To compare the patency control of dysfunctioning forearm arteriovenous graft (AVG) using percutaneous transluminal angioplasty (PTA) in patients with loop versus straight grafts.Between January 2012 and March 2017, hemodialysis patients with forearm AVG were treated with PTA at two hospitals. We reviewed technical and clinical success rates of each procedure. Procedure time and patency of the graft were compared for all patients as well as for subgroups of stenosis only and thrombosis using paired-sample t-test and Kaplan-Meier analysis.p = 0.217), with or without thrombi. There was no statistical significance in primary and assisted primary patency .Sixty-six patients  underwent PTA. Thirty-eight patients (58%) had loop grafts and 28 (42%) had straight grafts. Among 66 patients, 54 (82%) had thrombosis. Technical success rate was 95.5%  and the mean procedure time was 48.00 ± 16.75 minutes in all patients. Although there was a tendency towards shorter procedure time in patients with loop grafts (45.24 ± 20.24 minutes) than those with straight grafts (51.85 ± 22.76 minutes), the difference was not statistically significant (Our study suggests there is no different patency outcome between straight and loop arteriovenous grafts after PTA. Hemodialysis plays an important role in patients with chronic kidney disease 2. Accord45In the past, treatment of dysfunctional AVGs required surgical revision 8. With t29101112In this study, we compared the effectiveness of PTA for dysfunctioning forearm AVG between patients undergoing hemodialysis with loop and straight grafts.This retrospective study was approved by institutional review boards, and the requirement for written informed consent was waived. From January 2012 to March 2017, hemodialysis patients with AVG failure treated by PTA were retrieved from the records of two hospitals . Failed hemodialysis was first diagnosed by physical exam or during hemodialysis. Indications for PTA were elevated venous pressure causing difficulty in hemostasis, abnormal urea recirculation (more than 20%), abnormal physical findings  and unexplained decrease in dialysis dose. Contraindications to PTA were graft infection or severe aneurysmal dilatation.All patients were treated by interventional radiology in dedicated angiographic suites. We included the patients with an AVG in the forearm. Patients with AVGs in the upper arm or lower extremities were excluded. In addition, graft revisions performed by doctors other than interventional radiologists were excluded. Demographics, clinical data, and operation data for all patients were collected from patients’ electronic medical records from the hospital database.All interventional procedures were performed by four trained interventional radiologists with 3 to 20 years of experience in intervention radiology. Before the procedure, careful physical examination was performed in all patients with or without an ultrasound assist, to evaluate the location of stenosis or thrombosis. Pre-procedural antibiotics were not routinely administrated. Local anesthesia was administered at the puncture site using 2% lidocaine .In cases with loop grafts, a single puncture of the graft apex was performed with a micro-puncture set . After accessing the graft, fistulography was performed to evaluate the stenotic lesion and the extent of thrombus. In patients with thrombus, aspiration thrombectomy was first attempted with 7 Fr Hoffman sheath . If aspiration was not successful, an additional device such as the Trerotola device  was used to dissolve the thrombosis. After thrombectomy, balloon PTA was carried out with a 6 to 8 mm conventional  or high pressure balloon catheter  in each direction of the arterial and venous sides for one minute. In cases of arterial plug, a Fogarty balloon catheter  was used to remove the plug, or a balloon PTA was used to compress the plug. In all procedures in loop-graft cases, a single puncture was sufficient for the procedure in each direction Figure .In straight graft cases, after pre-procedural evaluation, the puncture site was identified. Because of the straight configuration of the graft, changing direction to treat both arterial and venous side was more challenging. In these cases, additional puncture was needed for the opposite direction. The remainder of the procedure was similar to the loop type graft Figure .From medical records and the Picture Archival Communication System (PACS), procedure time for each intervention was recorded. With the PACS system, we reviewed technical success rate of the intervention. From medical records, the clinical success rate of hemodialysis after the procedure was recorded. Comparison was performed between loop- and straight graft cases for mean procedure time and success rates.Evaluation of the patients’ graft status and symptomatic lesion was conducted by two radiologists using the PACS system. Based on this information, patients were divided into two groups, stenosis without thrombosis, and thrombosis with or without stenosis. In each group, comparison was made between the two different types of graft. We recorded the dates of procedure and follow-up procedures to evaluate the primary patency rate and assisted primary patency rate of the graft.0.05.Statistical analyses were performed using SPSS software, version 21.0. Paired-sample t-test was used to compare the technical success rate and procedure time between the loop graft and straight graft in all patients and each subgroups of stenosis only and thrombosis. Primary and assisted primary patencies of the graft were estimated using Kaplan-Meier technique with life table analysis. Univariate log-rank analysis was used to compare the loop-graft and straight-graft groups. The level of statistical significance was set at p-value < Technical success was defined as less than 30% residual stenosis of treated lesion in only stenosis patients. In thrombosis patients, technical success was defined as restoration of flow with less than 30% residual stenosis for the associated stenotic segment. Clinical success was defined as successful hemodialysis at least one session after the intervention procedure . We defi14According to quality improvement guidelines, minor complications are considered when there is no additional therapy required, or only nominal therapy is required, which includes overnight admission for observation only. Major complications are defined when patients required unplanned increased level of care and hospitalization of more than 48 hours .In total, 66 patients  underwent interventions for malfunctioning forearm AVG. Of these, 38 (58%) had loop grafts and the remaining 28 (42%) were straight-graft patients. The most common type of AVG was the brachio-cephalic loop graft  and radio-cephalic straight graft . Graft types are listed in Table p = 0.426). The mean procedure time was 48.00 ± 16.75 minutes (range: 14–110 minutes) in all patients. Between the two different types of grafts, the mean procedure time in patients with loop grafts (45.24 ± 20.24 minutes) tended to be shorter than in patients with straight grafts (51.85 ± 22.76 minutes), but the difference was not statistically significant (p = 0.217). In analysis of the subgroups, there was no statistical significance in technical success rate or mean procedure time between loop- and straight-graft cases  and 97.0% (64/66), respectively. Technical success rate of both loop grafts (97.3%) and straight grafts (92.9%) was not different (/66 and 9p = 0.38). The assisted primary patency of loop grafts (mean: 677 ± 652 days) was longer than that of straight grafts (mean: 644 ± 590 days) .Primary patency of loop grafts (mean: 193.9 ± 247.7 days) was shorter than that of straight grafts (mean: 304 ± 394.1 days) . During the procedure, the distal tip of the Hoffman sheath fractured and embedded in the graft. However, hemodialysis was completed successfully. Following successful hemodialysis, the patient underwent surgical removal of the fractured tip.With the rising incidence of end-stage renal disease, management of vascular access is increasingly important in long-term hemodialysis patients 12. Howev229216There are several types of AVG used depending upon a patient’s vascular condition. The most commonly used AVG are loop and straight grafts 56. To ou5In our study, the procedure time in loop-graft cases was shorter than in straight-graft cases, although the difference was not statistically significant. The trend towards a shorter procedure time in loop-graft cases could be explained by previously described procedural differences. In contrast, in the stenosis group, the procedure time was shorter in straight type grafts. This may be because the pre-procedure examination of the graft for the exact location of the stenosis was easier, allowing the treatment of only the problematic stenotic lesion without changing direction. In these situations, the procedure time could be shorter than in cases with combined thrombosis which may need additional treatment.As reported in previous studies, the one-year patency rate of loop grafts was higher than that of straight grafts (44.8% vs. 33.3%). According to previous studies, the one-year patency rates of the loop graft were reported as 26–31% and those of the straight graft were 17% 2. The autAccording to a previous randomized trial from Katsanos et al., a drug-coated balloon angioplasty improves patency of venous stenosis of dysfunctioning arteriovenous access . Also, rThere are several limitations in this study. First, this study is retrospective in nature and is subject to selection bias. All data such as minor complications might not required and properly recorded in all patients. And there may have intervention and outcome measurement error to occur. Additionally, because of lack of random allocation, there were differences in the perspectives of many factors influencing the outcome. Further study with randomized clinical trials is required. Secondly, several operators performed the procedures with anywhere from 3 to 20 years of experience in the interventional field. There was likely to be a difference in proficiency with the procedure based on experience. Third, the number of the patients was small, possibly introducing statistical error. Finally, since this study included only forearm grafts, further study is needed to generalize the results with graft conduits.Despite the anticipated differences in technical difficulties, our study did not show significant dissimilarity in success rate, procedure time, and patency rate of PCA between the two types of AVG. Further and larger studies are needed to confirm that there are no differences in outcome of PTA in dysfuctioning straight and loop grafts.


