Orthopedic manual therapy (OMT) education demonstrates significant variability between philosophies and while literature has offered a more comprehensive understanding of the contextual, patient specific, and technique factors which interact to influence outcome, most OMT training paradigms continue to emphasize the mechanical basis for OMT application. The purpose of this study was to establish consensus on modifications & adaptions to training paradigms which need to occur within OMT education to align with current evidence.A 3-round Delphi survey instrument designed to identify foundational knowledge to include and omit from OMT education was completed by 28 educators working within high level manual therapy education programs internationally. Round 1 consisted of open-ended questions to identify content in each area. Round 2 and Round 3 allowed participants to rank the themes identified in Round 1.Consensus was reached on 25 content areas to include within OMT education, 1 content area to omit from OMT education, and 34 knowledge components which should be present in those providing OMT. Support was seen for education promoting understanding the complex psychological, neurophysiological, and biomechanical systems as they relate to both evaluation and treatment effect. While some concepts were more consistently supported there was significant variability in responses which is largely expected to be related to previous training.The results of this study indicate manual therapy educators understanding of evidence-based practice as support for all 3 tiers of evidence were represented. The results of this study should guide OMT training program development and modification. Clinical research suggests orthopedic manual therapy (OMT) provides comparable or superior effects for reducing pain in individuals with musculoskeletal disorders . MechaniThis study aims to establish consensus on modifications to training paradigms within post-graduate OMT education through Delphi study. Once consensus methods are identified, the potential of implementing these methods into training programs may increase.Institutional Review Board approval was obtained through Youngstown State Universities Institutional Review Board (2022-204) prior to data collection. Informed consent was obtained electronically via participants clicking URL to the questionnaire.This Delphi was completed electronically from July 2022–November 2022.A 3-round Delphi study following recommended guidelines for conducting and reporting of Delphi studies (CREDES) was performed .A priori goal of 30 participants completing all 3 rounds of the instrument was set as this has been recommended to be representative and feasible in qualitative Delphis . A panelFour individuals, including the primary investigator and 3 individuals experienced in qualitative research. All workgroup members were physical therapists with 9 to 33 years of clinical experience. Three workgroup members were mixed-methods researchers with experience in the Delphi method.Round 1 was an open-ended design developed to identify opinions/perceptions on the future of manual therapy training paradigms. Round 1 identified basic demographics including experiences experts had with training programs. Open-ended questions asking participants to identify recommended training paradigms for manual therapy techniques was implored. Face validity was investigated through a pilot survey of 5 individuals with qualifications to participate in the study whom were not included in final data collection .Following Round 1, the workgroup examined each individual response and utilized qualitative thematic coding . Round 2Round 3 included the same themes and grading scales as Round 2 with the addition of graphs representing the descriptive statistical scores computed from Round 2. With this information available, the respondents were asked to rescore each item on the same 4-point Likert scale. All responses were de-identified before data analysis by removing columns containing identifiable data from report.Protocol information is provided in IBM SPSS ver. 29.0 (IBM Corp.) was used for all quantitative analyses. Scores for Round 3 were divided into 2 categories based on descriptive identifiers: The tally of ‘‘strongly disagree’’ and ‘‘disagree’’ represent the percentage of scores in the “not recommended” category, meaning that the proposed training paradigm is not recommended. On the contrary, the tally of “strongly agree” and “agree” represented the percentage of scores in the “recommended” category, meaning that the proposed training paradigm is recommended. Consensus was determined a priori if 75% or greater of the respondents score the component of education as either “not recommended” or “recommended” . When an[n1×(-2)]+[n2×(-1)]+[n3×1]+[n4×2]n1: number of respondents answering “strongly disagree” with component of trainingn2: number of respondents answering “disagree” with