SMP incorporation. Lactose has a GI score of 43 and falls under the low GI category, while sucrose has a GI score of 60 and falls under the moderate GI category64. Energy value of ODM was significantly lower than that of MDM, likely due to lesser sugar, fat and carbohydrate contents in the former. Significantly higher starch content of ODM than that of MDM might be because of high proportion of rice flour in ODM. Since high amylose rice flour was used as base material for preparation of ODM, which may have led to its high amylose content as compared to MDM. Variation in SMP, rice flour and other ingredients possibly led to observed disparities in compositional analysis of ODM andMDM. Higher RS content (4.38%) was recorded in phirni reconstituted from ODM as compared to MDM phirni (0.50%), which can be attributed to high amylose content and CMC incorporation in ODM. Due to linear chain structure, amylose is more susceptible to retrogradation during heating–cooling cycle, which might have increased the RS content in ODM phirni. In addition, various chemical changes take place during phirni preparation, which may have facilitated protein denaturation and formation of complexes between starch and non-starch components that are resistant to amylolytic hydrolysis65. The lower glycemic response of ODM phirni (48.12) relative to MDM phirni (60.20), was possibly due to its higher RS and dietary fiber content. The presence of sucrose may possibly have spiked the pGI of MDM phirni as well. Variation in glycemic index of phirni reconstituted from ODM relative to MDM highlighted the importance of rice and sugar type including the effect of hydrocolloid on postprandial hyperglycemic effect.Physico-chemical composition of optimized drymix (ODM) and market dry mix (MDM) is depicted in Table phirni reconstituted from ODM and MDM is shown in Table phirni reconstituted from MDM as compared to that reconstituted from ODM. Higher protein content reduces the leaching of amylose possibly leading to reduction of the hardness of ODM phirni. It can be presumed that network of casein micelles dominated the texture of ODM phirni. Equation  incorporation46.TPA of Equation  also ind66. Noisuwan et al.40 reported that proteins adsorb onto the starch granules and restrict the diffusion of water into the starch granules during pasting, which may increase the pasting temperature of ODM. However, peak viscosity and hold viscosity were higher in MDM as compared to ODM  in ODM may have restricted the development of viscous paste and thus, significantly lowered its peak and hold viscosities. In addition, due to high protein content (25.12%), the protein molecules in ODM tend to encircle the starch granules in the matrix which hinders its water absorption. One of the possible mechanisms which can explain the influence of SMP on pasting behaviour of rice flour could be that proteins compete for water during gelatinization of starch and thus, restrict the swelling of granules. At the same time, lactose and salt diffuses into starch granules which affects the leaching of amylose into continuous phase by anti-plasticizing effect of lactose and stabilizing effect of cations on starch structure, respectively24. The paste has lower breakdown viscosity (BDV) and has better stability against shearing, which is a desirable trait for puddings68. The lower BDV of ODM indicated higher reinforcing effect of protein matrixes on starch-protein interaction, possibly due to disulfide bonding, which may have improved the shear resistance of ODM as compared to MDM. Final viscosity (FV) and setback viscosity (SBV) of ODM were significantly higher than that of MDM  than MDM. However, onset temperatures recorded for both the samples showed non-significant difference. CMC, protein and amylose molecules compete with each other for water72, which may have enhanced the peak and end-set temperatures of ODM. Furthermore, high amylose starches also exhibit higher gelatinization temperatures74. Uthumporn et al.72 also reported that protein and starch granules compete for water molecules which results in inhibited swelling and increased gelatinization temperature. Higher ∆Hgel suggested that more organized amylose structures were present in ODM as compared to MDM and thus, higher energy was required to break the hydrogen bonds between the monomers in case of ODM.Differential Scanning Calorimetric (DSC) results presented in Table 75. Overall,it appeared as if the surface of ODM was dominated by the proteins and different constituents of rice were encased by protein miscelles. Further, the interaction of CMC and casein particles may also have resulted in the agglomeration of particles, which may have acted as a physical barrier to enzymatic hydrolysis76. In contrast, coarse sheet like structures were observed in MDM  and