Similar trends were found in the subgroup of preterm babies. A shorter LOS was found in the OMT group vs. the usual care group both in overall population  and in preterm babies . In severe preterm babies, mean LOS was more than halved as compared to the control group. OMT was associated with a more marked weekly weight increase and, especially in preterm babies, to a relevant LOS reduction: OMT may represent an efficient support to usual care in newborn babies admitted at a NICU.The aim of this study was to assess the impact of osteopathic manipulative treatment (OMT) on newborn babies admitted at a neonatal intensive care unit (NICU). This was an observational, longitudinal, retrospective study. All consecutive admitted babies were analyzed by treatment . Treatment group was randomly assigned. Between-group differences in weekly weight change and length of stay (LOS) were evaluated in the overall and preterm populations. Among 1249 babies (48.9% preterm) recorded, 652 received usual care and 597 received OMT. Weight increase was more marked in the OMT group than in the control group (weekly change: +83 g vs. +35 g;  Worldwide, the estimated number of newborn babies is 136 million, among those, 9.6%  is preterm. Prematurity is defined as the birth before 37 weeks of gestational age (GE). Prematurity rate varies across continents, with a higher incidence rate in Africa and Asia, where 85% of all cases is observed . Data frPremature babies are characterized by higher rates of neurologic, respiratory, cardiovascular, metabolic, psychologic, and cognitive diseases in the first five years after birth ,7. It isThe average length of stay (LOS) in a neonatal intensive care unit (NICU) is 1.9 days for full term babies and ranges from 29.9 days to 64 days for babies with moderate to severe prematurity, respectively . The aveCurrently, in several Italian hospitals, osteopathic manipulative treatment (OMT) is an integrated activity for the care of babies admitted in the NICU, in spite of robust evidence about its efficacy being lacking. In some randomized clinical trials, OMT was documented to be effective on outcomes such as LOS, weight gain, vomiting, and evacuation as compared to usual care ,15,16,17Given these premises, the aim of this study was to assess the impact of OMT on clinical and physiological parameters and LOS as compared to usual care in a large cohort of newborn babies admitted in a NICU by retrospectively analyzing the large clinical database used in the center.This was an observational, longitudinal, retrospective study. All consecutive babies hospitalized at the NICU of Santo Spirito Hospital in Pescara  from September 2008 to November 2016 were eligible for the study. A chart review for this retrospective analysis was performed. Starting from all patients registered in the clinical database, the following exclusion criteria were applied: HIV or birth from sieropositive mother; transferred from or to other hospital; genetic or congenital disease; oncologic babies; cardiovascular, urinary, or hematologic abnormalities; suspect or overt necrotizing enterocolitis or abdominal obstruction; birth trauma; surgical patients; pneumoperitoneum; atelectasis.All babies in the cohort were followed-up from admission to discharge and divided into two groups based on the routine practice. In fact, osteopaths were present in the NICU on two specific days a week and consecutive babies admitted in the NICU in those days were treated with OMT in addition to routine care (OMT group); all other babies admitted in those days when osteopaths were not present in the center served as a control group . The usual care administered in the NICU were minimizing parent/infant separation; reducing environmental stressors; protecting sleep; feeding; skin to skin care (SSC); pain and stress management; caregiving interactions; and positioning of infants . The disbaseline information, i.e., personal and socio-demographic information of the baby and the parents, diagnosis at admittance (disease classification based on ICD9-CM standard code), delivery type, and clinical data of the baby at birth ;follow-up information, i.e., weight, length of stay, spontaneous stool, regurgitation, bilious stasis, blood stasis, gastric vomiting.All data collected during the hospitalization was recorded two times a week on an ad-hoc electronic clinical database routinely used in the NICU. The collected data included:The study protocol was approved by the local ethics committee.Osteopathic medicine is a complementary and alternative medicine that uses manual techniques to treat somatic dysfunctions and improve the patient’s health (ICD-10 code: M99.0-99.9). Osteopathic interventions were divided in two steps. The first step was the structural examination to locate the somatic dysfunctions. Tissue texture abnormalities and tone, areas of asymmetry and misalignment of bony landmarks, and the quality of motion, its balance and organization were evaluated. The second step consisted in the osteopathic treatment. The term OMT currently encompasses more than twenty types of osteopath-performed manual treatments . In treaThe osteopathic structural examination and treatment were performed by registered osteopaths with experience in the neonatology field. Manipulations were administered twice a week during the whole hospitalization period with an average duration of 20 min for each session.Analyses were performed in the overall cohort of hospitalized babies and in the subgroup of preterm babies . Preterm babies were further stratified by three clinically relevant classes of gestational age at birth . Baseline characteristics were expressed as mean and standard deviation or frequency and percentage for continuous and categorical variables, respectively, and compared using Mann–Whitney or chi-square test, as appropriate. Diagnoses at admission were identified based on the ICD9-CM codes and reported if they had a prevalence >2% in the overall cohort. The distribution of the same diagnoses was also assessed in the subgroups of preterm babies. Frequencies were compared between study arms through Poisson regression analysis.The primary end-point was the weight gain. The secondary end-points were reduction of length of stay and rate of spontaneous stool, regurgitation, bilious stasis, blood stasis, and gastric vomiting during the hospitalization. Weight change from admission to discharge over time was assessed using mixed models for repeated measurements, with study arm as a factor and time as a covariate, and an autoregressive correlation structure: mean estimated weekly rate of change, as well as between-groups contrast, is provided along with its 95% confidence I\interval (95% CI). Length of stay was estimated through adjusted linear regression models: results are expressed as means and mean changes with their 95% CIs. Rates of spontaneous stool, regurgitation, bilious stasis, blood stasis, and gastric vomiting were estimated with Poisson regression models and expressed as number of events/person-year: results are expressed as incidence rates (IRs) and incidence rate ratios (IRRs) along with their 95% CIs.p-values < 0.05 were considered statistically significant. All analyses were performed using SAS software release 9.4 .The Overall, 1249 babies recorded in the clinical database were analyzed, of whom 652 received the NICU routine care, and 597 received OMT in addition to routine care. There were 611 preterm babies, representing 48.9% of the cohort, of whom 315 received the NICU routine care and 296 received OMT in addition to routine care. p < 0.001 (p < 0.001)  B.p = 0.04) (p = 0.002), while no effect was documented in the other subgroups  . With thubgroups .Babies treated with OMT had 14% higher likelihood of spontaneous stool and 43% lower likelihood of blood stasis; on the other hand, they also showed a 91% higher likelihood of bilious stasis . In pretThe median (interquartile range) number of OMT sessions was 2 (1–3) in the overall population and 3 (2–5) in the preterm subgroup. Among the preterm babies, the median (interquartile range) number of OMT sessions was 7 (4–9) in the gestational age (GA) 27–31 weeks subgroup, 4 (3–5) in the GA 32–33 weeks subgroup, and 2 (1–3) in the GA 34–36 weeks subgroup.A cohort of 1249 consecutive premature babies admitted in the NICU of Pescara was analyzed to assess the impact of OMT vs. routine care on many different clinical endpoints. First of all, a positive impact of OMT was found on body weight gain during the admission. After the physiologic weight loss, the rate of weekly weight increase was significantly higher in the OMT group. Remarkably, the gap between OMT and control group widened over time. Moreover, the study shows some benefits of OMT in terms of length of stay. Gestational age plays an important role on the between-group difference in the LOS. It was not considered as a confounder, but rather as a treatment modifier. A statistically significant difference of over one month of admission was found between very premature babies  treated with OMT vs. control group, while no statistically significant differences emerged in the other subgroups. Additional clinical benefits of OMT emerged in terms of rates of spontaneous stool and blood stasis on the overall sample; on the other hand, a doubled likelihood of bilious stasis was found. These effects of OMT are plausibly mediated by an improved trophotrophic activity, which is in turn due to parasympathetic activity. Actually, preterm babies exhibit reduced heart rate variability  at term A previous multicenter randomized trial showed that OMT can reduce LOS by almost 4 days  per premature baby  as compaThe study has strengths and limitations. The main strength is the large population involved, which was representative of the whole practice of the center. Moreover, in the absence of randomization procedures, the random allocation of babies in the two groups was naturally ensured by the day of baby admission . The major limitation is the retrospective design, in spite of the adjustments for all available possible confounders. Additional limitation is represented by the lack of information about other potential confounders, e.g., interventions used in spontaneous births that may affect the anatomical structure or physiological function or the APGAR score (Appearence–Pulse–Grimace–Activity–Respiratory effort) at birth. On the other hand, the absence of a placebo group is not considered as a bias, since, reasonably, newborns are not exposed to a placebo effect. Available scientific literature does not have enough proof to demonstrate when the placebo effect starts, although it is related to brain development and potentially to expectation or other brain mechanisms .In conclusion, this study documented that compared to usual care, OMT is associated to a more marked weekly weight increase and an improved trophotrophic activity, which is in turn due to parasympathetic activity. The study also confirmed the LOS reduction seen in RCTs and showed also more marked decline in LOS in the real-word vs. the experimental setting. Considering these results, osteopathy has proven to be an efficient support of conventional medicine in newborn routine care.