component of trainingn3: number of respondents answering “agree” with the component of trainingn4: number of respondents answering “strongly agree” with the component of trainingSum of individual composite scores was used to establish a combined composite score. The higher the combined composite score, the more important the training paradigm to manual therapy education. Mann-Whitney U statistics assessed differences in scores between Round 2 and Round 3.One-hundred sixty-four educators were identified and invited to participate representing 4 countries . Advanced degrees included Doctor of Science (DSc), Doctor of Philosophy (PhD), and Fellowship training .Forty-one participants responded to Round 1 for a response rate of 25% . ThematiQuestion 1 investigated which areas should be focused on within OMT education with consensus reached supporting all 25 themes . ComposiQuestion 2 investigated what areas of focus should be omitted from OMT education with only one of the themes  reaching consensus . SeveralQuestion 3 investigated what foundational knowledge is needed to apply OMT. Thirty-four of the 37 themes met consensus supporting . Three tNo significant difference was found between Round 2 and Round 3 composite scores for Question 2 assessing themes to omit from OMT education . Question 1  and question 3  both showed significant differences between Round 2 and Round 3 composite scores.The Delphi method is a recommended tool for achieving consensus in medical education . The valAll 25 themes from Round 1 reached consensus to be included within OMT education. Patient factors all rated highly amongst the participants. This aligns with published clinical trials that have shown the moderating effect of comfort, therapeutic alliance, and expectations on OMT outcomes . A lesseNineteen themes were identified in Round 1; however, only 1 of those themes met consensus to omit from OMT education. The contradiction among respondents’ answers likely corresponds to differing OMT philosophies. Some were strongly opposed to omitting biomechanical principles  while others were strongly in favor of omitting these same principles .Omitting focus on visceral manipulation education was the only theme to meet consensus with 78% agreement. A recent review suggests a lack of quality unbiased studies demonstrating efficacy in this domain . Some suThirty-four of the 37 themes from Round 1 reached a consensus. One undecided theme emerged involving the ability of individuals to lock out joints. The rating of this theme was variable with opposing positions to this requirement. Themes supporting patient-centered care, communication, therapeutic alliance, and patient safety all ranked amongst the strongest recommendations. This aligns with responses to question 1 and with the aforementioned literature supporting the importance of the therapeutic alliance in OMT outcomes.There are limitations related to a true representation of the sample population. With significant variation between manual therapy philosophies, some may not be represented within this sample and others may have differing opinions from this panel of experts. While we attempted to be representative by including international participants, a significant proportion was stationed within the US IFOMPT accredited education programs are represented across 25 countries; however, most of these programs did not report faculty members and contact information on the associated websites; therefore, several countries were not appropriately represented.Given the international representation of this study along with fair representation of different OMT philosophies these results can be relatively generalized to post-graduate manual therapy education including continuing education, advanced manual therapy certification and fellowship training; however, care should be taken given the above stated limitations related to geographical restrictions.Future studies should attempt to understand the reasoning behind the overwhelming consensus related to included themes and the minimal consensus on excluded themes. Furthermore, given the proposed changes in training paradigms future studies should identify if these same principles indicate a shift in the clinical application of OMT.The combined high consensus rate for themes to focus on within OMT education along with the low consensus rate of themes to omit focus on within OMT education stresses the breadth of knowledge which appears to be pertinent to OMT. Of interest was that while 91% of respondents supported focus on training related to biomechanical mechanisms, 60% supported omitting treatment based on biomechanical findings and 40% supported omitting training on segments localization. This suggests that the biomechanical effect should be more of a focus than the biomechanical rationale for applying the technique. The included themes were developed by the respondents; however, variability in interpretation of the themes, along with differences seen within OMT training paradigms likely contributes to this discrepancy. Future studies should look to differentiate which biomechanical findings are viewed as important versus not in OMT assessment.Overall support was seen for education promoting understanding the complex psychological, neurophysiological, and biomechanical systems as they relate to evaluation and treatment effect. The support for care based on all aspects of evidence-based practice model supports patient centered care and the understanding of complex interactions surrounding manual therapy intervention.