loss modulii (G") were recorded for MDM phirni which indicated its more solid like behaviour as compared to ODM phirni. Due to flavoring agents and additives, the ingredient interaction was probably stronger in MDM phirni which might have increased its G′ and G". Therefore, it was presumed that total solids and other particulate matter exhibited the dominant affect on pudding structure and gel strength. Lower G′ and G" of ODM phirni indicated its less firm structure as compared to MDM phirni sample. Although, ODM was prepared from high amylose rice flour with CMC incorporation (0.85%), but the G′ and G" values indicated that ODM phirni was less solid-like as compared to MDM phirni. At low concentration (≤ 4%), hydrated CMC molecular chains act as “diluent” and disperse around amylose molecules, thereby, prevent the amylose-amylose interaction which may reduce the rigidity of the pastes78. Further, due to high SMP percentage, the casein micelles in ODM may also have restricted the interaction between amylose and other ingredients. It is likely possible that either amylose leaching may have been inhibited by casein aggregates or leached amylose granules would have been encased by casein network40. El-Garaway and Salam 79 also described that high protein concentration imposed hinderance on formation of strong gel network between amylose-amylopectin and CMC. Tan δ of ODM phirni was higher than MDM phirni  and viscous (G") components confirmed that phirni reconstituted from both ODM and MDM exhibited soft gel behaviour. However, ODM phirni had less firm texture than MDM phirni. Texture profile analysis also indicated that ODM phirni had lower hardness but higher adhesiveness and cohesiveness as compared to MDM phirni. The outcome of the present study can help to prepare a low GI diet for people suffering from diabetes and swallowing difficult. However, this is the first reported study which investigated the glycemic index, glycemic load and resistant starch content of traditional dessert-phirni. Therefore, prior to its commercialization, there is a need to conduct in-vivo testing of such product among the target population in future to validate its impact on glycemia.Perusal of the results revealed that addition of CMC can play a predominant role in enhancing the RS and lowering the pGI of traditional milk-based rice pudding-


Pregelatinized starch (PGS) is often used to improve the processing quality of foodstuffs, but little attention has been paid to the effects of different reheating methods and degree of starch gelatinization (DSG) on their rheological and textural properties. In this study, pregelatinized rice starches (RS) with gelatinization degrees ranging from 58% to 100% were prepared via different Rapid Visco Analyser (RVA) heating procedures and reheated in various methods, including high-power microwave (HM), low-power microwave (LM), and water bath. The rheological behavior and textural properties were explored, and the results demonstrated that the consistency, gel strength, hardness, and springiness of PGS in all tested samples decreased significantly after reheating. The storage modulus (G’) of PGS increased dramatically while the thermal stability decreased. Interestingly, the reheating methods possessed various effects on the starch of different DSG. Convenience is a major trend in the food industry . The impGelatinization, which is one of the most important properties of starch, refers to the process when starch granules are heated to a certain temperature in water, the volume of the starch granules increases, and the hydrogen bonds between the molecules are broken due to expansion and the ordered structures are destroyed, forming viscous paste-like solution . CompareDongtingchun soft rice was purchased from Hunan Dongtingchun Rice Industry Co., Ltd. . All other chemicals were of analytical grade and obtained from commercial sources.3 to test). The end-products were dried in an electric blast oven  and ground for further use.Rice starch was prepared using alkaline extraction method. The rice was first washed 2–3 times with water, then soaked in the volume of 0.3% (W/V) NaOH 3 times and replaced with new NaOH every 8 h for 24 h. After wet milling by colloidal mill, the rice starch slurry was centrifuged at 3500 g for 10 min, while the supernatant and yellow precipitate were discarded, and only the white starch layer remained. The white product was then soaked in 0.3% NaOH and stirred for 15 min. After being kept static, the supernatant was discarded and NaOH solution was added, and the procedure was repeated many times within 24 h. Later, the above solution was adjusted to pH = 7 with HCl (0.1 mol/L) and then the white centrifugal precipitate was repeatedly washed utilizing distilled water until the supernatant was free of precipitate , γ˙ is the shear rate (s−1), and n is the flow behavior index (dimensionless).A rheometer  with the rheometer plate (40 mm diameter) and a 1 mm gap was used to measure the rheological properties of the samples. The starch solutions  were heated in a boiling-water bath for 0.5 h, and after cooling to 25 °C they were transferred to the rheometer measurement platform. The change of shear stress was measured at a measuring temperature of 25 °C. The data acquisition and recording were performed automatically by computer. The static starch rheology data were modeled by using the power law Equation (3).After being solubilized, starch solution was maintained at 25 °C under magnetic stirring for 40 min, and then rheological test at this temperature was performed. A constant frequency of 1 Hz was used in the test, and the strain amplitude for the frequency sweep measurements was chosen to be 1%, which was in the linear viscoelastic region for all samples. For constant dynamic rheology properties of the samples, the temperature was carried out with heating (25–95 °C) and cooling gradients (95–25 °C) at a rate of 3 °C/min. Small-amplitude oscillatory shear flows with frequencies from 0.01 to 10 Hz were used to measure storage modulus (G′) and loss modulus (G″).3 pieces of the same size. The gel strength of the samples was measured with a P/0.5 cylinder probe. The procedure was to move down and compress the gel to 10 mm of the original sample height at a rate of 2 mm/s. After contacting the sample with a trigger force of 5 g, the test speed was set to 1.0 mm/s and the post-test speed was set to 0.5 mm/s. The strength of the gel structure is the product of the maximum force (g) and the maximum distance (mm) required to compress the sample. The hardness, cohesiveness, gumminess, and springiness of the gels were conducted using a P/36R cylinder probe with a two-cycle program at a compression ratio of 50%, a trigger force of 5 g, and a test speed of 1 mm/s. Each measurement was repeated 5 times. The gel texture properties were measured via a Texture Analyser  following the previous description with slight modifications . A total2, 20 mg/mL KI) and the volume was fixed to 100 mL with distilled water. Then, the absorbance was measured at 680 nm after being placed in the dark for 15 min. The iodine-binding properties of starch are characterized by the iodine blue value, which was executed as previously described . A totalp < 0.05 was considered statistically significant.The data were expressed as mean ± standard deviation. One-way ANOVA and multiple comparison tests were performed using IBM SPSS software version 20.0 . To evaluate the effects of reheating methods on the microstructure of starches with different gelatinization degrees, the low-, medium- and high-gelatinized starch samples were reheated by microwave or water bath individually. Representative micrographs for starches with different gelatinization degrees before and after reheating are shown in −1, 1047 cm−1, and 1022 cm−1 were related to the hydrogen bonds formed between hydroxyl groups of starch macromolecules, ordered structure, and amorphous structure in starch, respectively [−1 and 995/1022 cm−1 are commonly used to measure changes in the short-range ordered structure of starch.The FTIR tests were performed on PGSs with different gelatinization degrees, and the results are presented in ectively . The ratAs for nonreheated samples, the values of both R1047/1022 and R995/1022 ratio were similar in RS and LSG, respectively. Moreover, the values of these ratios increased as DSG increased. This result indicated that storage of PGSs at 4 °C could generate a higher short-range ordered structure. This may be due to the reorganization of starch chains and double-helix structures through intermolecular and intramolecular hydrogen bonding . After rRheological properties refer to the deformation and flow properties under the action of external force. The variation trends of shear stress following shear rate changes in PGS of different DSGs with/without reheating is shown in 2 values of all samples were between 0.969 and 0.996, indicating that Equation (3) can nicely fit the static rheological data of starches with different DSG. In addition, all starch samples exhibited a lower flow behavior index (n < 1), which was attributed to shear strain breaking the molecular network in the starch paste [To further analyze the static rheological properties of starch paste, the data were modeled by a power law equation. As shown in ch paste . During ch paste . During G′ and G″ reflect the elasticity and viscosity of starch, respectively . Figure During the heating process (25 °C to 95 °C), the increasing amplitude of G′ showed its highest level when the temperature was below the gelatinization temperature. A major reason