Two-piece abutments consisting of customized zirconia abutment copings and prefabricated titanium bases are popular due to their biological and esthetic advantages. Glass–ceramic solder (GS) is an alternative biocompatible connective agent. This in vitro study evaluated the retentive force of GS in comparison to classical resin composite cements (RC) after artificial aging and autoclaving. Ninety specimens consisting of prefabricated titanium bases and zirconia abutment copings were fabricated. The two parts of each specimen were fixed either by RC (n = 30) or GS with a luting space of either 30 µm (n = 30) or 100 µm (n = 30). Ten specimens of each group underwent autoclaving before artificial aging . Twenty specimens (including the 10 autoclaved specimens) of each group were exposed to a mechanical load. The retentive force between the zirconia and titanium in all specimens was determined. A fractographic analysis was performed to analyze the fracture surfaces of the GS specimens. The RC- and GS-connected two-piece abutments showed no relevant differences, independent of the luting space. RC appears to be more vulnerable to the thermal and mechanical loads than GS. Thus, GS may be an appropriate alternative to RC for two-piece abutments, especially for patients with enhanced biocompatibility requirements. In dentistry, the fabrication of fixed partial dentures using dental implants became popular during the last decades . For thiThe connection of the zirconia abutment copings and titanium bases using glass–ceramic solder yields two interfaces with distinct adhesion mechanisms. The adhesion mechanism between titanium and glass–ceramic solder is similar to that in a classic metal-silicate ceramic composite. The mechanical retention is primarily decisive for the adhesive bond. The ceramic mass, which should have a lower coefficient of thermal expansion (CTE) than the metal alloy, shrinks onto the metal surface during the cooling process. In addition, adhesive oxides are formed during the heating of the metal. These can form a chemical bond with silicon dioxide. This bonding technology is considered mature and is recommended for routine clinical use ,13,14,15To date, only two studies from the field of dental medicine have dealt with the glass–ceramic solder bond between zirconia and titanium. In a four-point bending test, Mick et al. determined strength values of 104–119 MPa between zirconia and titanium cylinders joined with glass–ceramic solder. On average, these values were five times higher than those of a control group luted with composite (13–30 MPa) . In the Currently, there are no data describing the stability of the bond between zirconia abutment copings and prefabricated titanium bases joined with glass solder in comparison with conventional luting with resin composite cements. This study aims to investigate the retentive force between zirconia copings and titanium bases luted with resin composite cements or glass solder, after autoclaving, artificial aging, and mechanical loading. The glass solder specimens in this study are also subjected to a fractographic analysis. The following hypotheses were tested: (1) The connection of customized zirconia abutment copings with prefabricated titanium bases using glass–ceramic solder enhances the retentive force in comparison to resin composite cement; (2) neither autoclaving nor mechanical loading affects the retentive force of resin composite cements or glass solder; and (3) an enlargement of the joining gap in specimens joined with glass solder does not increase the retentive forces.The study protocol is presented in The materials used in the study, their composition, and manufacturers are listed in To enable mechanical loading in the chewing simulator, zirconia abutment copings in the shape of a premolar crown were designed using computer-aided design (CAD) software . Two cylindrical retention aids were added to the vestibular and oral surfaces in the area of the crown equator for the planned pull-off tests. In the 2-D cross-section, the zirconia abutment copings exhibited the geometry shown in A total of 30 zirconia abutment copings with a luting space of 30 µm were luted with resin composite cement (group RC30). For this purpose, the titanium bases were screwed onto implant analogs  to protect the interface. The shoulders of the titanium bases and screw channel openings were covered with adhesive wax to protect them from blasting sand. The luting surfaces of both the titanium bases and the zirconia abutment copings were blasted with 50 µm aluminum oxide and a pressure of 1.5 bar. Subsequently, the components were thoroughly cleaned with oil- and water-free compressed air. The bonding surfaces were conditioned with primers for at least one minute, namely the titanium bases with Alloy Primer  and the zirconia abutment copings with Clearfil Ceramic Primer Plus . Pastes A and B of the luting composite  were then mixed in a ratio of 1:1 and applied to the surfaces to be luted. After joining the components, the excess was removed, and an oxygen inhibitor  was applied in the screw channel and at the luting space. After a setting time of 20 min, the specimens were finished and polished.A total of 30 zirconia abutment copings with a luting space of 30 µm (group GS30) and 30 zirconia abutment copings with a luting space of 100 µm (group GS100) were luted with glass solder. The titanium bases were screwed onto the laboratory analogs and covered with adhesive wax in the shoulder areas. The luting surfaces of both the titanium bases and the zirconia abutment copings were blasted with 50 µm aluminum oxide at a pressure of 1.5 bar. Subsequently, the components were thoroughly cleaned with oil- and water-free compressed air. Afterwards, the screw channel openings were sealed with a firing pillow  to protect them against solder run-in. The titanium surfaces underwent a coating with a connect spray  and a sintering process. The temperature was increased at a rate of 55 K/min under vacuum up to a value of 800 °C and was maintained for 1 min in a ceramic firing furnace . The powdery base material of the glass solder  that was dissolved in an alcoholic fluid  was sprayed onto the preconditioned surfaces. For sintering, the compound specimens were thermally treated in the abovementioned furnace. The temperature was increased to a rate of 40 K/min under vacuum up to a value of 770 °C and was maintained for 1 min. After sintering and a slow cooling process (1 K/min), the specimens were cleaned by steaming. Finally, the excess solder was removed, and the edges were finished and polished.First, 10 specimens from each group (./. autoclave) were autoclaved three times at 134 °C and a pressure of 3.1 bar for 3 min . Then, all specimens were artificially aged. They were stored in water at 37 °C for 60 days in an incubator  and then subjected to an additional 30,000 thermal load changes in a thermal cycler with hot and cold baths . Per cycle, the specimens remained in the water bath for 30 s (Aqua dest.) at temperatures of 5 and 55 °C ) that were required to separate the zirconia copings from the titanium inserts were recorded. The data were collected using the program testXpert II .The retention between the zirconia copings and the titanium bases was measured in tension by using a universal testing machine  at a crosshead speed of 2 mm/min. The specimens were screwed to the lab analogs. The specimens were then inserted into the towing device, with the lab analog being screwed tightly in the lower holding device and the zirconia abutment coping subsequently being placed into the upper holding device, which was fixed moment-free to the testing machine with one chain. The forces and loads  and energy-dispersive X-ray spectroscopy  to assess their elemental composition. Due to its size and rotationally symmetrical shape, the fracture surface of the titanium bases was divided into six measurement positions. One EDX spectrum was recorded for each position. A map was created for the chemical elements titanium (Ti), silicon (Si), and zirconium (Zr). Based on element mapping, a quantitative analysis was then performed , Olympus Soft Imaging Solutions, Münster, Germany). The degree of the coverage or the percentage of the surface area on the titanium base was determined.t-tests, one-way analysis of variance (ANOVA), and Bonferroni tests were used to analyze the differences between the groups. P values lower than 0.01 were considered to be statistically significant. The analysis was performed using IBM SPSS Statistics, version 23.0 .After descriptive analyses, results were tested with respect to normal distribution using a Kolmogorov–Smirnov test. Since the results were normally distributed, One specimen from the group RC.none and one specimen from the group GS100.chew showed an incorrect bond. Their retentive forces were below 10 N. Both specimens were not considered in the statistical evaluation. p = 0.41). A 10% reduction in the mean pull-off forces (p = 0.97) was noted between GS30.none and GS30.chew, while a 15% reduction in the mean pull-off forces (p = 0.57) was observed between GS100.none and GS100.chew. The RC.chew specimens luted with composite showed higher retentive forces than the glass solder-joined specimens GS30.chew and GS100.chew .For the specimens that were only aged (group.none), the lowest mean retentive forces were observed for RC.none (692.33 ± 285.97 N), and the highest values were observed for GS100.none  and GS100.autoclav . Furthermore, there was a high standard deviation among the luted specimens (see p = 0.19).Among the initially autoclaved specimens, the luted RC.autoclav showed higher pull-off forces on average than the soldered GS30.autoclav . Between the glass solder groups GS100.autoclav and GS100.none, a 7% reduction in mean pull-off forces was noted (p = 1).Between the glass solder groups GS30.autoclav and GS30.none, a 3% reduction in the mean pull-off forces was observed , silicon (violet), and zirconium (orange) in a specimen section are shown as an example in High concentrations appear intensely bright. In the black areas, the element is below the detection limit (approx. 0.5%). High concentrations of titanium are found a in a smThe exposed proportion of titanium on the fracture surface is very low, averaging 3.75%. The silicon content varies between 31% and 74% (mean: 50.9%), and the zirconium content is between 11.3% and 60% (mean: 38.8%). In addition to pore formation, a mixed adhesive–cohesive fracture between the glass solder and the zirconia is visible. Based on the findings obtained from the SEM image and the EDX analysis, the group GS100.autoclav can be concluded to have a fracture in the area of the boundary layer between the glass solder and the zirconia abutment coping.The present study investigated the retentive force between zirconia copings and titanium bases luted with resin composite cements or glass solder after autoclaving, artificial aging, and mechanical loading. Specimens that underwent aging showed no relevant differences between the two bonding methods. Mechanical loading and sterilization led to an increase in the retentive forces with a high standard deviation in the luted specimens. The applied mechanical loads and sterilization did not reduce the retentive forces of the soldered specimens. Moreover, an enlargement of the solder gap had no influence on the retentive forces in the specimens joined with glass solder. The EDX analysis indicates a fracture between the glass solder and the zirconia.For the resin composite-cemented specimens, an average retentive force of 692.33 N was measured after artificial aging . Studies with comparable pretreatment showed similar values. Mehl et al. found retentive forces of 687.7 N, while Arce et al. found 595.5 N and Gehrke et al. at 532.4 N ,27.p = 0.410) [In accordance with the findings reported by Zenthöfer et al., an average increase in adhesive strength was observed after artificial aging  and chewing simulation (1.2 million cycles) in the group RC.chew (= 0.410) . However= 0.410) .p = 0.19) [In accordance with the results reported by Fadanelli et al., a significant average increase in adhesive strength was observed after initial autoclaving (3× 134 °C), artificial aging , and chewing simulation (1.2 million cycles) in the group RC.autoclav ( = 0.19) . One rea = 0.19) .To our knowledge, there are only two studies to date that have dealt with the joining of titanium and zirconia using glass solder. Mick et al. investigated the bending strength of the glass solder bond between titanium and zirconia . For thi2, B2O3, Al2O3, Na2O, and K2O. The effects of the addition of 1 wt.% Fe2O3 and of 1 wt.% Fe2O3 with 1 wt.% Bi2O3 respectively was investigated. During the shear strength test in a universal testing machine, shear strength values of 14 to 17 MPa were determined in the groups of the soldered specimens.In the second study, Vu et al. tested the shear strength of the glass solder joint of titanium and zirconia in a different test setup . For thiIn our study, the tensile bond strength for the specimens joined by glass solder was 12.7–14.8 MPa. Notably, the two previous studies and the present study used different test methods and specimens with different geometries. Due to the closed ring structure of the luting bases in the present study, higher forces would be expected than with the joined cylinders in the study by Vu et al. . The cheA space of 30 µm has become established for adhesive abutments ,7. In a However, in the present study, the width of the solder gap showed no relevant influence on the retentive forces, independent of autoclaving, artificial aging, or mechanical loading.The pore formation observed in the SEM images cf.  in the sIn order to alleviate this problem and improve the bond between titanium and glass–ceramic, cobalt oxide can be added to the glass–ceramic mass. This causes the following reaction (2).The additional wedging of the cobalt precipitate resulted in an improvement of the adhesive forces in experiments .The surface analysis of the titanium bases in the present study revealed a material failure, primarily along the zirconia-glass solder interface. This is not consistent with previous publications. For the evaluation of the fracture surfaces, Mick et al. used SEM and EDX, while Vu et al. used light microscopy with 25× magnification ,21. In b5Si3), to be a weak point of the glass solder bond [−6/K in the tetragonal phase to approx. 7−10−6/K in the monoclinic phase. However, the CTE of the glass solder is aligned with the tetragonal phase. Thus, adhesion-reducing occurs in monoclinic areas. This phase transformation can be reversed by heat treatment after sandblasting [2O3 at a pressure of 1.5 bar.The bond between titanium and glass solder can be improved by modifying the composition of the glass solder. Brow et al. considered the reaction product of titanium and silicon dioxide, titanium silicide (Tider bond . An alteder bond . Howeverder bond . One reablasting . Howeverblasting . In ordeIn conclusion, the use of glass solder to join titanium bases and zirconia abutments yielded retentive forces that are equivalent to those achieved with composite luting. To what extent these in vitro results are also applicable to everyday clinical practice cannot be clearly stated to date. In practice, many more factors, such as the ease of processing, production time, cost-effectiveness, acceptance by dentists and dental technicians, would influence the bonding method that will ultimately be used for two-piece abutments. In this regard, further studies—especially clinical studies—with the glass solder material should be conducted before a final recommendation for the procedure can be made. Two relevant aspects of the clinical application can be derived from the study. Firstly, the glass solder bond achieves and retains bond strengths—even after aging—that are of the same order of magnitude as those achieved with clinically established types of composite cement. Secondly, the glass solder composite tolerates the clinically necessary autoclave sterilization procedures without a relevant influence on the bond strength. Based on this knowledge, clinical investigations can now be conducted on the behavior of the composite concerning bacterial colonization and inflammatory reactions of the peri-implant tissue.Furthermore, autoclave sterilization did not show any negative effects on the luted abutments. On the basis of the present study, it can therefore be recommended that this form of sterilization can be used in the future, especially for procedures involving blood contact—such as the one-abutment-one-time concept—without restrictions for the adhesive bond.