To develop a cascaded deep learning model trained with apparent diffusion coefficient (ADC) and T2-weighted imaging (T2WI) for fully automated detection and localization of clinically significant prostate cancer (csPCa).This retrospective study included 347 consecutive patients  with high-quality prostate MRI data, which were randomly selected for training, validation, and testing. The ground truth was obtained using manual csPCa lesion segmentation, according to pathological results. The proposed cascaded model based on Res-UNet takes prostate MR images (T2WI+ADC or only ADC) as inputs and automatically segments the whole prostate gland, the anatomic zones, and the csPCa region step by step. The performance of the models was evaluated and compared with PI-RADS (version 2.1) assessment using sensitivity, specificity, accuracy, and Dice similarity coefficient (DSC) in the held-out test set.In the test set, the per-lesion sensitivity of the biparametric (ADC + T2WI) model, ADC model, and PI-RADS assessment were 95.5% (84/88), 94.3% (83/88), and 94.3% (83/88) respectively . Additionally, the mean DSC based on the csPCa lesions were 0.64 ± 0.24 and 0.66 ± 0.23 for the biparametric model and ADC model, respectively. The sensitivity, specificity, and accuracy of the biparametric model were 95.6% (108/113), 91.5% (665/727), and 92.0% (773/840) based on sextant, and were 98.6% (68/69), 64.8% (46/71), and 81.4% (114/140) based on patients. The biparametric model had a similar performance to PI-RADS assessment (p > 0.05) and had higher specificity than the ADC model  based on sextant.The cascaded deep learning model trained with ADC and T2WI achieves good performance for automated csPCa detection and localization. Prostate cancer (PCa) is one of the most common malignant tumors in men worldwide. The clinical behavior of PCa ranges from low-grade indolent that is generally considered to be non-life-threatening to high-grade aggressive tumors with a Gleason of Score 7–10, i.e. clinically significant PCa (csPCa), that may progress rapidly to metastatic disease and may be life-threatening . Recent In the recent years, artificial intelligence (AI) methods, particularly deep learning, have achieved promising results in automated csPCa diagnosis of mpMRI –14. A raOur study aimed to develop a fully automated cascaded deep learning model for the detection and localization of csPCa using apparent diffusion coefficient (ADC) maps and T2-weighted imaging (T2WI), as well as to seamlessly integrate these AI predictions into the radiological workflow using the structured report.Our institute’s review board approved this retrospective study and waived the need for informed consent. The inclusion criteria for the study were mpMRI scans performed on a GE 750 3.0T MRI scanner at Peking University First Hospital from March 2017 to February 2020 on consecutive patients who underwent mpMRI before a biopsy, with a clinical suspicion of PCa due to an elevated serum prostate-specific antigen (PSA) level, abnormal digital rectal examination (DRE), and/or abnormal transrectal ultrasound (TRUS) results. Exclusion criteria were patients without a subsequent biopsy performed within 3 months after mpMRI examination, a negative biopsy for csPCa without clinical follow-up >1 year, or showing potential csPCa during the clinical follow-up (progression of PSA or MR findings), as well as images with severe artifacts or incomplete pathology results which could not be matched with MR images. In total, 347 patients were included. All of the mpMRI examinations were performed on a 3-T MR machine . A 32-channel abdominal phased array coil was used as the receiving coil. All patients were scanned following the unified prostate mpMRI protocol. The main sequence parameters are summarized in All of the mpMRI cases in the dataset of the test were retrospectively interpreted according to PI-RADS (version 2.1) by a urogenital radiologist with 10 years of experience in prostate MRI diagnosis. The radiologist was informed of the clinical information of the patients, such as age, biopsy history, PSA, etc., but was blinded to the pathology results and the previous MRI reports. The lesions detected were delineated on a prostate sector map.All of the patients in this study underwent TRUS-guided systematic and targeted biopsy