for this phenomenon may be that the starch did not gelatinize during the initial heating stage, so the system was unstable and the viscoelasticity varied considerably. However, as the starch granules continued to break up with heating, amylose dissolved and interconnected to form a network structure, which greatly increased the elasticity of the system, while the viscosity increased slower. When the temperature was higher than the gelatinization temperature, the prolonged reheating time caused partial cleavage of the hydrogen bonds between the starch gel structures, thereby increasing the mobility of amylose and the viscosity of the starch system. During the cooling process, the changes of both G′ and G″ slowed down, which was probably because the starch molecules were hydrogen-bonded to the water molecules, and resulted in a stabilization of the gel viscoelasticity. In addition, MGS showed the highest peak G′ after water bath treatment rather than microwave reheating, which was different from LGS and HGS, suggesting that the reheating methods had different effects on the rheological behavior of PGSs with different DSG. These results can be explained by MGS having the highest amylose content and the amylose leaching during the reheating process enhancing the interaction with the granules.After gelatinization and retrogradation, starch molecules can form a dense three-dimensional gel network, the gel properties of which can be closely related to the processing characteristics of starchy foods and the quality of the products . Thus, wThe reheated PGS exhibited significant changes in the texture characteristics, including hardness, cohesiveness, springiness, and gumminess. The hardness and springiness dramatically reduced, which may be related to the regelatinization of starch during the reheating process. The reheating treatment led to an increase in the damages to the crystalline region of starch granules and a decrease in the stability of the gel structure. In addition, the gumminess of all PGSs increased after reheating. The gumminess increase was greater in microwave reheating, especially in the low-power microwave treatment group, in comparison with that in the traditional water bath reheating method. This may be due to the degradation of long-chain starch molecules to short chain starch by the nonthermal effect of microwaves. These short-chain starch molecules could swell and stretch more fully during gelatinization, resulting in an increase in the overall viscosity of the starch gel. Hence, the low-power microwave treatment group with a longer treatment time increased gumminess more significantly in comparison to high-power microwave processed samples. It is noteworthy that MGS always had a relatively larger gel strength after reheating compared to LGS and HGS, probably because LGS was incompletely gelatinized, while the molecular chain of HGS were broken during the reheating process and resulted in the destruction of the gel network structure.The WBC and WSI of starch are important indicators to evaluate its physical properties, and could reflect the tightness of the internal structure of starch granules to a certain extent. The WBC and WSI of the RS and PGSs before and after reheating are presented in Effects of reheating on the iodine blue values of PGSs of different DSG are shown in Reheating methods affect the rheological behavior, textural properties, and molecular structure of starches with different DSG differentially. Meanwhile, rice starch paste is a non-Newtonian fluid with shear-thinning behavior, and its rheological properties conform to the rheological law τ = k*γn. Starch paste with higher DSG tends to form a more stable three-dimensional network structure with higher gel strength. The variation amplitude of storage modulus increased significantly in PGSs with different DSG after reheating. In addition, due to a shorter microwave treatment time to reach the same temperature compared with the conventional water bath heating method, as well as the dual effect of microwave radiation and dielectric heating, the microwave-treated PGS has a rougher granule surface structure, poorer molecular structure stability, and higher blue values compared to samples reheated by water bath. Moreover, these starch pastes possess lower hardness and springiness, while exhibiting higher gumminess. MGS always had the relatively larger gel strength after reheating than RS, LGS, and HGS after reheating, and thus has great application potential in starch/food research and industrial areas. These results may be related to the interaction between amylose and starch granules, but the concrete mechanism and how our findings can guide the production of starchy ready-to-heat food as well as processing applications remains to be investigated by further experiments.