The coronavirus SARS-CoV-2 is a member of the Coronaviridae family that has caused a global public health emergency. Currently, there is no approved treatment or vaccine available against it. The current study aimed to cover the diversity of SARS-CoV-2 strains reported from all over the world and to design a broad-spectrum multi-epitope vaccine using an immunoinformatics approach.For this purpose, all available complete genomes were retrieved from GISAID and NGDC followed by genome multiple alignments to develop a global consensus sequence to compare with the reference genome. Fortunately, comparative genomics and phylogeny revealed a significantly high level of conservation between the viral strains. All the Open Reading Frames (ORFs) of the reference sequence NC_045512.2 were subjected to epitope mapping using CTLpred and HLApred, respectively. The predicted CTL epitopes were then screened for antigenicity, immunogenicity and strong binding affinity with HLA superfamily alleles. HTL predicted epitopes were screened for antigenicity, interferon induction potential, overlapping B cell epitopes and strong HLA DR binding potential. The shortlisted epitopes were arranged into two multi-epitope sequences, Cov-I-Vac and Cov-II-Vac, and molecular docking was performed with Toll-Like Receptor 8 (TLR8).Escherichia coli expression system. The molecular docking with TLR8 also demonstrated that they have a strong binding affinity and immunogenic potential. These in silico analyses suggest that the proposed multi-epitope vaccine can effectively evoke an immune response.The designed multi-epitopes were found to be antigenic and non-allergenic. Both multi-epitopes were stable and predicted to be soluble in an  COVID-19 has been declared a pandemic by the World Health Organization (WHO) as of the 11 March 2020 . The outCoronaviruses (CoVs) are a family of viruses causing diseases ranging from the common cold to more severe illnesses such as Severe Acute Respiratory Syndrome  and Middle East Respiratory Syndrome  . BelongiThe genome contains six open reading frames (ORFs), including ORF1ab, ORF3a, ORF6, ORF7a, ORF8, ORF10, encoding spike glycoprotein trimer S, nucleoprotein N, membrane protein M and envelopes small membrane protein pentamer E . SARS-CoConsidering the gravity of the situation of COVID-19 worldwide, there is a dire need for the development of an effective vaccine or antiviral drugs that are effective in treating this viral infection. Currently, there is no FDA approved treatment or licensed vaccine against COVID-19. Vaccination is the most desired option available at our disposal to eradicate the diseases associated with infectious microorganisms . ReverseTo elicit strong immunogenic responses and have long-term efficacy, vaccines against coronavirus must activate both humoral and cell-mediated immune responses . Virus-shttps://bigd.big.ac.cn/) and GISAID (available at https://www.epicov.org/epi3/cfrontend) database as of 15 March 2020 to identify conserved immunogenic epitopes representing the novel coronavirus strains (collection) and to design a potent multi-epitope vaccine against the COVID-19 infection.In this study, we have utilized the 475 genomes of SARS-CoV-2 available in NGDC (available at: https://www.epicov.org/epi3/cfrontend) and NGDC databases were mined to retrieve updated complete genomes of SARS-CoV-2. The retrieved genomes were then aligned using the Multiple Alignment using Fast Fourier Transform tool (MAFFT) (available at: https://www.ebi.ac.uk/Tools/msa/mafft/) (GISAID (available at /mafft/) . Default/mafft/)  to generhttp://crdd.osdd.net/raghava/ctlpred/) was used for prediction of CD8 T cell epitopes (http://crdd.osdd.net/raghava/hlapred/) and ProPred1 (available at: http://crdd.osdd.net/raghava/propred1/) (CTLpred (available at: epitopes . Consensopred1/) .http://www.ddg-pharmfac.net/vaxijen/) (All CTL epitopes were screened for antigenicity using VaxiJen (available at: axijen/) . VaxiJenhttp://tools.iedb.org/immunogenicity/)  . This tohttp://www.cbs.dtu.dk/services/NetMHC/)  . The tooNetMHC/) . FurtherNetMHC/) .http://crdd.osdd.net/raghava/ifnepitope/scan.php) (http://crdd.osdd.net/raghava/abcpred/) using a default threshold (http://www.cbs.dtu.dk/services/NetMHCII/). These alleles were DRB1_0101, DRB1_0103, DRB1_0301, DRB1_0401, DRB1_0402, DRB1_0403, DRB1_0404, DRB1_0405, DRB1_0701, DRB1_0801, DRB1_0802, DRB1_0901, DRB1_1001, DRB1_1101, DRB1_1201, DRB1_1301, DRB1_1302, DRB1_1501, DRB1_1602, DRB3_0101, DRB3_0202, DRB3_0301, DRB4_0101, DRB4_0103, DRB5_0101. HLA-DR alleles are present on the surface of antigen-presenting cells and present the epitopes to helper T-cells initiating an immune response (The ORFs that didn’t yielded prioritized CTL epitopes were subjected to Helper T Lymphocytes (HTL) epitope (CD4 T cell epitopes) prediction by the HLApred server. This was done to cover the whole proteome of the virus. All alleles of MHC-II were selected, and experimental as well as predicted binders were included in the analysis. A default threshold was used, and all predicted epitopes that shared no identity with humans were selected. The predicted epitopes were screened for their antigenic potential using VaxiJen as discussed earlier. The antigenic epitopes were further screened for their IFN-gamma induction potential using IFNepitope using hybrid approach that involves both SVM and Motif based approach. The prediction model chosen for analysis was IFN-gamma vs non IFN-gamma (available at: can.php) . The epihreshold . Lastly,response . HLA DRBresponse . Lastly,Epitopes were arranged as per their arrangement in the reference sequence, the CTL epitopes were linked together using a flexible linker GGGGS as recommended by Different physicochemical properties of multi-epitopes were predicted using ProtParam tool including prediction of in vivo half-life, theoretical isoelectric point (pI), molecular weight, instability index, aliphatic index and Grand Average of Hydropathy (GRAVY) index of peptides . The deghttp://crdd.osdd.net/raghava/algpred/) (http://ddg-pharmfac.net/AllergenFP/) (Both multi-epitope constructs (with and without adjuvant) were screened for their allergenicity using two online servers; AlgPred (available at: lgpred/)  and AllergenFP/) . In AlgPhttp://www.ddg-pharmfac.net/vaxijen/)   and Antiaxijen/) . Scratchhttp://www.ebi.ac.uk/thornton-srv/databases/pdbsum/)   was usedhttp://scratch.proteomics.ics.uci.edu/)  (http://biocomp.chem.uw.edu.pl/CABSflex/) (Tertiary structures of both vaccines were predicted by Scratch Protein Predictor-hosted 3Dpro tool (available at ci.edu/)  and refi=REFINE) . The modBSflex/)  was usedhttp://haddock.science.uu.nl/services/HADDOCK/haddockserver-guru.html) (http://haddock.science.uu.nl/services/HADDOCK/haddockserver-refinement.html) (https://bio3d.colorado.edu/imod/paper/). The interacting residues between each complex were predicted using PDBsum analysis (The models were then checked for their interaction with Toll-Like Receptor 8 (TLR8). Active and passive residues for these analyses were predicted using CPORT . Moleculru.html)  with defnt.html) . Moreovent.html)     and codoThe recruited 475 complete SARS-CoV-2 genomes showed a high level of conservancy upon multiple sequence alignments and in the phylogenetic tree . The conA total of 13 CTL epitopes were shortlisted for designing multi-epitopes. These shortlisted epitopes were predicted to be antigenic (as determined by VaxiJen tool), immunogenic (as determined by MHC-I IEDB Immunogenicity tool), and had potential to bind with HLA superfamily alleles (as predicted by NetMHC) . All theA total of 10 HTL epitopes were scrutinized for multi-epitopes. These shortlisted epitopes were predicted to lack homology with Human proteome (as determined by HLApred), had overlapping B cell epitopes (as determined by ABCpred), showed potential to induce IFN-gamma response (as determined by IFNepitope server) and demonstrated strong binding affinity with HLA DR alleles (as predicted by NetMHCII) . All theTwo multi-epitope constructs were designed with and without β-defensin adjuvant to analyze and compare whether the designed multi-epitope is efficacious only in presence of adjuvant or has the ability to elicit immune response solely. Cov-I-Vac was the multi-epitope construct without adjuvant and Cov-II-Vac was with adjuvant .E. coli.Physio-chemical analysis of Cov-I-Vac and Cov-II-Vac revealed that both constructs are reasonably stable (38.48 and 39.91 respectively), have