The basic anatomy and morphology of subarachnoid cisterns of the brain are interesting and challenging topics with high clinical significance. These enlarged CSF-filled expansions are important as they transmit various neurovascular structures. The cisterns can be classified based on their location as supratentorial, at the level of the tentorium, and infratentorial. They are also classified as paired and unpaired cisterns. The anatomical and radiological information about the cisterns is clinically and surgically relevant in diagnosing and managing many neurological disorders. It is also essential in medical teaching. This pictorial essay reviews the radiological images where the subarachnoid cisterns are delineated in four unique circumstances. The subarachnoid cisterns are clinically and surgically significant enlarged cerebrospinal fluid (CSF)-filled pockets of the subarachnoid space that transmit important neurovascular structures including cranial nerves and intracranial vessels. The pia and arachnoid mater are closely approximated over the convexities of the brain . However, although the concavities of the brain are closely approximated by the pia mater, the arachnoid mater only loosely approximates the concavities of the brain. Thus, the subarachnoid space varies in depth and the more expansive spaces form the subarachnoid cisterns . YasargiIn this study, we deeply reviewed the radiological images where the subarachnoid cisterns are delineated in four unique case scenarios: a case of suspected CSF rhinorrhea who underwent computed tomography (CT) cisternography, CT brain with negative contrast demonstrating a case of extensive pneumocephalus, CT brain with positive contrast demonstrating a case of subarachnoid hemorrhage (SAH), and a patient with trigeminal neuralgia who underwent routine three-dimensional (3D) constructive interference in steady state (CISS) MRI of the brain. CT cisternography was performed for a 35-year-old female who presented with watery nasal discharge to evaluate for suspected CSF rhinorrhea . A pre-cCT brain with positive contrast was performed in a 45-year-old male patient who presented with loss of consciousness to evaluate for SAH. CT brain with negative contrast was studied in a 40-year-old male patient with loss of consciousness after a road traffic accident to evaluate pneumocephalus. Routine 3D-CISS sequence MRI was studied for a patient with trigeminal neuralgia. 3D-CISS is a gradient echo MRI sequence that is useful in evaluating a variety of pathological states where regular MRI does not provide appropriate anatomical information. 3D-CISS sequences are highly useful in evaluating cranial nerves, CSF rhinorrhea, and cisternal spaces due to the detection of subtle CSF intensity lesions that may be missed on routine sequences. The superiority and higher sensitivity of the 3D-CISS sequence are attributable to the accentuation of T2 values between CSF and other structures ,8.Normal anatomyThe central nervous system (CNS) components are all encased within three layers known as the meninges. The innermost layer is known as the pia mater, which is closely adherent to the brain and follows the contours of the sulci and gyri on the cerebral cortex. The outermost layer is known as the dura mater, which lies in close contact with the periosteum. The middle layer contained between the dura and pia mater is known as the arachnoid mater (spiderweb-like), and it is loosely adherent to the brain -14. The Classification of cisternsCisterns can be anatomically classified based on their location as either supratentorial, at the level of the tentorium, or infratentorial and whether they are paired or unpaired cisterns ,13,15,16Schematic representation of the subarachnoid cisternsFigure Paired supratentorial cisternsOlfactory CisternsOlfactory cisterns Figures -3C are tCarotid CisternsCarotid cisterns Figures -4D are pSylvian CisternsSylvian cisterns Figures -6C are TOculomotor CisternsThe oculomotor cisterns Figures -7E are pCrural CisternsCrural cisterns are paired cisterns that are located between the cerebral peduncles medially and the uncus laterally ,13,27. TUnpaired supratentorial cisternsCisterna ChiasmaticaThe cisterna chiasmatica (chiasmatic cistern) is a midline structure Figures -8F that Cisterna Laminae TerminalisThe cisterna laminae terminalis  Figures -9E is a Cisterna PericallosaWhen viewed in the sagittal plane, the cisterna pericallosa  has a convex shape to it  Figures -11D is sUnpaired cisterns at the level of the tentoriumCisterna InterpeduncularisCisterna interpeduncularis (interpeduncular cistern), also known as the intercrural cistern, Figures -13E is aCisterna QuadreigeminalisBordered anteriorly by the dorsal mesencephalon, the quadrigeminal plate, and the pineal gland, posteriorly by the vermis, superiorly by the splenium, and inferiorly by the collicular bodies and lingula of the cerebellum, the cisterna quadrigeminalis  Figures -14E is fSuperior Cerebellar CisternThe superior cerebellar cistern Figures -15E is lPaired infratentorial cisternsCisterna PontocerebellarisThe cisterna pontocerebellaris  is a rhomboid-shaped space encasing the pons Figures -16E, locMedullary CisternThe medullary cistern Figures -17E encaUnpaired infratentorial cisternsCisterna MagnaCisterna magna Figures -18D is tWe believe that this study provides the necessary and additional information about the subarachnoid cisterns, which can be relevant to the radiologists, neurologists, and neurosurgeons to better understand, diagnose, and manage various neurological disorders. The detailed knowledge about the subarachnoid cisterns is also highly relevant in undergraduate and postgraduate medical teaching. The cisterns are akin to the byzantine cisterns of ancient Rome but have been simplified in this article using special radiological imaging circumstances.


The transition of aortic dissection from acute to chronic is poorly understood. We examined time-dependent mechanical behaviour and biochemical properties of chronic dissection tissues.n = 10), TL  and FL (n = 4).Aorta samples were obtained from 14 patients with mixed aetiology who were undergoing elective surgery for chronic dissected aneurysms, ranging from 3 months to 15 years post-dissection. The tissue elastic modulus and tissue deformation following application of loading for 5 h were measured for the false lumen (FL), true lumen (TL) and flap (FP) tissues with a custom-indentation technique. Collagen, elastin and glycosaminoglycan levels were determined with established biochemical assays. Elastin fragmentation was graded from histological sections. The number of tissues characterized was as follows: FP . FP [0.5 (0.08) mm] also exhibited reduced deformation relative to TL [0.7 (0.02) mm] and FL [0.9 (0.08) mm] , lowest collagen concentration  and the lowest collagen: elastin ratio [0.4 (0.1)] relative to the other tissues . Significant elastin loss was evident in the FL-stained tissue sections whereas highly aligned, long fibres were visible in the FP and TL. A linear relationship was found between the stiffness, deformation and the time from the dissection event to surgical intervention for the FP. All data are presented as median (interquartile range).Tissues stiffness was highest in FP [59.8 (14.8) kPa] as compared with TL [50.7 (6.2) kPa] and FL [40.5 (4.7) kPa]  is characterized by the pathological formation of a new vascular lumen within the tunica media, and can be acute or chronic. It was noticed that the central displacement for FP was the lowest relative to TL and FL  µg/mg, P = 0.003]  µg/mg, P = 0.003]  µg/mg] as compared with FP and TL , P = 0.003] .The mean IIEO was 4 years, with a minimum of 3 months and a maximum of 15 years. Correlations between biomechanical properties with IIEO are shown for all groups in Degeneration of the dissected aorta is characterized by progressive FL dilatation. Our study demonstrates the biomechanical changes in the properties of the aortic wall underpinning this change, which is related to greater compliance of the FL. In turn, biomechanical degeneration appears to be caused by a loss of elastin and elastin fragmentation, which is most apparent in the FL. Our data also suggest that aortic degeneration in AD occurs independently of the presence of an underlying connective tissue disorder. Finally, our analysis elucidates the mechanism leading to progressive stiffness of the FP over time. In fact, stiffness (high E) was highest and deformation lowest in FP relative to TL and FL, and central deformation of FP was significantly lower than in TL and FL.The biomechanical characteristics of the FP were related to densely packed elastin fibres with little fragmentation. Interestingly, whilst FP increases in stiffness in time, the biomechanics of the TL and FL do not appear to depend on IIEO.In patients with IIEO >5 years, central deformation was minimal but still detectable, with no deformation observed for the patient with IIEO of 15 years. This finding suggests that some aortic remodelling post-AD may be expected to occur even after several months or a few years post-onset, hence that the transition between the sub-acute and chronic phase is a gradual phenomenon, which is only fully complete after several years of onset. To date, there are limited studies in the literature on the behaviour of human dissected tissues. A recent study demonstrated that chronic FPs exhibit increased stiffness and decrease compliance, supporting our findings . These fet al. [The stiffness of the FP and FL compliance could be explained by understanding the elastin distribution and architecture seen via histological images. The elastic fibres in TL and FP tissues were highly compact close to the intima layer, with long and aligned elastin fibres observed, similar to findings by Moriwaki and co-workers . They reet al. , who fouet al. , 19. TheOur findings offer a biomechanical and pathological explanation of the therapeutic effects of endovascular therapy of AD. In the acute and sub-acute phase, stents are used to cover intimal tears and to expand the TL, thus inducing secondary collapse of the FL. This can only be achieved if there is limited stiffness of the FP . As the Interestingly, the biomechanical data are independent of tissue aetiology (Marfan syndrome or non-syndromic) or location (ascending or descending). This finding suggests that endovascular therapy should have the same effects on TL re-expansion in syndromic and non-syndromic patients. Nevertheless, the choice of therapy should not be simply dictated by the likelihood of response in the dissected segment but also by the likelihood of late dissection and expansion of the adjacent normal aorta (the landing zones), which is significantly greater in patients with connective tissue disorders. In this group of patients, surgical therapy may prevent late re-perfusion of the FL in segments treated endovascularly, when proximal dissection occurs, as occasionally observed in our practice and by other authors .Our limited sample size with a male only cohort allows limited extrapolation to the general AD population. Similar studies on larger numbers would be needed to confirm our findings and to define the evolution of biomechanical properties of dissected tissues over time. Such studies may allow the re-definition of the sub-acute phase of AD on the basis of the likelihood of response to endovascular therapy, if coupled with bench testing on the effects of the forces generated by commercially available stent grafts on tissues with various stiffness/compliance. Further, it would be interesting to correlate histological and biomechanical features of the FP to its mobility through the cardiac cycle as this cannot be visualized with dynamic diagnostic modalities such as magnetic resonance and ultrasound.Inflammatory reactions are likely involved in the development of AD and exhibit different time courses of their changes in acute-phase reactions and between acute and chronic AD, but this is beyond the scope of this paper. Further, in order to gain insight into the FP behaviour at the hinge points, the biomechanical properties of FP at the hinge points should be investigated. Finally, given assumptions with the use of Our study probed biomechanical and biochemical changes in chronic AD tissues  and their relationship with IIEO. We show a loss of tissue compliance in FP and TL relative to FL, with FP being the stiffest. Loss of tissue compliance in FP and TL was related to compact, long and aligned elastic fibres, whereas the FL was highly compliant with high elastin fragmentation. Such changes were unrelated to the presence of underlying connective tissue disorders. This study contributes to understanding of how the structural properties of dissection tissues within the aortic wall alter with time and may explain why and how endovascular therapy works in various phases of AD.ICVTS online.ivac029_Supplementary_DataClick here for additional data file.