using 12- or six-core needles. For cognitive targeting, lesions suspected of malignancy on mpMRI had been marked on a prostate sector map  using stwww.itksnap.org)  retrospectively reviewed all csPCa cases and mapped the detailed pathology results of the csPCa foci to the MR images with consensus. The ground truth of the csPCa lesion segmentation was obtained using manual delineation by the urogenital radiologist (X), in consensus with and under the supervision of the other urogenital radiologist (Y), using the open-source segmentation software ITK-SNAP  . The forvia rigid transformation using the coordinate information stored in the DICOM image headers. B-spline interpolation to the third order was employed for all MR image interpolation tasks, while Gaussian label interpolation was used for the csPCa and prostate segmentation masks. Following this, a coarse segmentation of the prostate was obtained by K-means clustering in DWI high b value images to localize the prostate region. Once the prostate region was identified, the images were cropped to a patch of size 128 × 128. The prostate region of interest was then normalized into the range of . We augmented the data in the training set by mirroring, random rotation (rotation angle within 10°), and adding noise .After collecting the mpMRI data, the first step of image preprocessing is T2WI and DWI/ADC image registration. Patient motion is minimal and the two sequences are temporally close to each other during the scanning. T2WI and DWI/ADC images were registered The base architecture for the deep learning framework used in this study is a CNN inspired by the 2D U-Net  and Res-Following McNeal’s criterion , the proAll of the training steps were performed using a GPU NVIDIA Tesla P100 16G at Peking University First Hospital, using the operating system Ubuntu 16.04. The software and packages used included Python 3.6, Pytorch 0.4.1, Opencv 3.4.0.12, Numpy 1.16.2, and SimpleITK 1.2.0. The input data were 128 × 128 images of ADC alone and ADC combined with T2WI, respectively, with an annotation of the csPCa lesions. The automated segmentation of the whole prostate gland and its different zones was completed using the previously developed and described method . For trahere X is the pixel set of csPCa segmented manually as the ground truth and Y is the pixel set of csPCa prediction by the model.Initially, the prediction results were “csPCa” or “non-csPCa” depending on the patient concerned. When “csPCa” was the output, the three-dimensional diameter of the suspicious csPCa lesions and the whole prostate gland would be filled into the structured report, as well as the key image of the suspicious csPCa lesions , based oStatistical analysis was carried out using SPSS 20.0 and MedCalc 15.8. We evaluated the performance of the biparametric (ADC + T2WI) model, ADC model, and PI-RADS assessment using the testing set. For PI-RADS assessment, PI-RADS ≥3 was considered positive for csPCa. For per-lesion analysis, to limit the influence of very small overlap regions, only the predicted lesions of the model overlapping ≥50% of the manual csPCa segmentation lesions in at least one slice were considered as true positive. Otherwise, the predicted lesions were considered to be false positives. For sextants analysis, only sextants overlapping at least 50% of an MRI lesion, or being occupied at least 50% by an MRI lesion, were considered to contain the MRI lesion . For perIn the test set, 88 csPCa lesions were included and the mean greatest dimension was 1.6 ± 0.7 cm. In addition, the mean DSC based on csPCa lesions in the test were 0.64 ± 0.24 and 0.66 ± 0.23 for the biparametric model and the ADC model, respectively. vs. 92.9% (105/113), 91.5% (665/727) vs. 92.2% (670/727), and 92.0% (773/840) vs. 92.3% (775/840), respectively, all with p > 0.05. The ADC model demonstrated a comparable sensitivity of 91.2% (103/113) when compared with the biparametric model where p = 0.125, while the ADC model had a specificity of 86.8% (631/727) and accuracy of 87.4% (734/840), which were both lower than the biparametric model . Considering all the mpMRI sequences and detailed pathological results, 61.5% (59/96) of the false-positive sextants from the ADC model were hyperplastic nodules and asymmetric central zone, which is shown in A total of 840 sextants from the test set were analyzed, including 113 sextants of csPCa and 727 sextants of non-csPCa. The diagnostic efficacy and comparisons of the models and the PI-RADS assessment based on sextants are summarized in vs. 98.6% (68/69), 64.8% (46/71) vs. 66.2% (47/71) and 81.4% (114/140) vs. 82.1% (115/140), respectively . ADC model had a similar sensitivity of 97.1% (67/69) compared with the combined model and PI-RADS assessment. The specificity and accuracy of the biparametric model were slightly higher than those of the ADC model ; however, the statistical significance was not reached .For the 140 patients  in