molecular weight <50 kDa, lower GRAVY indexes , with a pI of 9.97 and 10.03, respectively. The N terminus of Cov-I-Vac has Threonine so its half-life in mammalian reticulocytes was predicted to be 7.5 h (if tested in vitro) using Protparam. Meanwhile, Cov-II-Vac, because of Glycine at N terminus, has a half-life of >30 h in mammalian reticulocytes, as predicted using N-end rule. However, no difference in in vivo half-life was predicted, and was found to be >20 h in yeast and >10 h in The antigenicity potential was found to be retained in both multi-epitopes and was estimated as 0.6153 and 0.5947 for Cov-I-Vac and Cov-II-Vac, respectively. Both constructs were reported as antigenic by AntigenPro as well with an antigenicity score of 0.516406 and 0.386605.E. coli. The safety profile also showed that constructs do not exhibit any experimentally reported allergens and thus projected to be non-allergens.Moreover, both vaccines were soluble upon overexpression in The secondary structure prediction of Cov-I-Vac shows that it has a sheet and beta hairpin between two strands , six helices, 42 beta turns and two gamma turns . The secThe tertiary structure of Cov-I-Vac had 10.2% poor rotamers with 90.5% Rama favored residues; however, the refined structure selected for further analysis had an RMSD of 0.541 with 0% poor rotamers and 93% Rama favored residues. Similarly, the initial structure of Cov-II-Vac had 5.9% poor rotamers with 89% Rama favored residues, but the refined shortlisted structure with RMSD 0.548 had 92.9% Rama favored residues and 0% poor rotamers.The trajectory of 10 models was generated after simulation . The RooTrajectory analysis of fast simulation of Cov-II-Vac was analyzed and the RMSF of the structure was found to be 0.75–7.25 Å. The maximum fluctuation was observed at residue 227 while minimum fluctuation was residue 39–59 .The active and passive residues of Cov-I-Vac, Cov-II-Vac and TLR8 are provided in For an in depth analysis of protein–protein interactions, PDBSum analysis revealed that a total of 36 residues of Cov-I-Vac interact with 43 residues of TLR8, with one salt bridge, 15 hydrogen bonds and 210 non bonded interactions. The detail of the interaction is illustrated in NMA analysis of both multi-epitopes showed that Cov-I-Vac has higher stability than Cov-II-Vac, as the Eigenvalue, the energy required to deform the structure, was higher for Cov-I-Vas as shown in E. coli K12 strain. The total length of the Cov-I-Vac clone was 3.6 kbp while Cov- II-Vac clone was 3.8 kbp. Both sequences were designed to be added to the plasmid between restriction sites AfiIII-pciI and BspQI-sapI  were within the optimum limits . The CAIpQI-sapI .The COVID-19 pandemic has affected 213 countries around the world with almost 6.3 million patients and more than 378 thousand deaths . The curThe phylogenetic analysis of 475 genomes of SARS-CoV-2 reveals that genome sequences reported from China belong to clades containing those from almost all of the countries of the world and covering the whole span of a phylogenetic tree. The relatedness of SARS-Cov-2 strains was expected considering that the outbreak originated from China .The present study was mainly conducted to propose multi-epitope based vaccines against SARS-CoV-2 by an immunoinformatics approach similar to other studies . These vIn recent years, epitope-based vaccines, developed via immunoinformatics approach, have gained global recognition as an alternate therapeutic strategy because of the various advantages they possess. A multi-epitope vaccine was designed against MERS, a virus belonging to the same family of viruses as SARS-CoV-2, using in silico tools . AnotherThe vaccine designed in our study used all predicted ORFs and therefore covers the complete proteome. Epitopes selected were 13 CTL based and 10 HTL based that elicit cell mediated and humoral immune responses, respectively. Therefore, our subunit vaccines are projected to be effective and immunogenic against SARS-Cov-2. Coding sequences of the proteins of SARS-CoV-2 from NCBI were evaluated for their antigenicity. Highly antigenic sequences were used to predict B and T cell epitopes, the key step in vaccine development. Antigenic T cell epitopes were screened to overlap with B-cell and IFN-gamma epitopes . HTL epiThe multi epitope vaccines, proposed in this study, were designed with the help of linkers; epitopes were linked with GGGGS (CTL based) and GPGPG (HTL based) linkers. Linkers were added to help maintain the proper functioning of each epitope after being imported to the human body independently . GGGGS lAn adjuvant, β-Defensin was added to the N-terminus of Cov-I-Vac to make it Cov-II-Vac, using EAAAK linker, in order to increase the immunogenicity of the vaccine. N-terminus amino acid plays a role in ubiquitin mediated degradation . The EAAβ-defensins are effector antimicrobial peptides having antimicrobial activity including antiviral, antibacterial and antifungal activity . They reThe two multi-epitopes Cov-I-Vac and Cov-II-Vac are 317 and 367 amino acids long respectively with a molecular mass of 31.6 kDa and 37.2 kDa, respectively. Both predicted proteins are basic according to theoretical pI values. The instability index and aliphatic index scores calculated using in silico analysis indicated that the vaccine proteins can prove to be stable and thermostable in a test tube, if tested experimentally. The GRAVY score for our vaccines was positive and suggests that both are hydrophobic, which may necessitate the use of micelles for better interaction of the vaccine protein within the polar environment of the body . The effCov-I-Vac and Cov-II-Vac were found to be antigenic, immunogenic, non-allergenic and strong MHC binders. These factors suggest that the multi-epitopic vaccines will have a robust immune response without allergic reaction.Molecular Dynamic Simulation studies are mainly conducted to check the stability of vaccine by simulating it in a cellular environment . HoweverThe efficacy of a multi-epitope vaccine depends on the population for which the vaccine is prepared. The human CTL and HTL based T cell epitopes included in our multi-epitope vaccines were 99.29% similar to those of the world population, indicating that it holds great potential to be an effective approach to combat the ongoing pandemic. In order to induce effective immunological responses in the body, the strong binding of the vaccine products with immune receptors is necessary. The molecular docking analysis of our designed multi-epitope based vaccine showed significant interaction with an immune receptor, TLR8, further predicting the efficacy of both vaccines. However, the vaccine Cov-I-Vac showed a stronger interaction with TLR8. The docking scores indicate that the epitopes predicted in this study have higher binding affinity with TLR8 and thus, have the ability to elicit an effective immune response. TLR8 recognizes the single stranded RNA and acts as a major switch to elicit protective immune responses. It initiates antiviral responses via MyD88-dependent pathway leading to the production of type I and III interferons and other pro-inflammatory cytokines via NF-κB activation  . These iE. coli K-12 system. The advantages of using pUC19 plasmid for cloning of Cov-I-Vac and Cov-II-Vac are high copy number, smaller sized plasmid and color differentiation upon over expression (color of recombinant colonies appears white while non-recombinant ones appear blue)  . The in We believe that immunoinformatics approaches are useful to design effective vaccine candidates that when tested in experimental studies yield proposed outcomes . All theThe study was aimed to predict a vaccine against SARS-CoV-2 using immunoinformatics approaches. Two multi-epitopes were designed, one without adjuvant (Cov-I-Vac) and the other with β-defensin adjuvant (Cov-II-Vac). The in silico designed multi-epitopes Cov-I-Vac and Cov-II-Vac are predicted to be antigenic, immunogenic, thermostable and safe for human applications. The multi-epitopes cover the predicted proteome of SARS-CoV-2 . Cov-I-V10.7717/peerj.9541/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.9541/supp-2Supplemental Information 2Click here for additional data file.10.7717/peerj.9541/supp-3Supplemental Information 3Click here for additional data file.10.7717/peerj.9541/supp-4Supplemental Information 4Click here for additional data file.10.7717/peerj.9541/supp-5Supplemental Information 5Click here for additional data file.