Waxyaffects grain fissure resistance and head rice yield by altering the layered structure of starch granules, thereby affecting their swelling response to moisture.The amylose synthase gene  Waxy is an important gene controlling GFR. Analysis of near-isogenic lines demonstrated that genetic variations in Waxy conferred different levels of tolerance to fissuring in grains. The null allele wx resulted in the highest GFR, while alleles that increased amylose synthesis reduced GFR. Increases in amylose content led to increases in the ratio of the widths of the amorphous layer to the semi-crystalline layer of the starch granules, and also to increased occurrence of chalkiness. The layer structure determined GFR by affecting the degree of swelling of granules in response to moisture, and chalkiness acted as an accelerator of moisture infiltration to rapidly increase the number of swelling granules. Our study reveals the molecular basis of GFR and HRY, thus opening the door for further understanding of the molecular networks of GFR and HRY.Head rice yield (HRY) is an essential quality trait, and is sensitive to environmental stresses during the grain-filling, harvest, and postharvest stages. It is therefore important for rice production and global food security to select for superior HRY traits; however, the molecular basis of this trait remains unknown. Using diverse rice germplasm material, we performed a genome-wide association study of grain fissure resistance (GFR), the phenotype most associated with HRY, and found that the granule-bound starch synthase I gene  Oryza sativa) feeds about half of the world’s population. Head rice yield (HRY), the proportion of the milled grains retaining at least three-quarters of their original length, is an important quality trait and is considered as an index of grading. Indeed, HRY directly determines the commercial value of the grain, and head rice is priced 20–50% higher than broken rice in international trade. Reductions in HRY due to breakage during grain dehulling and milling is estimated to cause up to 30% loss of commercial yield from paddy fields  are causally connected with increases in HRY . Dissect, and 12 . One locWaxy (Wx), which governs amylose synthesis in crops and is a well-known controller of cooking and eating quality in rice, are associated with differences in GFR. Our results suggest that Wx-mediated changes in the amorphous and semi-crystalline layers of the starch granules influence their swelling behaviour and hence GFR under damp conditions. In addition, chalkiness appears to act as an accelerator of moisture infiltration to increase the number of swelling starch granules.In an effort to discover QTLs for HRY, in this study we evaluated the percentages of fissured grains in 286 diverse rice germplasms using the optimized fissure-induction approach (Wxb knockout lines (CL1 and CL2) in the background of Oryza sativa subsp. japonica Nipponbare as described by Wx expression in Nipponbare and the two knockout lines, the GBSSI proteins were extracted and detected as described by Wxa (from Teqing), Wxin (from IR64), and Wxb (from Minghui 63) into a wx-type indica rice variety (Yangfunuo 4), as described by We generated and genotyped two CRISPR/Cas9-mediated indica and japonica; Wx NILs were grown in paddy fields amended with similar amounts of fertilizers, using standard local management practices during the summer growing seasons when the fluctuations in temperature and humidity were relatively small. The 286 rice varieties were grown at Yangzhou, Jiangsu Province, in 2016 and at Lingshui, Hainan Province, in 2017. The Wx NILs and the CRISPR-knockout lines were grown at Lingshui in 2018 and at Institute of Botany, Chinese Academy of Sciences, Beijing, in 2019, respectively. The varieties were planted in three batches at 15–20-d intervals according to their expected days to maturity, which ensured that they all matured around the same date (within 10 d). Plants were grown in plots of 31 × 43 m at a spacing of 20 × 15 cm. To minimize grain fissuring in the field, the plants were harvested individually once their panicles turned yellow and matured whilst still looking moist and pliable. For slow drying and minimization of grain fissuring during storage, the harvested panicles were spread on dry floors in a well-ventilated room and kept under shade at room temperature for at least 3 months to allow the grain moisture to decrease and equilibrate to ~12%. These protocols resulted in low proportions of fissured grains before the fissure-induction experiments  or to light rain for 30 min. To determine the percentages of head rice, at least 100 plump and non-diseased grains were dehulled with a JLJG 45 dehuller (Woliang) and milled with a Pearlest Polisher (Kett) for 40 s before counting the head rice.To assess the effects of sun-drying or drenching on HRY, newly-harvested grains were spread on an outdoor cement floor and exposed to the sun for 7 d  against the reference japonica genome . Single-nucleotide polymorphism (SNP) calling for each variety was performed using the HaplotypeCaller function of GATK  following the best-practice workflow. SNPs were filtered by applying the following criteria: minor allele frequency (MAF) ≥0.05 and missing rate <0.5. SnpEff (http://snpeff.sourceforge.net/) was used to annotate the effects of SNPs. Principal components analysis (PCA) was conducted using the twstats program within EIGENSOFT  and linkage disequilibrium (LD) was calculated using PLINK as described by The genomic DNA of the different rice genotypes was extracted from leaves from 1-week-old seedlings using a DNeasy Plant Mini Kit (Qiagen) following the manufacturer’s instruction, and then sequenced by Annoroad Gene Technology Co., Ltd (Beijing), on a HiSeq 2500 PE125 platform (Illumina) with 500-bp libraries. The raw sequencing data were processed by removal of adaptors and low-quality reads. The clean reads were mapped using BWA  and converted to 1000-grain weight.Brown rice was visually selected to remove immature and diseased grains. For most varieties, the plump and non-diseased dehulled grains were examined using the RGQI20A inspector to determine the grain length, width, and thickness. For varieties with long or red grains and the The dehulled grains used for the evaluation of dimensions were then examined using a Diode Array 7200 Near-Infrared Reflectance (NIR) Analyzer (PerkinElmer) to estimate the amylose, protein, and moisture contents of each variety as described by plusC Texture Analyser (Stable Micro Systems) and used to calculate the grain tensile strength as described by The breaking force of plump and uncracked brown rice was measured by the three-point bending test using a TA.XT g for 10 min in transfer steps. Stained starch granules were imaged under an FV1000MPE laser confocal microscope (Olympus).To trace the process of moisture infiltration, 5- aminofluorescein (DTAF) staining of grains and starches was performed using the method of https://www.mediacy.com/).The moisture infiltration depth of an individual starch granule was considered as the longest distance from the bright fluorescent boundary that appeared in the endosperm after water soaking to the grain edges on the ventral, lateral, and dorsal sides, as measured using the Image-Pro Plus (IPP) software  Advantage-1 instrument (Surface Measurement Systems). The temperature was held at 25 °C. The relative humidity was 0% for the first 10 min and then directly increased to 98%, at which point changes in mass began to be recorded at 15-min intervals. Samples of extracted starch (3 mg) were evenly spread on the pan of the DVS instrument and subjected to the same procedure to obtain weight increase data. The percentage increase in weight was calculated at each time-point relative to the original weight at 0% humidity.