BACKGROUND: Corneal transplantation in keratoconus (KC) patients is generally considered to be successful with a high grade of patient satisfaction. Long-term studies suggest a 6% to 11% probability of KC recurrence manifested by keratometric instability and progressive corneal ectasia. METHODS: We propose to review the frequency, risk factors for the development, and the surgical options for the correction of high irregular astigmatism due to late graft ectasia following penetrating keratoplasty (PK). RESULTS: Post-keratoplasty ectasia is characterized by increasing corneal steepening with myopic shift and high irregular astigmatism, developing years or decades after PK, mostly occurring in KC patients. Contact lenses may adequately improve the visual acuity; however, because these patients are often elderly and intolerant to hard contact lenses, ultimately a surgical correction is proposed to the patient. Compressive suture and corneal wedge resection may improve corneal astigmatism, but the outcomes are unpredictable and often temporary. For this reason, a larger PK graft is often proposed for surgical rehabilitation with the consequence of removing more of the recipient’s healthy endothelium and exposing the patient to a renewed immunogenic stimulus and short-term graft failure for endothelial decompensation. More recently, lamellar keratoplasty using various techniques has been proposed as an alternative to PK in order to maximize the visual outcomes and minimize the complications. CONCLUSIONS: Management of advanced corneal ectasia is a significant challenge for corneal surgeons. Many surgical approaches have been developed, so there is a large arsenal of surgical operations to correct post-PK ectasia. Among them, large-diameter anterior lamellar keratoplasty may be a viable, safer, and effective alternative to PK for the correction of post-keratoplasty ectasia. Corneal transplantation in keratoconus (KC) patients is generally considered successful with a high grade of patient satisfaction . HoweverIn KC patients, increasing irregular astigmatism after penetrating keratoplasty (PK) may result from KC recurrence in the donor button, spontaneous evolution of KC in the host rim with consequent graft–host interface thinning and misalignment, or grafting a donor cornea with undiagnosed KC. Whatever the cause, post-keratoplasty ectasia is characterized by increasing corneal steepening with myopic shift and high irregular astigmatism, developing years or decades after PK, mostly in KC patients , often rBecause these patients are often elderly and intolerant to hard contact lenses, ultimately, a large PK graft is often proposed for surgical rehabilitation with the consequence of removing more of the recipient’s peripheral healthy endothelium and exposing the patient to a renewed immunogenic stimulus and short-term graft failure for endothelial decompensation.Herein, we propose reviewing the frequency, development risk factors, and surgical options to correct high irregular astigmatism due to late corneal ectasia after PK.Corneal ectasia is a disorder characterized by the gradual protrusion of the cornea with thinning and steepening, causing progressive visual loss . Causes Corneal ectasia after PK is characterized by decreased uncorrected visual acuity, increased corneal aberrations, and often loss of best-corrected visual acuity. Astigmatism is the most common complication following corneal transplantation, mainly when PK is performed for diseases associated with high preoperative astigmatism, among them, KC . CornealEctasia is usually preceded by thinning of the recipient’s corneal stroma at the graft–host junction, more frequently located inferiorly and rarely involving the superior quadrant . This isMeasurement of intraocular pressure by applanation tonometry  is artifactually reduced due to tissue thinning in ectatic disease. The red reflex should be assessed by examining the fundus to look for a dark area caused by total internal refraction (oil droplet) ,16.The diagnosis of post-PK corneal ectasia is usually based not only on patient history and symptoms, but also on characteristic findings on photo-keratometry, topography, and tomography . AlthougHandheld ultrasonic pachymetry remains the standard method for corneal thickness measurements, but the results cannot be related to topography values. There are various tools such as slit-scanning and Scheimpflug imaging that can be used for topographical and combined pachymetry assessment of the cornea. Slit-scanning provides pachymetry values, but repeatability and posterior curvature mapping are inaccurate. Scheimpflug imaging is the preferred modality by most corneal surgeons because it provides precise corneal thickness and