The editors of European Journal of Midwifery would like to thank all our reviewers who have contributed to the journal in Volume 3 (2019).Alé, FranckFranceΑlipour, zahraIranAntonakou, AngelikiUnited KingdomBaird, KathleenAustraliaBetron, MyraUnited StatesBonilla, HildaChileCurtis, KathUnited StatesDarra, SusanneUnited KingdomDey, TeestaUnited KingdomDieb, AmiraEgyptDurain, DawnUnited StatesEgenberg, SigneNorwayEscuriet, RamónSpainForbes, FayeAustraliaFox, DeborahAustraliaGrum, TeklitEthiopiaHarris, MelissaAustraliaHisano, MichiJapanHunter, BillieUnited KingdomKing, RosemaryAustraliaLagana, AntonioItalyLambert, JakiUnited KingdomMackenzie, IanUnited KingdomMas, Masresha L.EthiopiaMc Carthy, JaneIrelandMeneses-Rentería, AlbaMexicoMitchell, CreinaAustraliaMivšek, PolonaSloveniaMünstedt, KarstenGermanyNy, PernillaSwedenOo, WinMalaysiaProsen, MirkoSloveniaSandwell, RachelCanadaSharek, DanikaIrelandTeklesilasie, WondwosenEthiopiaTura, HalkenoUnited StatesVermeulen, JoeriBelgiumWerner, AnetteDenmarkWhitburn, LauraAustraliaWier, JacquelineUnited KingdomYurdakul, MineTurkey


Dear Readers,“La Radiologia Medica”.I reach the end of my term as Editor-in-Chief of I am leaving my position not without a hint of nostalgia, but also with the awareness and the pride for having contributed to the growth of the SIRM official journal, turning it into a reputable, international scientific journal that reached the psychologically unbreakable Impact Factor score of 2, never been so high in its more than centenary life.Eight years have passed since, at the end of October 2012, the then-President Carlo Faletti proposed to me to become Editor in-Chief of “La Radiologia Medica”, the official SIRM Scientific Journal.The President’s mandate was clear in its harsh and essential simplicity: the aims were to renew the magazine while preserving its tradition, to avoid financial and—mostly—editorial collapses, to increase international credibility, and to retain Members.At that time, the Journal was going through a difficult period: the number of manuscripts received by the editorial office was at a worrying historical minimum peak; a bilingual journal  printed and sent by mail in hard copy to all the SIRM Members was showing all the signs of the time and needed a deep renew.I proudly accepted the assignment with the serene concern of being embarking on a long and tough journey; in a short time, a new editorial line was defined on few but substantial characterizing points: 12 issues per year (instead of 8), a cover restyling, an online-only and English-only journal with abolition of hard copies; finally, a renovation of the revision process by improving the number and the selection of the reviewers, and a more attentive selection of the manuscripts on the basis of strict quality parameters.new edition, renewed in the graphics and in the content, was regularly published online in January 2013 in English language.The first issue of the Since then, the Journal, which became monthly, had a steady growth trend, with a double-digit percentage of increases both for the number of submitted manuscripts and as well as for the number of downloads per year.At present, the editorial office of “La Radiologia Medica” manages more than 1000 manuscripts yearly submitted from about twenty countries around the world.In few years, the acceptance rate dropped from 42 to 22%, this in contrast with a significant increase of 43% in the number of the published papers, for a total of 228 papers published per year.The number of the invited reviewers increased from a few dozens to over 460, guaranteeing a faster and more transparent reviewing process including a wide range of skills, with a consolidated, average of 2 weeks for the completion of the review process.A great satisfaction has been the constant increase of the IF which reached the value of 2, one of the highest among the radiological journals of the National Scientific Society, and with a self-citation rate significantly below 20%.Following this encouraging performance, the Journal strongly consolidated itself as a pivotal asset of the Society, establishing itself as the “SIRM-gold card”, and became at the same time the object and the active subject of stimulating discussions during the Institutional meetings, which were raised in number and effectiveness, that the successive SIRM Presidents held with the managers of other International Scientific Societies.Carlo Faletti, Carlo Masciocchi, Carmelo Privitera and Roberto Grassi who supported my efforts in the management of the Journal: my personal endless thanks go to all of them.These important and consolidated goals are the result of careful planning and of a believed and effective teamwork that involved the entire Editorial Board of the Journal, the office and the Springer editorial managers, irreplaceable for the great and punctual technical support, and the SIRM Presidents After 8 years in the role, at the end of my experience as Editor, I felt that the time to throw the “ball” to a new Direction, younger, more motivated, more capable of grasping the new challenges of scientific publishing: Open access, economic management independence, new direction and editorial experiences open to internationalization.Prof. Antonio Barile as the new Editor in-Chief, who supported me managing the Journal in the last two years, was conceived in this direction, as the natural continuum of a project begun in 2012 that aims to grow and bring “La Radiologia Medica” at even more ambitious levels.The choice of Antonio Barile is the right man at the right time, capable, determined, now master of the fine mechanisms of the scientific publishing world.Antonio: I’m sure I am leaving the Journal in the best hands possible at now.Good job I am saying this already as “Old” Editor in-Chief of the Journal, and I am saying that to you like the new SIRM President-elect.: from next week I will no longer have to look for a job… nor will it have to look for me.Paraphrasing a historic phrase by Oscar Wilde, I feel like sayingThank you all.Andrea Giovagnoni,Editor in-Chief,La Radiologia Medica.


International Journal of Telerehabilitation (IJT) is a biannual journal dedicated to advancing telerehabilitation by disseminating information about current research and practices. The journal is indexed by PubMed and Scopus.The This issue was produced in the days of the unrelenting 2020 COVID-19 pandemic. As would be expected for an e-journal, these unusual circumstances did not alter IJT's editorial and production processes, as IJT journal editors and publishing staff have always worked remotely. What was a departure from issues produced pre-COVID19, was the volume of new submissions, nearly a five-fold increase. This quickly required an enlarged pool of reviewers. Fortunately, our professional networks generously assisted, and IJT was able to quickly recruit many more expert reviewers.We cannot over-state the contributions that volunteer reviewers make to a journal, its authors, and to current and future readers. Discerning reviewers are essential to the quality control of every journal. The purpose of an IJT review is not just to advise the editors on whether to publish an article. Most importantly, reviewers dig deep inside an article and if needed, to advise authors how to elevate the quality of their work. We are most grateful to an assiduous group of new and returning anonymous reviewers, about whose efforts our authors routinely offer appreciation. One experienced scholar recently wrote: “Again, we want to pass on our sincere thank you for considering this submission and what a reviewer this is! They are exceptional and have provided great feedback.”International Journal of Telerehabilitation (IJT) features impactful research that spans rehabilitation disciplines and medical diagnoses. Among the eleven curated articles, three detail how telerehabilitation is strategically deployed in parts of three underserved regions: Brazil, Croatia, and Nigeria. IJT reviewers and editors are keenly aware that cultural and socioeconomic variables influence how telerehabilitation is most appropriately defined and creatively administered in different cultures. We are confident that IJT readers will absorb the content in these articles with cultural humility and recognize that the parameters of telerehabilitation are best locally determined. We invite even more work from non-US countries.The current issue of the multi-disciplinary


The results showed that the processing efficiency of potato starch foams varied depending on the level of polyvinyl alcohol, the shape of the forming die and the screw speed applied. The analysis of energy consumption, mechanical properties and FTIR analyses demonstrated that the type of the forming die and the initial moisture level had the most significant impact on specific energy demands during the processing of potato starch-based foams.Biodegradable materials are used in the manufacture of packaging and compostable films and various types of medical products. These have demonstrated high potential in medical applications: cardiac, vascular and orthopaedic conditions in adults as well in children. In our research, the extrusion-cooking technique was used to obtain environmentally friendly loose-fill foams as packaging. Potato starch was the basic raw material. Polyvinyl alcohol was used as an additive in the amount of 1%, 2% and 3% to replace starch. The components were mixed and moistened with water to various initial moisture contents of the blend . The processing of starch foams employed the TS-45 single screw extruder-cooker  with the L/D ratio of 12. The foams were processed with various screw speeds (100 and 130 rpm) and with two types of forming dies (circular and ring die). The extrusion-cooking process efficiency (kg h Rock, soil, wood, fiber and bones of living organisms are natural porous materials ,2. The nFirst polymeric foamed material was invented in the early 20th century. The first polymer foam was made in the 1930s  with theFoamed packaging materials are now mainly made of plastics, such as polyurethane, polystyrene or polypropylene ,6,7,8. TThe progress in the production and processing of foamed products is a consequence of the development of materials technology with a special focus on polymers. This technology is improving continuously . An examDue to the limited resources of crude oil and mounting environmental concerns, polymer materials (including foamed ones) are more and more often blended with renewable raw materials ,14. The 6H5O10) is a polysaccharide carbohydrate containing a mixture of amylose and amylopectin and other components such as lipids and proteins [An alternative to popular plastics is starch. It is a relatively easily available polysaccharide and one of the most widespread organic substances in nature ,16,17. Sproteins ,19. Depeproteins .Starch has always accompanied and has exerted a great influence on people’s lives . It is cStarch polymers are undoubtedly the most widespread group of biodegradable materials available on the market ,23,24. BIn the production process, starch serves as a filler known as thermoplastic starch (TPS). It is a component of synthetic polymers or is used as a basic raw material for the manufacture of a new type of biopolymers, such as polylactic acid (PLA) ,27. PolyThe aim of the study was to assess the efficiency and energy consumption during the processing of starch-based foams with various polyvinyl alcohol (PVA) addition as well as measuring selected mechanical properties of foams as well as FTIR spectra depending on the processing conditions and forming dies used. −3. Starch and PVA blends were moistened with water to 17%, 18% and 19% of the moisture content. To prepare the proper initial moisture, the amount of water was calculated per kg of dry mass as follows:Potato starch of the Superior Standard type  was used in the study. The moisture content of the starch was 16.7% and the pH 7.4. Polyvinyl alcohol PVA  was used as the foaming agent in the amount of 1%, 2% and 3% (w/w). PVA with the melting temperature 160–200 °C was odor-free white powder with the density of 1.2–1.3 g cmThe blends were mixed for 20 min in a laboratory ribbon mixer. The TS-45 single screw extruder-cooker  was used to process the starch foams with the L/D ratio of 12. The foams were processed at the temperature below 120 °C with various screw speeds (100 and 130 rpm) and with two types of forming dies: circular (3 mm in diameter) and ring  M1—circular die, (b) M2—ring die, (c) S1—extruder-cooker screw speed 100 rpm, (d) S2—extruder-cooker screw speed 130 rpm, (e) A1—1% addition of polyvinyl alcohol, (f) A2—2% addition of polyvinyl alcohol and (g) A3—3% addition of polyvinyl alcohol−1), m—mass of extrudate obtained in the measurement (kg) and t—time of measurement (h). The efficiency of extrusion-cooking of starch-based foamed materials was determined by the sampling of foamed extrudates at a specific time. The efficiency was calculated according to the formula : (2)Q=mt−1), n—screw rotation (rpm), nm—screw rating rotation  O—engine load compared to maximum (%), P—rated power (kW) and Q—process efficiency (kg h−1).Energy consumption, expressed as SME , was calculated taking into account the engine load, the extruder-cooker working parameters and the process efficiency of each test according to the formula ,33,34. were put on a working table at the angle of 90° to the cutting knife; the initial force was set to 0.1 N before recording the results. TestXpertII v3.3 software  was used to record the results based on force-displacement curves. The mean value from 10 replications was the final value of the cutting force.The cutting force and resistance to compression were evaluated using the Zwick BDO-FBO0.5TH universal testing machine . To determine the cutting force (N), Warner–Bratzler’s equipment a was use−1, and the measurements were made in the transverse direction to the diameter of produced extrudates. The initial force was set to 0.1 N before recording the results. TestXpertII v3.3 software was used for the analysis of results from 10 replications, and the mean values were taken as the final result [The Zwick BDO-FBO0.5TH apparatus  with two flat plates b was usel result ,37,38. 