–1.For sequential image capture of the occurrence of fissures, a translucent or white-belly grain was selected, soaked in water, and inspected using the Grainscope. An S8APO stereomicroscope (Leica) equipped with a pco.dimax cs3 high-speed camera  was used to image the occurrence of fissures at a speed of 2000 frames sThe extracted starches were treated with 8% HCl at 38 °C for 2 d and then washed with water three times. After drying at 40 °C for 48 h, these samples together with untreated, dry samples were dispersed evenly over double-sided tape attached to microscope slides and imaged under the Axio Imager A1 microscope. Water at room temperature was added, and soaked starch granules at the same position were imaged again. The IPP software was used to evaluate the degree of swelling of each individual starch granule on the basis of its area.To observe the natural fracture surfaces of fissured grains, broken brown rice induced by the high-humidity (98%) treatment described above was used directly as samples. For observation of starch granules on a cross-section of endosperm, brown rice was frozen in liquid nitrogen for 5 min and broken in half using tweezers. For examination of starch growth rings, extracted starch granules were cracked and hydrolysed with α-amylase for 2 h according to the method described by –1. The relative crystallinity of the starch granules was quantitatively calculated by separating the diffractograms into the crystalline and amorphous portions as described by X-ray diffractograms were collected using an Empyrean diffractometer  at 30 kV and 30 mA. The scanning 2θ angles ranged from 3.5° to 50°, and the scan speed was 1° min–1. Spectra were baseline-corrected and deconvoluted in the wavenumber region from 1200 cm–1 to 800 cm–1 using Bruker Opus 3.0. Infrared absorbance values at 1047 cm–1 and 1022 cm-1 were extracted from the baseline-corrected and deconvoluted spectra to assess the short-range ordered structure of the starch.Fourier-transform infrared spectroscopy (FTIR) spectra of the extracted starch were recorded on a Tensor 27 spectrometer (Bruker) equipped with a deuterated triglycine sulfate detector using an attenuated total reflectance accessory at a resolution of 4 cm–1 and a combination of GRAM100 and GM1000 analytical columns (PSS Polymer Standards Service) was used to analyse the chain-length distribution of the debranched starch molecules.The extracted starch was dissolved in DMSO solution containing LiBr (0.5% w/w), debranched by isoamylase, then subjected to size-exclusion chromatography (SEC) using an LC-20AD SEC system coupled with an RID-10A refractive index detector (both Shimadzu) as described by japonica and 174 indica varieties, both of which had rapid linkage disequilibrium (LD) decay  decay , and evaarieties , B. The arieties  whilst narieties . The perarieties , E. The arieties .FISSURE RESISTANCE DIVERGENCE 1 (FED1), was detected in both years of our experiments, which might have been the result of the minor variations between the data for fissured-grain percentage in the two years  fell in the intergenic region between the functionally unknown LOC_Os06g04210 and LOC_Os06g04220. In addition to the peak SNP, only one SNP  in the 36-kb LD block had a P-value less than the suggestive threshold (P<1 × 10–7), and it was located in the splice donor site of the first intron of LOC_Os06g04200. This is the well-known rice granule-bound starch synthase I (GBSSI) gene Waxy (Wx), which governs amylose synthesis in the endosperm. Considering the positive correlation between the amylose content and the fissured-grain percentage, Wx is the most likely candidate gene underlying the FED1 locus.Next, we detected QTLs for GFR through a GWAS of the fissured-grain percentage among the 286 rice varieties using a mixed linear model. We identified three significantly associated loci on Chrs 3, 6, and 8 . Only thwo years . The pea06g04250 . The peaWx alleles among the 286 rice varieties, namely Wxa, Wxin, Wxb, and wx. Compared to Wxa, Wxin had a missense mutation of adenine (A) to cytosine (C) in the sixth exon, resulting in the substitution of serine for tyrosine . The mean percentage of fissured grains was lowest in the wx group (known as glutinous rice), and was significantly less in the Wxb group compared with the Wxa and Wxin groups (japonica cultivars (74/103) carried the Wxb allele while more than half of the indica varieties (88/155) carried the Wxa allele  analysis. On exposure to high humidity, kernels steadily absorbed moisture and their weight increased linearly with the time of exposure . The moindosperm . The intWx NILs resulted from their differences in hygroscopic behavior and the consequent differences in the swollen state of their starch. Comparison of the moisture absorption behaviors of the starch granules in response to high humidity detected by DTAF-staining among the NILs indicated that dry starch granules showed relatively dim fluorescence on their exteriors while wet granules were entirely brilliant green ] generally corresponded to the amylose contents as determined by the lectin-binding method, with the exception of NIL-Wxin . The Wxiine test . Taken tWaxy (Wx), which is well-known for its vital role in amylose synthesis in the endosperm of cereal crops including rice, and which is central to determining the cooking and eating quality of rice  is a crucial quality trait in the milling recovery of paddy rice, and hence it is an important target for breeders in developing elite rice varieties; however, the genetic basis underlying this trait is almost unknown. Using a genome-wide association study (GWAS) and analysis of near-isogenic lines (NILs), our study has highlighted an important gene that mediates grain fissure resistance (GFR) and HRY. Unexpectedly, this gene was identified as Wx-mediated GFR. We found that Wx allelic variations resulted in differences in the amorphous and semi-crystalline layered structure of starch granules (Our study has uncovered the molecular mechanism of granules  as a resgranules , which igranules , consequgranules , K–M. Ougranules , and hengranules , which dgranules . We foungranules , causinggranules . In whitgranules , C–D, sogranules . Thus, tIn conclusion, our study clearly elucidates the molecular mechanisms underlying GFR and HRY, and demonstrates that the amorphous and semi-crystalline layered structure of starch granules is a key structural basis for GFR, with chalkiness accelerating the degree of starch granule swelling under damp conditions. Our results open the door for further understanding of the molecular networks that determine GFR and HRY.JXB online.The following supplementary data are available at Fig. S1. Percentage of fissured grains before and after high-humidity induction of fissuring.japonica and indica varieties.Fig. S2. Principal component analysis and linkage disequilibrium decay between the Fig. S3. Correlations among fissured-grain percentage and protein content, moisture content, and the thickness, length, width, and length-to-width ratio of grains.Fig. S4. Summary data for the GWAS on grain fissure resistance.Wx allelic lines.Fig. S5. Plant and grain phenotypes of the different Wxb on GFR and HRY.Fig. S6. Effects of CRISPR/Cas9-mediated knockout of Wx NILs.Fig. S7. Head rice yield is reduced by grain fissuring rather than chalkiness in the four Wx NILs.Fig. S8. SEM images of fracture surfaces of fissured grains from the four Wx NILs.Fig. S9. Moisture infiltration behaviors of translucent grains of the four Wx NILs.Fig. S10. Moisture absorption behaviors of starch granules of the four Wx NILs.Fig. S11. Contents of amylose and amylopectin in the four Table S1. Details of the 286 rice varieties used in this study.Wx NILs.Movie S1. Time-lapse images of the initiation and development of fissures in translucent and white-belly grains from the four erac330_suppl_Supplementary_Figures_S1-S11Click here for additional data file.erac330_suppl_Supplementary_Table_S1Click here for additional data file.erac330_suppl_Supplementary_Movie_S1Click here for additional data file.