posterior elevation with good repeatability .Anterior segment optical coherence tomography (AS-OCT) is a valuable instrument that can offer high-definition images of the cornea, angle, anterior chamber, and lens . The newGraft–host misalignment and malposition are associated with postoperative astigmatism in most patients. AS-OCT is useful for evaluating the graft–host junction, which is needful for diagnosing and managing complications, such as post-PK astigmatism, occurring at any time point postoperatively. Characteristically, in post-PK ectasia, corneal thinning is particularly pronounced at 1 mm on either side of the graft–host junction, corresponding to the area of maximal corneal steepening .AS-OCT is a fundamental exam for planning the correction of post-PK ectasia. It allows the surgeon to locate and measure the diameter of the donor graft, the extension of the graft–host thinning, and the exact position of the proximal healthy corneal tissue.After PK for KC, postoperative corneal ectasia has been estimated to occur in 6% to 11% of the patients at 20 to 25 years after surgery . The latPK for KC generally has an excellent long-term prognosis, but some patients may develop recurrence of ectasia years after surgery as PK is usually performed at a young age, and has a high graft survival rate, allowing for a greater chance of KC progression or recurrence ,21. RelaAfter PK, host keratocytes replace donor keratocytes. As a result of this process, keratocyte density in the donor cornea is lower than in a normal cornea . There iThe degree of post-PK corneal ectasia may range from mild to severe. Mild cases can be managed successfully with spectacles ; neverthPost-keratoplasty astigmatism can be managed with various CL types: hybrid, scleral, rigid gas-permeable, or piggy-back CL.Rigid gas permeable lenses are considered successful in managing irregular astigmatism encountered with corneal ectasia. They have an anterior and a posterior surface, creating a spherical anterior refractive surface over the ectatic cornea. In addition, tear film provides an optical bridge between the posterior aspect of the CL and the irregular cornea. Up to 80% of ectatic eyes may be successfully managed with rigid gas permeable lenses alone . They arAnother option is scleral CL, which is known to improve visual function in patients with corneal irregularity . Their pIn addition to existing full-size scleral lenses , other dHybrid CL have been developed to improve fitting tolerance in patients who cannot tolerate rigid gas permeable lenses. Hybrid lenses  consist of a rigid center with a soft skirt. This combines the advantage of good visual acuity provided by rigid lenses with the comfort of a soft CL. Other types are tandem CL composed of a soft silicone hydrogel lens fitted between the rigid gas permeable lens and the cornea, improving comfort and fitting. Tandem lenses can be used initially as lens adaptation, or they may be used for long-term management .In early cases of post-PK ectasia, sutures may help remodel the corneal curvature by placing multiple interrupted tight sutures at the ectatic graft–host junction in correspondence to the maximum steepening meridians. Sutures compress the ectatic graft–host tissue, inducing peripheral flattening and steepening of the central corneal curvature in the axis where they are placed. In order to maximize this effect, limited opening of the graft–host junction in correspondence to where sutures are positioned is recommended. The use of compression sutures alone to control postoperative astigmatism after PK has been reported by Roper-Hall and Atkins . SuturesThe advantage of this correction is that it is safe and reversible, but the limitation is that improvement may be unpredictable and subject to loss of effect with time due to the tissue elasticity and progression of the ectatic development.If ectasia is confined to a limited extension along the graft–host junction, a wedge resection can be performed in the same area to reduce astigmatism . Wedge rFurthermore, removing the diseased tissue may prevent or delay the need for repeat PK. For this reason, this procedure is often considered before planning a repeat PKP for high astigmatism secondary to “recurrent” KC . A wedgeToric Intra Ocular Lens (IOL) has been described to correct post-PK astigmatism in phakic eyes during cataract surgery. IOLs can provide a wide range of options for correcting spherocylindrical errors and do not require significant manipulation of the grafted tissue . A potenThe Artisan toric  AC IOLs provide a good range of solutions for the correction of post-keratoplasty astigmatism and ametropia for both phakic and aphakic eyes. Major concerns with this procedure are potential complications