2 atmosphere. Spectral measurements were recorded in the region from 500 to 4000 cm−1 at the resolution of 1 cm−1. The measurements were conducted at the Central Apparatus Laboratory of the University of Life Sciences in Lublin. The spectra were analyzed and processed with the Grams/AI software by ThermoGalactic Industries . All the spectra were measured at 23 °C. Infrared spectra measurements for the analyzed samples were conducted with the 670-IR spectrometer . An ATR  attachment was used in the form of a ZnSe crystal with adequate geometry (truncated at 45°) to ensure 20-fold internal reflection of the absorbed beam. During the measurement, 16 scans were registered and, subsequently, the program averaged the results for all spectra. Prior to the measurement, the ZnSe crystal was cleaned using ultra-clear solvents by Sigma-Aldrich. Prior to (1 h) and during the experiment, the measurement chamber was kept in an inert NThe results obtained during the multiple tests were archived and statistically analyzed using the following software: Microsoft Excel 2014, SAS Enterprise Guide 5.1, and Statistica 13.3 . The Excel software was used for calculating mean values with a standard deviation; the SAS Enterprise Guide 5.1 software was used for the multidirectional ANOVA analysis of variance with interactions; Tukey’s test was used for the means comparison at α = 0,05 level. For statistical analysis, RSM (response surface methodology) was used for fitting polynomial models; also - the quadratic equations of the tested characteristics were evaluated depending on the variables used in the experiment .The principal component analysis (PCA) was based on the data array of FTIR spectra of all examined samples. The first several scores of the PCA results were used to make a projection plot that provided a visual determination of similarities across the FTIR spectra. The OriginPro software  was used for the PCA in this work.−1.The results of processing efficiency measurements are shown in 2 = 0.98. The critical level, given in the last column of 0 test, it must be underlined that the rotational speed of the extruder-cooker screw and the type of die used had a major effect on the efficiency of the extrusion-cooking of starchy foams. In addition, simultaneous comparisons showed an increase in the efficiency of extrusion-cooking along with a higher addition of polyvinyl alcohol at higher screw speeds during the production of starchy foams.The measurements of all variables adopted in the research showed a significant fluctuation in the efficiency of the extrusion-cooking process. Changes were observed in the efficiency of extrusion-cooking of foamed starch materials depending on the level of moisture added to the raw material blends. As a result of the Tukey’s test and the observation of the extrusion-cooking process, significantly higher mean efficiencies of extrusion were reported for blends with a higher level of moisture. Based on obtained results of simultaneous comparisons, a significant decrease in the efficiency of the extrusion-cooking process was confirmed after reduction of the moisture level in the processed raw materials. The said efficiency was higher with a higher screw rotational speed for all raw material blends tested. A similar impact was observed in earlier studies  that stu−1.The results of SME measurements are shown in 2 = 0.97. Based on the critical level given in the last column of 0 test, it should be noted that the type of forming die used in the extrusion-cooking process and the level of moisture in the raw material blend had the strongest effect on energy-intensity of the extrusion-cooking process. From the perspective of processing and industrial processes, the use of the extrusion-cooking technique in the production of foamed starch materials should have as low energy-intensity as possible. Energy-intensity of the extrusion-cooking process was determined based on the special mechanical energy values (SME). The results of measurements of all variables adopted in the research showed major variations in energy-intensity of the extrusion-cooking process. The detailed comparisons of the means using Tukey’s test showed major discrepancies between all means for each variable except for the adjutant used in the study. In the case of 2% and 3% addition of polyvinyl alcohol (PVA), no significant differences were found between the means. The use of PVA in the production process influenced energy-intensity of the extrusion-cooking process. The higher amount of the additive, the higher the values of SME in the majority of raw materials blends. In addition, the results of simultaneous comparisons showed an increased energy consumption of the process along with a higher addition of adjutants.During the measurement of energy-intensity of the extrusion-cooking process of foamed starch materials, the influence of the moisture content in the raw material blends on the SME value was also examined. For all the samples produced using the M1 die and the vast majority of blends processed using the M2 die, the higher level of moisture resulted in a reduced demand for mechanical energy. The same tendency was observed by Willett and Shogren , who extAfter Tukey’s test, significantly higher energy-intensity of extrusion-cooking was reported for blends with a lower level of moisture. The results of simultaneous comparisons confirmed a significant decline of energy intensity of the extrusion-cooking process after raising the moisture level in the processed raw materials.The rotational speed of the extruder-cooker screw influenced energy-intensity of the extrusion-cooking of foamed starch materials. The measurement results for the majority of raw material blends with the addition of PVA showed that the value of SME was higher at the higher screw speed. Oniszczuk et al.  and MitrThe completed Tukey’s test confirmed the existence of the relationship in question. A significantly higher mean energy intensity of the process was reported for the screw speed of 130 rpm. Higher energy consumption values of the extrusion-cooking of foamed starch materials were observed when using the M2 die for the processing of most raw material blends. Tukey’s test showed a significantly higher mean energy intensity of extrusion in blends processed using the M2 die.To determine the cutting force of extruded starch foams is particularly important considering their potential functional use. The cutting force measurements are shown in 2 = 0.80. The critical level p given in 0 test, the type of the die was thought to have the strongest effect on the tested feature.Measuring the strength of foams in a cutting test is important since such products are intended for functional applications, e.g., for the protection of items susceptible to mechanical damage. During the analysis of measurement results, and for all the variables studied in the research, a significant variation of the cutting force of starch foams was confirmed. As a result of the detailed mean comparisons in the Tukey’s test, significant differences were exposed between all the mean cutting forces only for the type of the forming die. Between some means reported for the tested additives and moisture levels, the Tukey’s test simultaneous comparisons showed a significant variation. In the case of 2% and 3% addition of polyvinyl alcohol, 17% and 18% of moisture and the two screw rotational speeds, no significant differences were found between the means. In the case of polyvinyl alcohol, when increasing the quantity of the additive, the value of the tested parameter was rising, too. Based on the completed Tukey’s test, higher mean cutting forces of blends with polyvinyl alcohol were reported than in the case of control samples. Superior cutting force values were seen in foams obtained from the raw material blends with a higher moisture level. The highest cutting force was reported in products made from blends with the highest moisture level (19%). Completed Tukey’s test confirmed the relationship in question. Measurements for the majority of foams produced at higher rotational screw speeds showed lower values of the tested feature. A higher cutting force was noted for samples produced at the screw speed of 100 rpm. Superior cutting force values were recorded in all samples produced with the M2 die. A significantly lower mean cutting force was seen in extrudates produced with the M1 die.A compression test, as follows from the definition, is used for brittle, easily damaged materials. However, also softer materials (less likely to crack during compression) undergo this test to measure their flattening when high force is applied. The compression process involves two basic values: deformation and stress. Similar values are vital in stretching. When the elasticity limit is exceeded, permanent deformation in the tested sample is observed. The plastic material swells and takes a barrel-like shape. Consequently, the diameter of the sample increases and, as a result, more force is needed to continue deformation. The test is usually considered completed when clear plastic deformation is observed. In the case of brittle materials, samples are destroyed already after small deformations. The so-called sample chipping occurs. Owing to the compression test of plastics, it is possible to describe the full functional characteristics of the material. The measurements of resistance to compression are shown in 2 = 0.76. The critical level, given in the last column of 0 test, the amount of additive was considered to have the strongest effect on stiffness of produced foamed extrudates. The control samples showed the highest stiffness. After the use of adjutants, in the majority of raw material blends the value of the tested feature decreased. The higher the PVA additive, the lower stiffness of obtained products. Indeed, the highest average stiffness was reported for blends without adjutants added. Significantly higher mean values of the tested feature were reported for the majority of samples with the addition of PVA. The level of moisture in the raw material blends had an effect on the stiffness of foamed starch materials produced during the extrusion-cooking process. The research showed higher values of the tested feature for foams made from raw materials with higher moisture content. The highest mean stiffness was observed in foams made from blends with the highest moisture level. Based on the results of simultaneous comparisons, a significant decrease in stiffness of foamed starch was confirmed after the reduction of the moisture level in the processed raw materials. The results of stiffness tests of foamed extrudates reported during the compression test showed the influence of the screw rotational speed on the value of the tested feature. As the screw speed increased, stiffness of foamed starch materials decreased. Significantly higher mean stiffness was seen in the extrudates produced at the screw speed of 100 rpm. During the measurements, stiffness was observed to be influenced by the shape of the die. Higher values of the tested feature were obtained for all samples made on the M1 die. According to Mitrus [The degree of model matching with the experimental data was characterized by a relatively high coefficient of determination Ro Mitrus .