Background and Objectives: Early allograft dysfunction (EAD) is considered a surrogate marker for adverse post-liver transplant (LT) outcomes. With the increasing use of nonconventional donors, EAD has become a more frequent occurrence. Given this background, we aimed to assess the prevalence and impact of EAD in an updated cohort inclusive of both conventional and nonconventional liver allografts. Materials and Methods: Perioperative and one-year outcomes were assessed for a total of 611 LT recipients with and without EAD from Mayo Clinic Arizona. EAD was defined as the presence of one or more of the following: bilirubin > 10 mg/dL on day 7, INR > 1.6 on day 7, or ALT and/or AST > 2000 IU/L within the first 7 days of LT. Results: Within this cohort, 31.8% of grafts (n = 194) came from donation after circulatory death (DCD) donors, 17.7% (n = 108) were nationally shared, 16.4% (n = 100) were allocated as post-cross clamp, and 8.7% contained moderate steatosis. EAD was observed in 52.2% (n = 321) of grafts in the study cohort (79% in DCD grafts and 40% in DBD grafts). EAD grafts had higher donor risk index (DRI) scores , were more likely to come from DCD donors , were regionally allocated (p = 0.003), and had higher cold ischemia times . Primary nonfunction events were rare in both groups . Post-LT acute kidney injury occurred at a similar frequency in recipients with and without EAD , and there were no differences in ICU  or hospital  length of stay. For DCD grafts, the rate of ischemic cholangiopathy was similar in the two groups . One-year patient survival for grafts with and without EAD was 96.0% and 94.1% ; one-year graft survival was 92.5% and 92.1% . Conclusions: In this cohort, EAD occurred in 52% of grafts. The occurrence of EAD, however, did not portend inferior outcomes. Compared to those without EAD, recipients with EAD had similar post-operative outcomes, as well as one-year patient and graft survival. EAD should be managed supportively and should not be viewed as a deterrent to utilization of non-ideal grafts. With the growing number of people awaiting liver transplantation (LT), considerable efforts have been made by the transplant community to expand the available donor pool ,2,3. ThiThis was a single center retrospective study of patients who underwent LT at Mayo Clinic Arizona between 2015 and 2020. Patients who received a multivisceral transplant or a living donor liver transplant were excluded. Status 1A LT recipients were also excluded. This study was approved by the Mayo Clinic Institutional Review Board, and the need for written consent was waived (ID 20-006586). Two groups were compared: grafts without EAD (Group 1) and grafts with EAD (Group 2). Post-operative outcomes, including ICU and hospital length of stay, development of acute kidney injury (AKI), primary nonfunction (PNF), ischemic cholangiopathy, and one-year patient and graft survival were assessed.EAD was defined as the presence of one or more of the following: bilirubin > 10 mg/dL on post-LT day 7, international normalized ratio (INR) > 1.6 on day 7, or aspartate aminotransferase (AST)/alanine aminotransferase (ALT) > 2000 IU/L within the first 7 days . The donTime-zero formalin-fixed protocol post-reperfusion liver biopsies were obtained for most recipients. Patients received methylprednisolone induction and were then started on triple drug immunosuppression . Maintenance immunosuppression was reduced to tacrolimus monotherapy at 3–4 months post-transplant unless otherwise indicated, with trough levels maintained at 4–7 ng/mL.t-tests and Chi square analysis. A survival analysis was performed using the Kaplan—Meier method. A multivariable regression analysis was completed, looking at risk for graft loss at 1 year post-LT. Data were analyzed using GraphPad Prism 9.3.1 .Continuous variables were described using means and standard deviations; means and standard deviations, and medians; or medians and interquartile ranges (IQRs). Categorical variables were described using counts and percentages. Baseline and post-transplant characteristics were analyzed using n = 194) came from DCD donors, 17.7% (n = 108) were nationally shared, 16.4% (n = 100) were allocated as post-cross clamp, and 8.7% contained moderate steatosis. Post-LT, EAD was observed in 52.5% (n = 321) of recipients.In total, six-hundred and eleven LTs occurred during this period. Within this cohort, 31.8% of grafts (p = 0.0002) and were less likely to be undergoing re-transplantation (p = 0.003). Portal vein thrombosis  and transjugular intrahepatic portosystemic shunt  were observed at low frequencies in both groups. Donors in the EAD group had higher DRI scores  and BMI . Liver allografts with EAD were more likely to be regionally allocated  or to come from DCD donors . There were no differences in dWIT for DCD grafts in Groups 1 and 2 (p = 0.53). Grafts in Group 2 had higher CIT . Post-cross clamp allocation did not increase the prevalence of EAD .The recipient and donor characteristics for the two groups are shown in n = 236) of grafts in Group 1 (n = 277) and 86.3% (n = 277) of grafts in Group 2 (p = 0.10). A biopsy without histologic abnormalities was observed in 88.6% of grafts in Group 1 and 82.7% of grafts in Group 2 (p = 0.06). Grafts with EAD were more likely to have moderate steatosis . Hepatocellular necrosis was uncommonly observed in either group .Time-zero post-reperfusion liver biopsies were obtained for 81.4% (p = 0.60) or hospital  length of stay (LOS) between LT recipients in Groups 1 and 2. Most grafts with EAD (89.1%) exhibited only one EAD criterion (AST > 2000 U/L during first week post-LT week). Post-LT AKI occurred at a similar frequency in Group 1 and 2 recipients . PNF events were rare and did not differ between the two groups (p = 0.22). Need for early reoperation (within 30 days of LT) occurred in 23.1% of all recipients . Ischemic cholangiopathy occurred in 14.9% (n = 23) of Group 2 DCD grafts and 17.5% (n = 7) of Group 1 DCD grafts (p = 0.69). There were no differences in the types of ischemic cholangiopathy observed  between grafts in Groups 1 and 2 (p = 0.49).Post-LT outcomes are shown in p < 0.0001), AST (p = 0.03), ALT (p < 0.0001), and alkaline phosphatase (p = 0.01) were all higher in Group 2 grafts. Those differences remained present at 6 weeks post-LT . At one year, there were no differences in total bilirubin p = 0.29; ALT p = 0.42; AST p = 0.18; alkaline phosphatase p = 0.08 between graft Groups 1 and 2.Laboratory studies at one week, six weeks, and one-year post-LT are shown in p = 0.54) or graft  survival  and DCD (n = 194) grafts with and without EAD, EAD was observed in 79.4% (n = 154) of DCD grafts compared to 40.1% (n = 167) of DBD grafts (p = 0.001). Malignancy as an indication for LT was more commonly observed in recipients of DBD grafts with EAD (p = 0.001). Donor DRI scores were higher in DCD grafts with (2.3 ± 0.3) and without EAD compared to DBD grafts (p < 0.0001). Donor BMI was higher in DBD grafts with EAD (p < 0.001). Regional allocation was more commonly observed for DCD grafts with EAD (p < 0.0001). The largest proportion of nationally allocated grafts was noted in the DBD EAD cohort (p < 0.0001). Moderate steatosis was more common in DBD grafts with EAD . CIT was shorter in DCD grafts with and without EAD (p < 0.001); DBD grafts with EAD had the longest CIT (p < 0.001). There were no differences in ICU (p = 0.37) and hospital length of stay (p = 0.12) between the subgroups. PNF events were more common in DBD grafts with EAD . The characteristics of the four grafts with PNF are shown in p = 0.18) or graft (p = 0.36) survival.In comparing DBD (D grafts . RecipieWith ongoing efforts to increase the utilization of nonconventional donor organs, there has been an observed increase in the frequency of EAD ,22,23. HData supporting inferior outcomes with EAD have largely been based on outcomes pertaining to conventional DBD grafts ,12,13. TRecipients in Group 2 had a lower MELD score, were more likely to have malignancy as an indication for transplant, and were less likely to be undergoing re-transplantation. Despite seemingly favorable characteristics, Group 2 recipients were more likely to experience EAD at the time of transplant as a result of donor-related variables. Group 2 grafts had a higher DRI score and were more likely to come from DCD donors. They were also more likely to be declined by local centers, thereby resulting in regional sharing and higher CITs. In contrast, Group 1 recipients had a higher MELD score, were more likely to have indications for transplant other than malignancy, and were more likely to be undergoing re-transplantation. Although these characteristics can contribute to increased surgical complexity, Group 1 recipients were less likely to experience EAD following transplant as a result of more favorable donor and graft characteristics. This juxtaposition highlights the importance of optimal donor—recipient pairing, particularly when utilizing less ideal grafts. Within the United Sates, there is considerable variability in liver transplantation rates and the median MELD at the time of transplant. Some attribute this finding to deceased donor availability; however, much of this variability is explained by transplant center practices and willingness to use ideal, standard, and non-ideal grafts, such as those coming from DCD donors . AlthougAlthough a lack of impact of EAD in DCD LT outcomes has been inferred, inferior outcomes with EAD in DBD grafts continue to be commonly reported ,23. GiveIt is noteworthy that the majority of EAD grafts in this study met only one EAD criterion, AST > 2000 U/L during the first week post-LT. Fodor et al. previously noted that bilirubin and INR have a stronger predictive capacity for patient and graft survival compared to AST . SimilarTo our knowledge, this is the first study investigating EAD that has specifically focused on nonconventional donor types. It is also one of only a few studies to show a lack of impact of EAD on DCD and DBD post-transplant outcomes, including length of stay, AKI, and patient and graft survival. We do, however, acknowledge that, as a single center study, there are inherent limitations in generalizability due to practice-specific nuances. As a center with experience utilizing nonconventional grafts, the outcomes described here are reflective of carefully selected grafts. Donor—recipient pairing is a crucial component influencing outcomes, and similar outcomes would likely not be observed with the use of the same grafts in higher MELD patients. In addition, with the increased use of normothermic machine perfusion in liver transplantation, the clinical phenomenon of EAD will likely become increasingly uncommon, even with increased risk grafts. We hope that by sharing our experience, we can help improve the utilization of nonconventional donors where EAD is a common and non-detrimental occurrence.In summary, the ongoing reassessment of EAD, risk factors for EAD, as well as graft and patient outcomes is important to allow for further expansion of the donor pool and the successful use of non-ideal grafts. With efforts to expand the donor pool, EAD has become commonplace and no longer portends inferior outcomes, particularly for DCD grafts. In the context of non-ideal grafts, EAD should be managed supportively and should not be viewed as a deterrent to utilization.