the test set, the performance and comparisons of the models and the PI-RADS assessment based on patients are shown in Our approach using cascaded CNNs could automatically detect and segment the suspicious csPCa lesions on MR images without any human intervention. The whole prediction process could be completed within a few seconds per case, which was much faster than human interpretation using PI-RADS, which normally takes several minutes. There are several benefits of using a cascaded framework for the segmentation of hierarchical structures. First, many proposed methods try to solve the segmentation problem using a single neural network. Considering the great variability in the shape, size, texture, and appearance of the prostate gland and PCa, we suggest using cascaded CNNs for the segmentation task to improve the segmentation accuracy, and each network can focus on one segmentation problem. Thus, they are easier to train and can reduce over-fitting. Second, in consideration of the PCa lesions, these can vary in frequency and malignancy depending on the zone; the hierarchical pipeline follows the anatomical structures of the prostate and uses them as spatial constraints. Thus, the model for automated csPCa detection and classification will likely benefit.The results demonstrated that the biparametric model had high sensitivity  and acceptable specificity  and had comparable performance to PI-RADS evaluation by an experienced radiologist, which is consistent with Schelb’s findings . The preT2WI and ADC derived from DWI are recommended by PI-RADS as the most important sequences for the evaluation of TZ and PZ lesions, respectively. Many studies demonstrated that the diagnostic performance of biparametric MRI without DCE was similar to those of mpMRI , 34. TheIn contrast with studies that were training models using public data , 38, theAn optimal AI model should not only have good performance for csPCa diagnosis but should also have a perfect output form facilitating clinical practice. One advantage of the proposed approach is that it had a perfect output and added AI into the radiological workflow seamlessly by automatically integrating the prediction results into structured reports, which makes this approach more convenient for clinical application. At present, our model can output whether a patient has csPCa or not and the size of the prostate gland. If csPCa lesions were found, it would further output the size of csPCa lesions and also mark the area of csPCa on MR images. These prediction results could be automatically transferred into a structured report before radiologists open the reporting system. However, a complete structured report includes many other contents, such as whether the csPCa lesions invade the prostate capsule and adjacent structures, as well as lymph node condition, bone metastasis, etc. Our institution is now exploring each of the above, and some of them have achieved good performance . Our ultSeveral limitations of our study were as follows. First, all of the images were from a single MR machine in a single institution. Multi-center and multi-machine data functionality should be added to improve the generalization ability of the model in further studies. Secondly, this U-Net model was trained only using ADC and T2WI. Future research involving the addition of more MRI sequences and/or clinical information may be investigated to improve the performance of the model. On the other hand, the model in this study achieved good results with biparametric MRI, so streamlining MRI sequences with an advanced algorithm may be another possible research direction. Thirdly, even though the reference standard using TRUS-guided systematic and targeted biopsy had high sensitivity for csPCa, it still has a false-negative rate when compared with radical prostatectomy. Nevertheless, our cohorts may be optimal, for radical prostatectomy cohorts would exclude many patients who only had a prostate biopsy and could lead to bias. Finally, this model was only applicable to the detection and localization of csPCa instead of staging and active surveillance.In conclusion, our study demonstrated that a cascaded deep learning model trained with ADC and T2WI achieved good performance for the fully automated detection and segmentation of csPCa and demonstrated comparable performance with an experienced radiologist using PI-RADS (version 2.1). The proposed approach can automatically integrate prediction results into the radiological workflow seamlessly by using a structured report. As a preliminary exploration, this study provided a reference for future AI clinical implementation. Further studies are needed to explore the optimal paradigm of AI clinical integration.The datasets presented in this article are not readily available because the datasets are privately owned by Peking University First Hospital and are not made public. Requests to access the datasets should be directed to XYW, wangxiaoying@bjmu.edu.cn.The studies involving human participants were reviewed and approved by Peking University First Hospital. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.LZ and XYW designed the study. CH, XL, and DL contributed to acquisition of data. LZ and XYW annotated the images data. YZ, WL, XPW, and JZ designed the model and implemented the main algorithm. LZ and GG analyzed the data. LZ wrote the paper. XYW and XZ reviewed the paper. All authors contributed to the article and approved the submitted version.The authors would like to acknowledge Xin Yue and Suisui Zhang from the Beijing Smart Tree Medical Technology Co., Ltd., for their help in constructing the structured report.Authors WL, XPW and JZ are employed by Beijing Smart Tree Medical Technology Co. Ltd.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Time to independent ventilation (TIV) was modeled with GA and BW as dependent variables and OMT as the factor. A negative linear effect of GA and BW on TIV was shown. OMT exposure studied as the factor of GA had effects on TIV in infants born up to the 32nd gestational week. Preterm infants exposed to OMT were associated with earlier achievement of NIV weaning. This result, together with the demonstrated OMT safety, suggests the conduct of clinical trials in preterm infants younger than 32 weeks of GA.Ventilation weaning is a key intensive care event influencing preterm infants’ discharge from a neonatal intensive care unit (NICU). Osteopathic manipulative treatment (OMT) has been recently introduced in some Italian NICUs. This retrospective cohort study tested if OMT is associated with faster non-invasive ventilation (NIV) weaning. The time to NIV weaning was assessed in very preterm and very low birth weight infants who either received or did not receive OMT. The propensity score model included gender, antenatal steroids, gestational age (GA), birth weight (BW), and Apgar score 5′. Out of 93 infants, 40 were included in the multilevel survival analysis, showing a reduction of time to NIV weaning for GA (HR: 2.58, 95%CI: 3.91 to 1.71,  Very preterm infants often need positive pressure ventilatory support due to the immaturity of their chest wall pulmonary system; the reduced quantity and quality of surfactant; the neurological and thoracoabdominal asynchrony; the weakness of the intercostal muscles; and the relative shape and position of the diaphragm affecting ventilation, causing atelectasis and subsequently the tendency of the lungs to collapse. To prevent respiratory failure, respiratory distress syndrome (RDS), and bronchopulmonary dysplasia (BPD), preterm infants often require the support of non-invasive ventilation (NIV) ,4,5,6,7.However, even though respiratory support is fundamental during intensive care, recent studies showed that a too-long period—either of invasive ventilation or non-invasive ventilation—is associated with an increased risk of mortality or neurodevelopmental disability, due to the hemodynamic instability and cerebral inflammatory response ,9. ThereThe osteopathic manipulative treatment (OMT) is a non-invasive complementary manual therapy that enhances the functional integrity of the body, improves the physiological function, and supports homeostasis ,19; it eThe main aim of this propensity-score-matched retrospective cohort study is to understand if the OMT is associated with faster NIV weaning; as secondary aims, it was assessed if the OMT is also associated with LOS, anthropometric growth, and time to autonomous respiration.This is a single-center propensity-score-matched retrospective cohort study: the data were collected from the tertiary level NICU of Del Ponte Hospital in Varese from March 2015 to January 2017. All the peri- and post-natal data—including information about demographic entities, delivery, medical procedures, and perinatal and maternal information—were retrieved from an electronic dataset. During the hospital stay, a multidisciplinary team evaluated the infants; it was composed of neonatologists, pediatric nurses, physical therapists, and pediatric osteopaths. An expert neonatologist was available for immediate consultation during OMTs. The Provincial Ethics Committee of Varese approved the study on 02/14/2017. The manuscript was edited in conformity with STROBE guidelines.The study population included very preterm and very low birth weight (VLBW) infants—i.e., with gestational age (GA) between 26 and 32 weeks and birth weight (BW) < 2000 g—treated with NIV support; they could be a singleton or twins. Infants affected by major congenital malformations, severe neurological disease , severe cardiovascular diseases, triplet births, or infants treated with intubation were not screened for eligibility. A total of 40 out of 94 infants were fully eligible and were propensity score matched on the basis of relevant demographic and clinical perinatal parameters.when infants were at risk of