such as SIA due to the large implantation incision, endothelial cell loss due to the AC implant, chronic inflammation due to chronic damage of the aqueous blood barrier, and cystoid macular edema. The toric lens is iris-claw fixated and has a 5 mm optical zone that requires a 6 mm limbal incision for implantation. The stability of the postoperative refractive cylinder after Artisan toric lens implantation for up to 36 months was reported excellent . A potenThe Intraocular Collamer lens (ICL)  is a posterior chamber phakic intraocular lens (pIOL), and it is reported to be effective for the correction of moderate to high myopia, hyperopia, and astigmatism. Concerns have been raised, because after ICL implantation, mechanical contact and rubbing between the ICL and the posterior iris surface can increase pigment dispersion, leading to pigmentary glaucoma and the induction of synechiae iris sphincter erosion, and iris transillumination. Laser iridotomy or surgical iridectomy and adequate ICL sizing are essential to prevent angle-closure glaucoma and pigmentary glaucoma. In addition, ICL implantation may provide an effective alternative for correcting anisometropia and astigmatism after corneal transplantation ,41.Another approach for correcting residual pseudophakic astigmatism induced by post-PK ectasia is the piggy-back IOL technique, which minimizes the risk of complications such as zonular, capsular, and corneal endothelial damage and provides more predictable results than in cases undergoing cataract surgery or clear lens extraction for high astigmatic correction. With this technique, a posterior chamber in the bag IOL replaces the cataractous or clear lens to correct the spherical refractive error, and a purposely designed piggyback IOL is implanted in the sulcus to correct the astigmatic error. Sulcoflex  and off-label use of ICL have demonstrated good refractive outcomes to correct pseudophakic astigmatism as a piggyback lens. The major advantage of this technique is the reversibility of the implant and the possibility of rotating the piggyback IOL after time to adjust the astigmatic correction. Complications to be considered are endothelial cell loss, ciliolenticular block, and pigment dispersion .A large diameter (8.5–9.5 mm) PK is often the treatment of choice in patients with extensive ectasia involving the graft–host junction. Still, numerous disadvantages are associated with this procedure, such as an increased risk of graft rejection, late endothelial failure, cataract development, and augmented risk of postoperative glaucoma . In addiPost-PK astigmatism with thinning of the cornea that involves the periphery makes surgical management exceptionally challenging. Tuck-in lamellar keratoplasty (TILK) is a surgical procedure that can be used for the management of cases with advanced corneal ectasia involving the corneal periphery and the graft–host interface ,47. UsinMalbran et al.  proposedOverlay deep anterior lamellar keratoplasty (DALK) for ectasia after PK consists of a large diameter (9–10 mm) lamellar stromal dissection encompassing the PK graft and the thinned graft–host junction, leaving behind the Descemet membrane and a thin layer of the stroma. Then, a same diameter full-thickness donor graft or a stromal lenticule of 300–400-micron thickness, prepared using a microkeratome, is sutured in place. With this procedure, once a cornea of correct profile and thickness has been reestablished, a smaller central PK can be performed should visual acuity results be inadequate due to an irregular graft–host interface . This teThis allows the creation of a main smooth recipient bed, favoring the formation of a clean graft–host interface that avoids the potential need for a subsequent central PK. Further modification of this technique was proposed by Yu et al. , who desCollagen crosslinking (CXL) exploits riboflavin as a photosensitizer followed by ultraviolet-A light. Collagen fibers in the cornea respond to treatment by developing chemical covalent bonds by photopolymerization, increasing corneal rigidity. Most crosslinking occurs in the 300–350 μm anterior stroma within the central 8–9 mm cornea. According to different trials ,56, thisDALK is an alternative surgical procedure to PK to treat various corneal pathologies, among them KC, without the involvement of the endothelium. Several studies demonstrated that DALK provides comparable visual outcomes to PK  with theManagement of advanced corneal ectasia is a significant challenge for any corneal surgeon. Over the last decade, many surgical approaches have been developed, so there is a large arsenal of surgical operations to correct post-PK ectasia . HoweverFurthermore, there are, so far, only a few anecdotal  cases of