The crystalline region of the starch in blanched ginger slices was broken, which might be beneficial for uniform colouring. The effect of CaCl2 pretreatment on starch properties depended on the concentration. The influence of CaCl2 at a concentration higher than 3.5 mol L−1 was more pronounced than that at a lower concentration. The uniformity of colouring was close to the effect of blanching treatment. Furthermore, the starch crystallization was destroyed, the granules were broken, and the polarized cross disappeared, which was consistent with that observed for the starch in blanched ginger slices. Therefore, it is possible to achieve a uniform colour in red ginger slices at room temperature through CaCl2 pretreatment.The colour of sushi red ginger slices without blanching is not uniform, which seriously affects their sensory quality. The effect of calcium chloride (CaCl −1 CaCl2 change the crystallization and polarization properties of starch at room temperature, which made ginger coloring evenly.4 mol L Among them, sushi red ginger slices is popular with consumers for its bright colour and refreshing taste and is widely exported to Europe, America and Africa.Ginger belongs to the family Zingiberaceae, and it is a perennial grass root plant with abundant nutritional and medicinal value, such as exerting anti-oxidative, anti-tumour and hypoglycaemic effects.5 It is usually added to food products in order to achieve the desired colour and has been used in soft drinks, sweets,6 kimchi,7 a traditional Korean fermented food and others. Blanching is a traditional thermal treatment that applied to various fruits and vegetables. The main purpose of blanching is to inactivate enzymes and destroy microbial cells. However, heat treatment also causes loss of nutritional and sensorial quality attributes.8,9 Blanching leads to the leaching out of phytochemicals in ginger and decreases the antioxidant potential.10 In the processing of sushi red ginger slices, blanching ensures uniform colouring quality. However, this process consumes large quantities of energy and is a costly commercial operation.11 Considering energy conservation and business benefit, the industry hopes to directly add colour seasoning liquid to non-blanched ginger slices. However, we found that the problem of uneven colouring will occur during the production if the seasoning liquid contains Allura red, especially for old ginger slices. The phenomenon of uneven colouring is mainly due to the difficulty in colouring the middle part of the ginger slices and the easiness of the edge part, which seriously affects the quality of appearance of the product and, thus, affects the economic benefits.Sushi red ginger slices is an industrial product prepared by adding colour seasoning liquid containing Allura red (E129) to desalted ginger slices after blanching at 95 °C. Allura red (2-hydroxy-1-(2-methoxy-5-methyl-4-sulphonatophe-nylazo)-naphthalene-6-sulphonate) is one of the most widely used synthetic diazo colorants.12–14 In sewage treatment, crosslinked amphoteric starch flocculants have a strong adsorption effect and can effectively enhance flocculation and sedimentation.15 Starch/polyaniline nanocomposite might effectively adsorb dyes from textile effluents.16 Heat treatment during the blanching process is a common method of gelatinizing starch and destroying crystallization.17 The gelatinization onset temperature (To) of ginger starch is 69.7 °C, peak temperature (Tp) is 77.3 °C and conclusion temperature (Tc) is 90.5 °C.18 Therefore, blanching pretreatment at 95 °C can gelatinize starch, which might facilitates the adsorption of pigment and renders the ginger colouring more even. During heat treatment, the gelatinization process mainly consists of water swelling in the non-crystalline region, gradual disappearance of the crystalline region with water entry, and cracking of the starch granules. In addition, factors such as pH, sugar, salt, lipids, and emulsifiers also have different effects on the gelatinization properties of starch.19–22The reason for difficulty in colouring may be related to the component of the ginger, which include water, starch, cellulose, pectin and others. The content of starch in old ginger is high, accounting for nearly 56% of the dry mass, and starch content in young ginger accounts for only about 19%. Several approaches have been made to modify starch as a potential adsorbent for dyes.23–26 Research has shown that different types of salt exhibited different effects on the energy required for starch gelatinization and the gelatinization temperature curve.27 Salting ions increased the gelatinization temperature and enthalpy of maize and waxy maize starch, and the effect of salt-soluble ions was the opposite.28 Furthermore, the degree of influence on the gelatinization temperature was also different. Some salts, such as NaCl and KCl, have little effect on starch gelatinization temperature.29 Ahmad showed that alkali metal salts  changed the gelatinization temperature of sago starch. When the alkali metal salt reaches a certain concentration, the starch can gelatinize at room temperature.29 Among the alkali metal salts, calcium chloride (CaCl2) exhibits the potential to be used as a food-processing aid for ginger slices considering food safety. In addition, calcium ions are often used as a firming agents in the processing of fruits and vegetables, which may have a good effect on the texture of the ginger.30 Because desalination is performed before the use of ginger slices, we performed the pretreatment of ginger slices with CaCl2 before the desalination process and removed the residual CaCl2 during desalination. Although many studies have been conducted to disclose the relationship between ions with starch gelatinization, clear descriptions are limited regarding the effect of ions on the property of ginger slices and starch. It is challenging to address the influence of ion concentration and environmental conditions on the property of ginger slices as a coloured matrix. These investigations further inspire us to explore a non-blanching method for ginger slices with good pigment absorption property.Salts have an obvious effect on the gelatinization of starch.2 concentration, processing time and temperature on the uniformity of colouring were investigated with a* value as an index. To obtain further insights on the influence of CaCl2 treatment on ginger slices, the dependence of starch structure on the CaCl2 concentration was elucidated via X-ray diffraction and polarization microscopy. These studies could provide guidance for improving the uniformity of colouring and quality of appearance of non-blanched red ginger slices.To achieve energy conservation, a creative non-blanching method to evenly colour ginger slices was developed in this study. The effects of blanching on ginger starch properties were compared. The effects of CaCl2.2.1Kaempferia galanga) slices  and Allura red  were provided by Laiwu Manhing Foods Corporation . Analytical grade reagents, including sodium hydroxide, CaCl2 and anhydrous ethanol, were purchased from Shanghai Chemical Reagent Corporation . All aqueous solutions were prepared with deionized water (Milli-Q water).Salted ginger . The liquid material contains salt, edible acetic acid, citric acid, aspartame, sodium saccharin, potassium sorbate, monosodium glutamate, and 0.03% Allura red. A non-blanched sample was used as the control.Salted ginger slices  were immersed in a thermostatic water bath (1 : 2 w/v) at 95 °C for 5 min. After blanching, the sample was placed in deionized water for 20 min (1 : 2 w/v) to remove salts, and this process was repeated 4 times. The sushi ginger slices were prepared 2.32 solution was prepared with different concentration . Salted ginger slices (200 g) were weighed and added to CaCl2 solution (1 : 2 w/v) respectively. Then the system were mixed for 10, 20, 30, 60, 90 and 120 min with a stirring paddle at 50 rpm. The processing temperature was set at 20, 30, 40 and 50 °C respectively. The ginger slices were then separated from the CaCl2 solution and placed in deionized water for 20 min (1 : 2 w/v) to remove salts and CaCl2. The desalting process was repeated 4 times. After desalting, the sushi ginger slices were prepared by vacuum sealing after adding the liquid material to it (2 : 1 w/v). The liquid material used was the same as that described above.The CaCl2.4L* (lightness), a* (redness) and b* (yellowness) values were recorded. The average a* value and the coefficient of variation were calculated to indicate the adsorption degree of pigment on the ginger and the uniformity of ginger colouring, respectively.The colour of ginger samples were assessed using a high-precision chromometer . Before measurement, the blackboard and the whiteboard were used for zero correction. Five ginger slices were randomly chosen from each pack, and 4 points were selected on each ginger slice to determine the colour value of the ginger slices. The a* value, the a* value of the pigment solution  was measured using the high-precision chromometer. The regression equation is Y = 2.115X + 8.4467 (R2 = 0.94), in which Y represents a* value, and X represents the concentration of Allura red.To reflect the relationship between the concentration of Allura red and 2.5−1 NaOH and was washed repeatedly until the washing water was rendered neutral. The starch was collected and freeze dried  for 48 h. Then, the dried starch was ground with a mortar and pestle, and passed through a 200-mesh sieve to obtain starch powder which was stored in a sealed container at room temperature.31The desalted ginger slices were macerated at a low speed in a Jiuyang blender (200 g of ginger slices : 200 g of deionized water) for 1 min. The homogenate was poured through four layers of muslin cloth, and the yellow residue that settled was washed with deionized water twice. Next, the mixture was sieved through a 100-mesh sieve to remove the residue. Ethanol was added to the filtrate to make its concentration more than 30%, followed by centrifugation at 8000 rpm for 10 min. The colourless precipitate was deproteinated using 0.01 mol L2.6The starch and water were used to prepare starch milk at a proportion of 1 : 100 w/v. A drop of starch milk was placed onto the glass slide, and was gently shaken to evenly