RDS;when infants with a GA < 30 weeks did not need mechanical ventilation;when FiO2 > 0.30 from nasal cannula or mask to keep oxygen saturation;when PaO2 < 0.50 mmHg or in the case of apnea of prematurity.NIV was performed on the basis of the NICU guidelines for assisted ventilation, that is,A loading dose of intravenous caffeine (20 mg/Kg) was administered at NICU admission, followed by a maintenance dose of 5–10 mg/Kg. The FiO2 was adjusted by a physician to stabilize SaO2 at 90–95%. All the ventilatory support was delivered by CNO .The routine clinical management depended on the infants’ conditions; hence, it was adjusted day by day following the oxygen requirement. The weaning started after 24 h of stable ventilatory parameters at a pressure of 4–5 cmH2O. The protocol of weaning in the ward was a gradual weaning at “ON–OFF” intervals. It started with an “OFF” period, during which the infant stayed in the crib oxygen or air as long as the ventilatory and cardiovascular parameters were stable. Then, there was a fixed “ON” period of 6 h. During these “ON–OFF” intervals, it was expected that we would see a gradual incremental pattern of the “OFF” periods. The “ON–OFF” interval ended when the infant was stable for at least 16 h during the “OFF” period, whereas if the baby met a failure criterion, a 6-h “ON” period was recommended.Increased breathing load (use secondary and accessory muscles), with a respiratory rate > 75 bpm.Increased apneas or bradycardia event based on the previous 6 h (>2 in 1 h).pH < 7.2.Increased oxygen requirement to maintain saturation 86% or PaO2 < 45mmHg.PaCO2 > 65 mmHg.Major events requiring resuscitation.Failure criterion considered at least 2 of the following points:The OMT was the exposure variable; it was performed by trained pediatric osteopaths with more than 3 years of experience in the NICU. OMTs were performed after 1–5 days from birth, twice a week until discharge for a duration of up to 30 min per infant. Our NICU used a standardized protocol for safety during treatment sessions and it was based on SaO2 > 0.85, more than 3 apneas, or alarming heart rate (<100 or >150 bps). If one of these scenarios occurred, the session was suspended or not performed.The osteopath with a manual palpatory grip between the skull and the sacrum evaluated the quality of movement and mobility on the three planes of movement. The examiner assessed the movement variability within the neutral zone (NZ) of the spine with a sacro-occipital stance . The exaMyo-fascial tissue texture (TT) assessment was performed using a bimanual compression in the scapular, pelvic girdle, lower chest, upper chest, diaphragm, and abdominal and spinal regions, as well as using a gentle compression of the fascia of the spine with the same sacro-occipital stance. An altered elastic response to compression defined an atypical tissue resilience and consequently an abnormal TT.Finally, to evaluate the tenderness status, the reaction during slight compression between the head and sacrum was evaluated using facial expression, the presence of reflex moves, crying, or the sudden increase in heart rate.Osteopaths were trained to perform a specific examination protocol using the variability model of SD ,29. The The examiner assessing the variability of movement within the NZ was the fundamental analysis guiding all other assessments. At the end of the procedure, two OMT practitioners assigned the SD severity to the infant, considering the variability of movement, TT, and tenderness. Consequently, the manipulative treatment was decided on the basis of the SD grade. The principal guide to osteopathic anamnesis has always been the alteration of motion symmetry in NZ. Osteopathic treatment of SD used cranial, visceral, and myofascial release techniques. The most dysfunctional areas were the skull base, the diaphragmatic area, and the dorsal and costal area.The multidisciplinary team observed the patients and recorded the clinical events on daily bases for medical, nurse, and ventilatory support data. All the information was collected in an accessible hospital database, from which we performed the data extraction and analysis.The time for ventilation weaning was considered as the time in days that occurred from the NIV initiation to the full independence from ventilation. Hence, in our statistical model, the event was the ventilation weaning, and the time variable was the time to independent ventilation (TIV), as previously defined. Other assessed perinatal and clinical variables were gender; antenatal steroids (ANS); GA; BW; body length; head circumference; Apgar at 1 and 5 min from birth; the number of small for gestational age infants (SGA); the type of NIV; and the occurrence of apneas, BPD, RDS, or patent ductus arteriosus (PDA).Clinical and demographic variables were reported with descriptive statistics for continuous variables (mean and standard deviation) and with frequencies for categorical