−1, occurring in this type of additives either because of their degradation effects or introduced with additives used) in the starch fraction of the tested product is relatively scarce or is not present at all. On the other hand, absorption in this area (for the carbonyl group) quickly grows in intensity in materials containing various types of additives. It is also worth noting that starch alone produces very intense and interesting infrared spectra because, as one of the carbohydrates (plant polysaccharides), it consists of glucose units linked by α-glycosidic bonds (as mentioned earlier). However, starch actually consists of two main fractions: first of all, unbranched amylose made up of glucose residues connected by oxygen atoms with α-1,4-glycosidic bonds and, secondly, branched amylopectin with extra α-1,6-glycosidic bonds. The use of modifications by the extrusion-cooking in the tested samples also revealed substantial changes in the infrared spectra. These changes clearly suggest a significant modification of molecular interactions in the obtained group of two types of samples, which was reflected in modified FTIR spectra in materials selected for the research [Infrared spectra (FTIR) measurements are more and more frequently used for the analysis of various types of compounds, including materials containing biodegradable additives , polylactic acid (PLA), keratin hydrolysate and many more ), as welresearch .For easier analysis and comparison of collected data, obtained FTIR spectra are shown in −1. These are deformation vibrations of the groups -OH - δm(OH) (absorber water) and from the range of 3600-3000 cm−1 with a peak at 3200 cm−1 and belong to stretching vibrations OH, ν(-OH) with absorber water. A change in intensity of these spectra obviously depends on the level of moisture used to obtain the given sample, however, interestingly, in several cases, it also depends on the extruder-cooker screw speed  hydrogen bonds in the structure of starch used to obtain the tested samples. Along with the change of additives used with the tested samples, the formation of hydrogen bonds may modify the internal structure of samples (and thus significantly modify the spectra observed). Another noteworthy vibrations range is 3000–2800 , which indicates C-H stretching vibrations belonging to CH2 groups. The vibrations described earlier with a peak of about 1640 cm−1 (deformation –OH) also originate in the vibrations of water molecules that are bound within the starch structure. In turn, the vibration range of 1300–1100 cm−1 is occupied by the stretching asymmetric C-O vibrations and C-O-C group vibrations. These vibrations typify molecule systems in natural polysaccharides. Next, a very important range of 930–700 cm−1 is assigned to vibrations characteristic of the polysaccharide ring. These belong to the pyranose ring in the individual units belonging to glucose itself.It should also be noted that only M1 samples were selected for the FTIR and PCA analysis (discussed below) because of the extensive volume of data. Still, these are sufficient and representative to discuss obtained results. It is evident that, due to the use of appropriate modifications/additives  or the addition of PVA), the structure of the samples selected for testing underwent visible changed, as demonstrated in the obtained infrared spectra. Such noticeable changes, mainly in intensity , clearly point to strong intermolecular interactions in the studied starch systems. Clearly, some water content can be observed in all the tested samples, as evidenced by the presence of quite intense spectra in the range of around 1640–1647 cmew speed . Vibrati−1 (−1), associated with the vibrations of particles in starch itself. For vibrations in the range of 3000–2800 cm−1 , the most intense spectra are observed in samples that exhibit changes in the ranges characteristic of various types of vibrations associated with water molecules. This may be related, first of all, to a similar content of amylose and amylopectin in the tested material and with a greater strength of intermolecular interactions in the tested samples when applying specific modifications during their production (like a variable amount of PVA additive). In the FTIR spectra of the examined forms altered with all additives/modifications, very deep changes were observed (mainly in spectra intensity) with a peak at about 1250–70, 1370 and for the range of 950–1190 cm−1. These vibrations are associated with the skeletal ones of C-O and C-C groups, characteristic of the starch used to produce the samples. First, this may testify to the very good homogeneity of ingredients used for the production of the mixtures/forms, and, second, to the existence of strong molecular interactions between them through the creation of strong hydrogen bonds between individual groups. Below about 850 cm−1, there are spectra characteristic of α-glycosidic bond, i.e., typical of starch only.For the range of 3600–3000 cm−1 , the chaIt is worth noting that changes observed in this area, especially along with the increase in the amount of PVA additive , prove structural changes within the glycosidic bond itself, but, of course, these depend on the moisture level of the samples. To sum up, it is evident that the additives/modifications used significantly modify the FTIR spectrum of both types of obtained forms ,47. It pIn order to pinpoint the relationship between the investigated FTIR spectra and PVA addition, as well as selected mechanical properties of foams depending on the processing conditions and forming dies used, the PCA method was applied.The use of mathematical and statistical methods, including chemometrics and many other statistical analysis and mathematical algorithms, in material science and technology has been on the constant rise in the last decades. There is a trend of combining these methods with spectroscopy, especially with FTIR spectroscopy, which is one of the most cost-saving and, still, very effective methods . One of the most popular chemometric methods in material research is the principal component analysis (PCA). PCA is a method that isolates spectral information based on the variance maximum principle. The method involves the reduction of variables into new, low-dimension variables instead of the original high-dimension ones. This study shows the data of FTIR spectra . As shown in The first principal component was the most important factor, and its variance contribution ratio was 51.7%; the second principal component had a variance contribution rate of 25%, and the third one a variance contribution rate of 11.2%. The first three main components had a variance contribution ratio of 87.9%, and only 12.1% of the information was lost. This means that the first three principal components conveyed 87.9% of the all information. Therefore, the first three principal components actually reflected the vast majority of spectrum information.More information concerning the basic differences of sample compounds can be obtained when using the PCA loading factors model. The loading factors atlas was drawn across the whole wave spectrum . PC1, PC−1 (st(C-H) and ν(C-H) in the CH2/CH3 group  type of vibration and ν(-OH) with absorber water (3308 cm−1). These types of vibrations corresponded to the positive values of PC2. Peaks with a higher contribution rate to PC3 cover peaks that corresponded to the lowest contribution to PC2 rate. These results indicate that the differences among tested samples were mainly reflected in the different shape of asymmetrical from 1645 cm−1–2925 cm−1. This result matched that of the FTIR analysis.Peaks with the lowest contribution rate to PC1 ranged from 757 to 928 cm−1 . This ra−1 . The nexAll process variables had some influence on the efficiency and specific mechanical energy of the extrusion-cooking process. With higher addition of polyvinyl alcohol, the efficiency of extrusion-cooking process increased. For the majority of processed mixtures, higher moisture generated a higher value of efficiency. The efficiency of the process was higher with higher screw rotations for the tested mixtures. Higher efficiency was also observed for blends processed using the circular die. With an increasing amount of polyvinyl alcohol, SME of the extrusion-cooking process was higher. Energy consumption decreased with a higher level of moisture content in the blends. A higher screw speed led to higher energy consumption values. Higher SME of the extrusion-cooking process was obtained during blend processing using the ring forming die. The results showed that the processing efficiency of potato starch foams varied depending on the level of polyvinyl alcohol, the shape of the forming die and the screw speed applied. A statistical analysis, including the F-test, demonstrated that the screw speed and the shape of the forming die were the most significant factors in the processing efficiency of the tested foams. The analysis of SME results proved that the type of the forming die and the initial moisture level had the most significant effect on specific mechanical energy requirements during the processing of potato starch foams. The samples obtained during the direct extrusion process were characterized by variable mechanical properties. Increased addition of polyvinyl alcohol to the recipe increased the cutting force but, at the same time, decreased stiffness of the tested foams. The F-test showed that the most significant effect of the forming die used in experiments was on cutting force values. However, as regards resistance to compression, the most significant effect was visible across variable levels of the additive.As demonstrated, the use of FTIR analysis combined with chemometrics methods to investigate starch foams exposed the reasons for their varying compositions. The results obtained in this study could serve as a method of optimizing evaluation procedures for the purposes of quality control analysis of biodegradable packaging materials.


A tracheo-innominate fistula is a rare but life-threatening complication of tracheostomy and has a mortality rate of 100% without therapy. The underlying cause is an acquired fistula between the brachiocephalic trunk and the trachea, induced by a tracheostomy cannula’s mechanical impact.A 25-year-old female was admitted with pulsatile bleeding from a tracheostomy. The cause of the bleeding was a tracheo-innominate artery fistula, which was difficult to recognize. Said fistula was treated with implantation of a self-expanding stent-graft. The bleeding stopped immediately after the implantation of the stent-graft. Dual antiplatelet medication with aspirin IV and ticagrelor PO, bridged with a bolus of eptifibatide IV, was started right after the stent deployment.Endovascular self-expanding stent-graft implantation is a viable treatment option for tracheo-innominate artery fistulae, especially in hemorrhagic emergencies. Tracheo-innominate fistula (TIF) is a sporadic (0.1%–1%) and potentially lethal complication after tracheostomy  was overinflated to control the bleeding in the short term. A diagnostic digital subtraction angiography (DSA) was carried out under emergency circumstances. The initial angiogram with the cuff inflated revealed no visible contrast medium extravasation. Therefore, the cuff of the tracheal tube was first deflated and then the tube was temporarily removed.General anesthesia was induced with propofol and sufentanil, neuromuscular blockade was achieved by atracurium. Maintenance was provided with continuous infusion of propofol and remifentanil. A 9F sheath (Terumo) was inserted into the right common femoral artery. A diagnostic digital subtraction angiography (DSA) was carried out using a Tempo4 vertebral 4F catheter (Codman) under emergency circumstances. Straight posterior-anterior and 20° right and left anterior oblique angiographic projections of the brachiocephalic artery with 6 frames per second were acquired with manual bolus injection of each 8 ml Imeron 300 (Bracco Imaging).The acquisition of an aortogram was considered but we decided to upfront continue with selective injections of the brachiocephalic trunk. The brachiocephalic trunk’s selective injection demonstrated a difficult to recognize small dot of contrast medium accumulation, which was considered the site of extravasation from the posterior wall of the brachiocephalic trunk to the anterior aspect of the adjacent trachea. We decided to implant a self-expanding stent-graft into the brachiocephalic trunk to seal the vessel wall’s erosion without covering the subclavian artery’s origin. Using the inbuild measurement tool of the DSA machine (Siemens Axiom Artis Zee) with a calibration of the distance between the target vessel and the table surface, the diameter and length of the brachiocephalic artery was determined as 6.9 mm and 36.7 mm, respectively. The available implant was a Fluency Plus Stent Graft 8 mm × 40 mm (BD Bard), mounted in an 80 cm long catheter with a 9F crossing profile. A stiff 0.035″ diameter and 300 cm length Radiofocus guidewire (Terumo) with an angled tip was navigated into the right external carotid artery using a 4F Tempo4 vertebral catheter (Codman) through a 9F sheath (Terumo), followed by the removal of the 4F catheter. The Fluency Stent Graft was inserted over the said guidewire into the brachiocephalic trunk without using a guide catheter. Deployment of the stent-graft immediately stopped the tracheal bleeding Fig. . Post-deLong-term tracheostomy may cause a fistula’s development between the trachea and the brachiocephalic trunk due to tracheitis, focal necrosis, cartilage loss, and then fistulization  and 30-day mortality  for the endovascular treatment compared to surgery. Endovascular stent-graft implantation is a rapid and safe procedure. However, possible complications such as graft infection, graft occlusion, and postoperative rebleeding due to tracheal erosion must be considered (Nakai et al. Taechariyakul et al.  identifiIn our case, we opted for an endovascular therapy due to the high-risk of the already unstable patient and because open surgery was considered hazardous, especially with a vaguely identified bleeding source. In the English literature, reports of post-procedural complications such as occlusion of the right carotid artery or right subclavian artery leading to steal syndrome can be found. Therefore, the decision for the correct stent dimensions and position is crucial.Endovascular treatment of TIF with a stent graft is both effective and safe. The procedure is well suited in acute situations to avoid fatal exsanguination.