distribute the starch, and was covered with a glass lid. The starch samples were observed under a microscope  at a 500× magnification.2.7θ), with a scanning speed of 2° (2θ) min−1 and a step of 0.05° (2θ). Starch crystallinity was analysed using the Jade5 software.The X-ray diffraction patterns of the starch from ginger were analysed using a D2 PHASER X-ray powder diffractometer  with Cu Kα radiation at a voltage of 300 W and a power of 2.2 kW. The scattered radiation was detected in the angular range of 3–45° (22.8p < 0.05) were conducted to determine significant differences.Each experiment was conducted in triplicate under the same conditions. The results were reported as the mean values ± standard deviation. Statistical analysis was performed using Origin 8.5. Analysis of variance (ANOVA) and bilateral Tukey's test , which was similar to that of the blanched ginger slices. Moreover, the colouring effect of the ginger slices improved significantly. Therefore, 4 mol L−1 was determined to be the best concentration. However, studies had shown that 3.5 mol L−1 CaCl2 could gelatinize starch at room temperature.29 It is possible that the concentration was slightly lower because the study was conducted in a pure starch system and the contact area was wider.a* value increased, and the coefficient of variation decreased with the extension of the processing time (10–30 min). The colouring of the ginger slices following 30 min of treatment was similar to that of the blanched ginger slices, and the colouring tended to be stable with longer processing times. Therefore, 30 min was determined to be the best processing time.The influence of pretreatment time on the colouring of the ginger slices is shown in a* value and its coefficient of variation showed a steady trend in the range of 20–50 °C, indicating that the effect of temperature was not obvious and that the treatment could be performed at room temperature.The influence of pretreatment temperature on the colouring of the ginger slices is shown in 2 could not be in full contact with starch in a short period of time. A certain concentration of salt solution could change the starch gelatinization temperature.28,36 CaCl2 at 4 mol L−1 had already lowered the starch gelatinization temperature to room temperature; therefore, changing the temperature had no effect on the result.The experimental results showed that the pretreatment time and temperature had little effect on the colouring of ginger slices. When the pretreatment time was less than 30 min, the colouring improved with increasing time. However, the effect of time was not obvious when the time was more than 30 min. This might be because CaCl3.32 on the colouring of sushi ginger was different. A high concentration of CaCl2 (≥4 mol L−1) produced a colouring effect in the ginger close to that obtained with the blanching treatment; therefore, this concentration might also transform starch properties. The crystallization characteristics, starch particle shape and other properties were compared by separating the starch from ginger slices that were treated with different concentrations of CaCl2.Blanched sushi ginger slices were more likely to exhibit even colouring because the high temperature of 95 °C changed the properties of the starch in the ginger slices. The effect of different concentrations of CaCl3.3.12 was less than 3.5 mol L−1, the crystalline structure of the starch was consistent with that from the non-blanched ginger, and the characteristic absorption peaks were obvious. The strongest diffraction peak was observed at approximately 15° at 2θ; a doublet between 17° and 18° and small peaks at approximately 5.7° and 23° were observed. The crystallinity was approximately 20% , which was also similar to the crystallinity for the non-blanched ginger starch. The characteristic absorption peaks of starch slightly decreased when CaCl2 was 3.5 mol L−1. The intensity of the peaks in the diffractogram could reflect the strength of the starch double-helix structure, and decrease in the reflections implied change in the structure.37,38 Therefore, this result indicated that the double-helix structure of starch was weakened, and the starch crystalline structure was slightly damaged; a crystallinity of 15.13% could also prove this inference. When the concentration of CaCl2 was ≥4 mol L−1, the crystallinity of starch was decreased by more than 95%. The crystallinity for starch treated with 4 mol L−1 CaCl2, 4.5 mol L−1 CaCl2, and 5 mol L−1 CaCl2 was 0.93%, 0.77%, and 0.33%, respectively. The X-ray diffractogram for the starch was similar to that of starch from blanched ginger, and the decrease in crystallinity might be due to the double-helical movement during treatment, which might have disrupted starch crystallites.39 Therefore, low concentrations of CaCl2 (<3 mol L−1) did not change the crystal form and the crystallinity of starch was similar to that of the non-blanched ginger slices. CaCl2 at 3.5 mol L−1 reduced the crystallinity of starch by 20.58%. However, a high concentration of CaCl2 (≥4 mol L−1) broke the crystalline structure and achieved the same effect as in the starch from blanched ginger slices.As shown in 3.3.22 pretreatment could influence the properties of starch, and the particle morphology of starch also changed accordingly. The morphology of starch from ginger slices was observed using a light microscope  could also break the starch granules and induce the polarized cross to disappear, which was consistent with the result for blanched ginger starch. This result showed that at room temperature, a high concentration of CaCl2 (more than 4 mol L−1) could lead to hydrogen-bond breaking and the gelatinization of ginger starch.Starch granules from blanched ginger slices were broken under light microscope. Research had shown that microwave-treated starch granules that were heated to a final temperature of 95 °C appeared completely ruptured.4.2. The experiments showed that different concentrations of CaCl2 had different effects on the starch crystallization structure, morphology, and polarization cross in ginger slices. Pretreatment with 4 mol L−1 CaCl2 almost completely destroyed the crystallization structure of the starch in ginger slices, broke the starch granules and led to the disappearance of the polarized light cross; this effect was close to that observed with blanching treatment. A high concentration of CaCl2 might be used in the pretreatment of ginger slices instead of the traditional blanching treatment. It could also cause the starch to gelatinize at room temperature, and the sushi red ginger slices exhibited even colouring and good sensory qualities.The uneven colour of ginger slices without blanching pretreatment is related to the characteristics of starch. The crystalline region of the starch is broken in blanched ginger slices. The properties of starch were evaluated in ginger slices treated with CaClThe authors have declared no conflict of interest.


Transplantation surgery teams often have to face complex cases. In certain circumstances, such as occlusion of the iliac vessels or prior pelvic surgery, heterotopic kidney transplantation may not be feasible and orthotopic kidney transplantation (OKT) could be a good alternative. Kidney autotransplantation (KAT) has been described as a potential treatment for complex renovascular, ureteral, or neoplastic conditions. There are scarce data regarding the complications and outcomes of these procedures; therefore, we present our experience.  We retrospectively analysed the medical records of both 21 patients who had received OKT and 19 patients who underwent KAT between 1993 and 2020. We collected demographic features and data regarding surgical technique, complications, and graft outcomes. Kidney graft survival was calculated using Kaplan–Meier survival analysis.  Regarding OKT, in 15 (71.43%) cases, it was the first kidney transplantation. The most common indication was the unsuitable iliac region due to vascular abnormalities (57.14%). The early postoperative complication rate was high (66.67%), with 23.81% of Clavien grade 3b complications. During the follow-up period (mean 5.76 -SD 6.15- years), we detected 9 (42.85%) graft losses. At 1 year, the survival rate was 84.9%. Concerning KAT, the most frequent indication was ureteral pathology (52.63%), followed by vascular lesions (42.11%). The overall early complication rate was 42.11%. During the follow-up period (mean of 4.47 years), 4 (15.79%) graft losses were reported.  Although OKT and KAT have high complication rates, these techniques can be considered as two valuable approaches for complex cases, in the absence of other therapeutic options. Renal transplantation is the treatment of choice for patients with end-stage renal disease (ESRD) for increasing life expectancy and for improving the quality of life. The increasing age of recipients, along with the presence of comorbidities, has increased the transplantation's complexity from both the surgical and medical points of view over the last decades. Furthermore, many complex situations cannot be solved using the conventional heterotopic kidney transplantation (HKT). Orthotopic renal transplantation (OKT) is a technically challenging but valid alternative for patients who are unsuitable candidates for HKT . NowadayKidney autotransplantation is an established but rarely used therapy in cases of renal vessel lesions, tumours of the kidney and ureter, long-distance ureter lesions, complex nephrolithiasis, and retroperitoneal fibrosis , which cThe surgical technique of OKT was first described by Gil-Vernet et al. in 1978, and it consists of a retroperitoneal approach to the splenic hilum via lumbotomy and was initially developed to treat hypertension secondary to left renal artery stenosis. After a nephrectomy is performed through a left lumbotomy, the vein is ligated near the renal parenchyma including its bifurcation. Artery revascularization is obtained with end-to-end anastomosis between the graft renal artery and the native splenic artery . Vein revascularization is obtained with end-to-end anastomosis between the graft renal vein and the native renal vein or splenic vein. Finally, the urinary system is reconstructed using pyelo-pyelic anastomosis in most cases .KAT shares similarities with the traditional surgical techniques for living donor nephrectomy and transplantation. Nephrectomy can be performed through lumbotomy and extraperitoneal access to the lumbar fossa, or using the laparoscopic approach. The renal vessels are carefully dissected and ligated. Gibson incision is performed in the iliac fossa, dissecting the iliac vessels and preparing them for anastomosis. It could be performed before sectioning kidney vessels and ureter, in an attempt to minimize ischemia time. Once retrieved, the kidney is perfused with preservation fluid . Vascular anastomoses to reperfuse the kidney are performed end-to-side to the external iliac vessels according to kidney transplant technique, with nonabsorbable 6–0 sutures. Finally, the reconstruction of the urinary tract is performed depending on each case; when possible (only vascular pathology), ureteral reimplantation is avoided to preserve the natural draining of the bladder trigone. When it is not possible, a stented tunneled extravesical ureteroneocystostomy or direct reimplantation can be chosen .There are scarce data regarding the outcomes of patients who undergo OKT and KAT. According to the literature review performed by Alameddine et al.  in 2018 This study aimed to analyse patients' characteristics, indications, complications, and outcomes of OKT and KAT in one of the largest series of these two techniques.We retrospectively analysed the medical records of patients who underwent OKT or KAT between 1993 and 2020 at our institution. We collected demographic characteristics of the recipients and donors and data regarding surgical technique and complications (early: <30 days or late: ≥30 days after surgery) as well as graft outcomes, including graft function at discharge, 1 month, 1 year, and 5 years, graft survival, and graft loss.Reviewed demographic data included age, gender, and age-adjusted Charlson comorbidity index (ACCI). Autotransplant outcome was evaluated using graft loss rates and laboratory data , because missing data regarding the date of graft loss meant that a survival analysis of KAT was not appropriate.Patients who did not require dialysis following transplantation were defined as having immediate graft function (IGF). Primary nonfunction (PNF) was defined as a permanent loss of allograft function starting immediately after transplantation, without vascular cause. Graft loss results in return to dialysis, retransplantation, or death.Graft rejection was histologically confirmed  or clinically suspected. Delayed graft function (DGF) was defined as the need for dialysis in the first posttransplantation week. The main cause of DGF was acute tubular necrosis (ATN).Non-death-censored graft survival was calculated from the date of transplantation to the date of irreversible graft failure  or the date of the last follow-up or to the date of death (death with functioning graft is considered as graft loss).Data were analysed with SPSS software . Descriptive statistics are shown as mean and standard deviation, or frequency and percentage. Kidney graft survival was calculated using Kaplan–Meier survival analysis.21 patients had received OKT between 1993 and 2020. The primary source of renal grafts was brain death donors. The mean age of the donors was 69.2 (SD 14.53) years. A preference for the selection of left kidneys was observed (72%). Regarding postoperative complications see , the earKaplan–Meier survival curve showing graft survival is seen in 2, respectively. Two patients experienced an improvement in eGFR (change in eGFR of 9.89 and 9.72). In contrast, one patient suffered a decline in renal function during follow-up (a reduction of eGFR in 25.77).19 patients underwent KAT between 1993 and 2020 at our institution. Patients' demographic characteristics are shown in The most frequent indication for KAT was ureteral pathology (52.63%), followed by vascular lesion (42.11%), which was the predominant one in the first years of our series. One rare case of a retroperitoneal residual germ cell tumour was performed in 2020 . The casThe overall early complication rate of KAT was 42.11% . The ratGraft outcomes are summarized in Few articles have addressed the issue of OKT and KAT, because these procedures are used to handle high-complexity cases. As a consequence, our knowledge is based on a small number of case series reported by high-volume centers. In light of this lack of data, we report our experience to contribute to widen our knowledge of these techniques and their outcomes.Certain conditions of candidates for kidney transplantation make this technique a complex and challenging surgery. For example, atherosclerosis, which is common in ESRD patients on dialysis, can be considered a relative contraindication to HKT in some cases. OKT is a good alternative when the heterotopic technique is not feasible and may play a role in selected patients with aortoiliac unworkable segments, occupied iliac fossae, or even in patients with special urinary tract conditions .  Table Prior works have proved that the most common indication of OKT is the unsuitable iliac region mainly due to vascular abnormalities . Our resKidney transplantation with arterial anastomosis on vascular prosthesis, in selected patients, can offer an alternative to dialysis . AccordiIn spite of the fact that acceptable outcomes have been reported on renal transplant on a prosthetic vessel (ARTPV), some reasons could justify the selection of OKT as a valuable option in patients with AIOD. In selected cases, the indication for OKT is clear. For example, unsuccessful or technically unfeasible vascular procedures, or vascular abnormalities . Regarding complications, redo surgery was necessary in 15% of cases, 30-day mortality was on average 6%, and most deaths occurred in cases of combined kidney transplantations and simultaneous ARTPV. Furthermore, the 5-year graft survival rate was reported in 12 studies and ranged from 17% to 100% [The data from our series were initially reported by Hevia et al. . They puRetransplantation rates have drastically increased to almost 25% over the past decades. Schachtner et al. studied 111 patients who underwent their second kidney transplantation and compared the outcomes between prior removed, or retained, allografts. Their data suggest higher cellular presensitization among kidney transplantations with the previous allograft removed, and it is associated with higher rates of acute cellular rejection and lower graft survival . In addiOther conditions, like inferior vena cava (IVC) thrombosis, agenesia, or stenosis, could require OKT. Chan et al. have published a series of 3 cases of OKT in this scenario .On the other hand, KAT is an attractive approach because it addresses the underlying pathology while eliminating the problems associated with allogeneic transplantation . There aDuprey et al.  evaluatePursuing the principle of nephron-sparing technique, KAT may allow in some cases the excision of renal masses in patients with a solitary kidney, or in those with large-sized masses, centro-renal location, and when the in vivo partial nephrectomy is technically difficult. In our series, only one KAT was performed due to oncological reasons, particularly a residual retroperitoneal mass in a patient with a history of germ cell cancer .In conclusion, aortoiliac occlusive disease and ureteral lesions are the leading indications for OKT and KAT, respectively.Musquera et al. reported the results of OKT in their center and compared indications, surgical techniques, and long-term results from two different periods (before and after February 1987). They noted that the overall graft and patient survival were similar between orthotopic and heterotopic kidney transplants performed during the same period. These authors concluded that OKT is a good alternative with acceptable rates of urologic and vascular complications for those patients for whom heterotopic transplant is considered unsuitable .As previously reported, the vascular complication rate of OKT ranges from 2.8 to 9.6%. In our series, 3 of 21 14.28%) patients developed vascular complications . According to Musquera et al., complications included renal artery stenosis in 3.6%, renal artery thrombosis in 4.8%, and renal vein thrombosis in 1% . Urinary.28% patiThe initial experience in elective OKT of Gil-Vernet et al.  informedSince the update on OKT published in 2010 by Musquera, no more large series have been reported. Some small series or case reports are being described in the literature. The orthotopic position has shown good recipient and graft results with an acceptable complication rate in selected patients . The oveRegarding KAT outcomes, the initial experience of our series was published by Ruiz et al., including 15 patients. We reported a complication rate of 46.7%. In our updated series, the overall early complication rate was 42.11%. This rate is similar to Moghadamyeghaneh et al. (46.2%) who have published the largest series  (15.79%)To sum up, OKT and KAT are highly specialized techniques in the field of kidney transplantation, with high complication rates.Furthermore, some groups have reported their series of robot-assisted kidney autotransplantation (RAKAT) and indicated that this technique is safe and feasible in selected patients with complex ureteral or renal pathology . This apRegarding OKT, the initial analysis of our series  revealed a DGF rate of 22.2% (2/9) . Our worAccording to Ruiz et al., after a mean follow-up of 73.1 months (range 7–312), 80% of the patients who underwent KAT have a functioning graft . Our curThe present findings and the review of the published series help to become established OKT and KAT as two valuable approaches for complex cases.Given the rising number of recipients suffering from vascular pathology, OKT is becoming a growing technique that lets us to avoid other techniques such as the use of arterial prostheses. However, this is a controverted issue. On the other hand, regarding KAT, its indications have remained solid and stable over the last years and are mainly ureteral iatrogenic lesions.Transplantation surgery teams increasingly have to face complex scenarios. In these challenging cases, although OKT and KAT have high complication rates, these techniques can be useful approaches to consider, with promising graft outcomes, in the lack of another surgical option.


The International Journal of Telerehabilitation (IJT) is a biannual journal dedicated to advancing telerehabilitation by disseminating peer-reviewed information about current research and practices. This open-source journal is indexed by PubMed and Scopus. IJT enjoys a diverse international authorship and readership.Such a diverse international audience would not be likely without the journal's use of an open journal system (OJS) and the generous sponsorship of the University of Pittsburgh's Office of Scholarly Communication and Publishing University Library System.IJT does not actively engage in marketing. We surmise that this wide readership is testimony to the expanding global relevance of telemedicine, telehealth, and telerehabilitation. IJT requires no readership or author fees.In the current issue, we are very pleased to publish work by authors from Australia, Belgium, Brazil, India, Israel, and Turkey, in addition to authors from the United States.As context, this issue was produced during an historic time. COVID-19, a global pandemic is, even post-vaccine, still dramatically affecting healthcare worldwide to greater or lesser degrees, as well as the global economy. Submissions to IJT continue to increase, ostensibly to document how telerehabilitation is meeting those challenges. We regret that we are unable to publish the high volume of articles that are being submitted. Instead, we strive to promptly suggest other placements for work that is not central to telerehabilitation or relevant to the larger IJT audience.International Journal of Telerehabilitation (IJT) features impactful research across rehabilitation disciplines including professionals engaged in cardiac rehabilitation; prevention, health, and wellness; occupational therapy; telerehabilitation post-organ transplantation; physical therapy (physiotherapy); and speech-language pathology. Some were generated by multi-disciplinary teams. Articles variously detail telerehabilitation across the lifespan.The current issue of the multi-disciplinary We cordially invite submissions to the Fall 2022 issue through October 31, 2022. IJT accepts original research, case studies, viewpoints, technology reviews, book reviews, and country reports that detail the status of telerehabilitation. References should adhere to the conventions of APA version 7.Sincerely,Ellen R. Cohn, PhD, CCC-SLP, ASHA-FIJT EditorJana Cason, DHSc, OTR/L, FAOTASenior Associate Editor


Gadolinium-induced acute pancreatitis is a rare phenomenon associated with the administration of gadolinium-based contrast agents. Only five cases of gadolinium-induced acute pancreatitis have been reported worldwide in patients with native pancreas and none with a pancreatic graft. We present a 32-year-old woman with prior history of simultaneous pancreas-kidney transplant who presented with generalized abdominal pain associated with systemic inflammatory response syndrome requiring admission to the intensive care unit. This occurred within 48 hours after having a magnetic resonance imaging (MRI) with gadolinium for investigation of subacute left optic atrophy. She was noted to have a marked rise in serum lipase, and the computed tomography findings were consistent with acute graft pancreatitis. Other causes of pancreatitis were ruled out, and she was managed conservatively with aggressive hydration, bowel rest, and analgesia with good recovery. This is the first reported case of gadolinium-induced acute graft pancreatitis occurring in a simultaneous pancreas-kidney transplant recipient. Clinicians should consider this rare differential diagnosis as a cause of graft pancreatitis in patients who have received gadolinium-based contrast agents. Gadolinium-based contrast agents (GBCAs) have been increasingly used in magnetic resonance imaging (MRI) to aid clinicians' diagnostic ability in neurological and inflammatory disorders. It is occasionally used in patients who are not suitable for iodinated contrast agents in computed tomography (CT) imaging . ContrarGadovist), 48 hours prior to investigate for subacute left optic atrophy.A 32-year-old woman, who was two years post simultaneous pancreas-kidney (SPK) transplant for type I diabetes, presented to the Emergency Department with sudden onset generalized abdominal pain. The pain was constant and dull in nature. It did not radiate, and there were no exacerbating or relieving factors. It was associated with fever, nausea, and vomiting, but there was no alteration in bowel habits leading up to this sudden abdominal pain. She denied any recent trauma, abnormal bowel movements, or urinary symptoms. She denied any illicit drug or alcohol use. The only relevant history was a recent magnetic resonance imaging (MRI) brain with gadolinium-based contrast agent (GBCA), gadobutrol , urea of 12.4 mmol/L, sodium of 145 mmol/L, and potassium of 4.6 mmol/L. Blood glucose was 8.4 mmol/L. Serum lipase was elevated at 3368 U/L . Liver function test was unremarkable, and C-reactive protein was not elevated. 12-hour tacrolimus trough level was 6.2 ug/L  of her abdomen demonstrated inflammatory changes of transplanted pancreatic graft with poor enhancement suggestive of graft pancreatitis . There wGadolinium-induced acute pancreatitis (gadolinium-induced AP) is a rare phenomenon. Despite the safety and tolerability of GBCAs, there are five cases which reported gadolinium-induced AP in patients with native pancreases –6. It ha3+) from chelated complexes leading to non-chelated Gd3+ being retained in organ tissues. Other studies also proposed that free Gd3+ leads to cytokine stimulation, macrophagic activation, and attraction of fibroblasts. However, none of the animal studies recorded the effects of GBCA on the pancreas.Multiple mechanisms of GBCA toxicity have been proposed. In a recent review , they suThere are no formalized criteria for gadolinium-induced AP. It is a clinical diagnosis that correlates with the development of acute pancreatitis following the administration of gadolinium. The diagnosis of acute pancreatitis itself is based on the revised Atlanta Classification which requires at least 2 of the 3 characteristics: abdominal pain consistent with pancreatitis, serum lipase value 3 times the upper limit of normal, and supportive imaging findings . CT findThere are three main differences compared to the other cases reported. Firstly, this is the first case of acute pancreatitis due to gadobutrol occurring in a pancreatic graft. She also developed symptoms after 48 hours of GBCA administration. Given the temporal relationship of GBCA administration and development of graft pancreatitis with no further recurrence during subsequent follow-ups while being on the same immunosuppressants, drug-induced pancreatitis attributed to her regular medications was deemed less likely as per the Mallory and Kern criteria .Another challenging aspect for our patient was to differentiate between other causes of transplant graft pancreatitis including pancreatic graft rejection. Transplant graft pancreatitis is the second most common complication after vascular thrombosis . ReporteSimilarly, pancreatic graft rejection can manifest as acute pancreatitis with elevated serum lipase with or without accompanying graft tenderness as the graft itself is insensate . The evaWhile both entities can lead to elevated amylase or lipase levels, graft pancreatitis would have a significantly higher reading compared to pancreatic graft rejection. Imaging adjacent to pancreatic allograft showing pancreatic infiltration, oedema, and peripancreatic fluid would also favour graft pancreatitis .To our knowledge, this is the first case report of gadolinium-induced acute graft pancreatitis in a patient with simultaneous pancreas-kidney transplant. While this is a rare occurrence, physicians should consider gadolinium-induced pancreatitis as a differential diagnosis for pancreatic graft pancreatitis.


Reconstructing diet can offer an improved understanding toward the origin and evolution of modern humans. However, the diet of early modern humans in East Asia is poorly understood. Starch analysis of dental calculus is harmless to precious fossil hominins and provides the most direct evidence of plant food sources in early modern human dietary records. In this paper, we examined the starch grains in dental calculus from Fuyan Cave hominins in Daoxian (South China), which were the earliest modern humans in East Asia. Our results reveal the earliest direct evidence of a hominin diet made of acorns, roots, tubers, grass seeds, and other yet-unidentified plants in marine isotope stage 5 between 120 and 80 ka. Our study also provides the earliest evidence that acorns may have played an important role in subsistence strategies. There may have been a long-lasting tradition of using these plants during the Late Pleistocene in China. Plant foods would have been a plentiful source of carbohydrates that greatly increased energy availability to human tissues with high glucose demands. Our study provides the earliest direct consumption of carbohydrates-rich plant resources from modern humans in China for the first time. In addition, it also helps elucidate the evolutionary advantages of early modern humans in the late Middle and early Upper Pleistocene. Homo erectus, China has been an important area of human evolution  . Fuyan C2 . Three s2 . The mor2 . The ori2 .Bos (Bibos) gaurus Smith, 1,827 excavated along with the human teeth at the same layer (layer 2) at Fuyuan cave confirms the original age to be older than 80 ka . Based on these reasons, we suggest that the original excavator’s determination of the age for our samples should be more reliable, and therefore, the age determined by the excavation team is applied here in this study.Recently, Adhered soil and other particles on 47 human teeth from Fuyan Cave in Daoxian were cleaned with a soft tooth brush. Microwear and dental calculus were observed under a digital microscope (VHX-600) using the extended depth of focus (EDF) technology. First, surface of teeth was thoroughly cleaned by blower and acetone before extracting dental calculus. Fifteen teeth had obvious calculus , and a dTo prevent samples from being contaminated, all implements were cleaned in an ultrasonic water bath before they were used. Two blank slides were placed on the laboratory table to check the air contamination in Ancient Starch lab of Zhengzhou University before the extraction experiment . When thd = 1.8 g/ml) was added to the sample to float the starch grains. After adding the distilled water into the new centrifuge tube and centrifuging it at 3,000 rpm for 10 min, the supernatant was pipetted and removed. This step was repeated a second time, and the remaining residue was kept for microscopic observation. The remaining sample was mounted in 1:2 glycerin/water on a slide and examined under polarized and transmitted light with an Olympus BX53 at 400 × magnification. Each starch grain was photographed, described, and counted, and the entire slide was examined. We observed and analyzed microwear under a digital microscope (VHX-600) using the EDF technology. In order to make a reasonable identification ancient starch grain, we made a one-to-one comparison with modern references native to the study area . This occurrence of dental caries may have been related to the consumption of carbohydrates found in acorns.High intake of starch plants (such as acorns) can lead to a certain degree of dental caries because frequent consumption of carbohydrates is a key factor in the initiation and progression of this disease . One earCastanopsis sp. and Cyclobalanopsis sp. have tannin and need to be processed before human consumption (Acorns including sumption . The earsumption , suggestConiferous fragments were found in the dental calculus of two Fuyan Cave hominins teeth 80 ka. Similar remains were also found in the dental calculus of a Neanderthal population from a 49,000-year-old site in Spain . Trace aOur results support that consumption of increased amounts of starch may have provided a substantial evolutionary advantage for early modern humans in the late Middle and early Upper Pleistocene in East Asia because of the energy it supplied to their increasingly large brain and other glucose-dependent tissues.We found acorns, roots and tubers, wild grass seeds, and other yet-unidentified starch grains from the dental calculus of Fuyan Cave hominins approximately 80 ka. This result reveals that these carbohydrates-rich foods played important roles in subsistence of the earliest modern humans in East Asia. Our study provides evidence of starch grains from acorns in dental calculus dating back at least 80 ka in South China. Additionally, starch grains that likely represent Triticeae were also found; although few were found, we should not underestimate the potential importance of wild grass foods as early as 80 ka in South China. Starch analysis of the earliest modern human dental calculus from Fuyan Cave documents definite consumption of plant food resources approximately 80 ka in the Late Pleistocene China. Furthermore, the discovery of different starch grains indicates that Fuyan Cave hominins may have ingested a variety of starchy plants to obtain carbohydrates and other energy to survive. Indeed, our study both reveals novel information about the diet of early modern humans in Late Pleistocene China and provides the earliest direct evidence for understanding the lifestyle of early modern humans in the late Middle and early Upper Pleistocene.The original contributions presented in this study are included in the article/YW designed the research. YW, DT, XW, and WL performed the research and analyzed the data. YW and DT wrote the manuscript. All authors contributed to the article and approved the submitted version.