variables (percentages). To deal with sampling bias and potential confounders, a propensity score model was implemented using a model including gender, ANS, GA, BW, and Apgar score 5′. The nearest-neighborhood matching method with a 1:1 ratio was used, applying a caliper of 0.1 of the standard deviation of the logit of the propensity score. Distribution and normality were tested with formal tests, whereas the potential imbalance after matching was tested at baseline between groups using the chi-squared test for categorical variables and the two-sided Student’s t-test for continuous variables.p-value was <0.05. Statistical analyses were performed with STATA version 15 and R software version 4.5, as needed.For the primary outcome, patients were observed until ventilation weaning. The effect of OMT exposure compared to the control group was graphically depicted with a Kaplan–Meier curve, including a risk table, and formally tested with a Log-rank test. The multivariable Cox proportional hazard model was used to compare the time to event in exposed and non-exposed groups, both adjusted for potential covariates. The proportional hazard assumption was tested with a phtest that did not reject the null hypothesis that the hazards were proportional to our model. To study the secondary endpoints, we used multivariate linear models for the prediction of TIV in different GAs and BWs and considered OMT as the factorial variable. For simplicity, the models were graphically reported. Statistical significance was considered if the Out of 94 screened infants, 20 infants per group were eligible and were included via the propensity score matching. At baseline, there was homogeneity for the main variables in the two groups, and the propensity score efficacy was tested with the standardized mean difference (SMD). Concerning the diseases, both groups mainly reported RDS, followed by PDA, apneas, and BPD. Instead, the prevalent type of NIV was nasal high-frequency oscillatory ventilation (NHFOV), followed by NCPAP. On average, a TIV difference of 9.85 (−0.93 to 20.62) days was registered between groups combined with a difference of 5.34 (−10.07 to 21.98) days of LOS, which was lower in the exposed group, although non-statistically significant see .p = 0.034), as depicted in p < 0.001) and OMT . The multivariate linear model analyzed the relationship between TIV and GA, as well as TIV and BW in both the exposed and non-exposed groups. All the observed infants reached NIV weaning. The univariate survival analysis shows that the OMT group had a statistically significantly lower time-to-event  were interrupted according to the previously mentioned safety protocol, without reporting any permanent mild adverse event or medical staff intervention. There was an average of 14.5 treatments per infant during the NICU permanence with a mean of three manipulative techniques performed within each treatment session. The diaphragmatic region was the most frequently treated, showing a mean relative frequency of treatment of 0.95, followed by the abdominal region (0.62) and craniosacral techniques (0.51). More details on the treatment descriptive analysis are reported in This model-based retrospective cohort study described the weaning time from NIV in preterm infants either exposed or not exposed to OMT during NICU permanence. The study protocol included propensity score matching to reduce the presence of confounders during analysis. As the primary endpoint, the analysis included the time-to-event assessment performed with survival analysis. Our multilevel model shows that the increase in GA (HR: 2.58) and the OMT exposure (HR: 3.62) enhanced the weaning probability. This result agrees with a review on continuous positive airway pressure (CPAP) weaning, highlighting the direct relationship between weaning and GA . ConcernIn the last twenty years, study groups have improved the analysis of term and preterm infants’ breathing patterns in therapy with NIV ,32,33,34Speculatively, the OMT may influence the somatosensory system, thus causing differences between groups. Myelinations of pre- and post-central gyri proceed actively around the 35th gestational week . TherefoBoth observed patterns may explain the increased ratio of NIV weaning by time in the exposed group and describe a significant oxygenation increment in preterm infants after an OMT session .This study has limitations. First, the information on drug administration during NICU permanence is limited by database details. Despite the propensity score matching, the therapeutic protocols may have slightly differed due to the physician’s assignment. This potential imbalance between groups may have led to a bias toward the null hypothesis in our results. Secondly, there may have been treatment heterogeneity due to the intrinsic modality of administration of manual techniques (such as OMT), case, experience, and manual abilities with consequences on efficacy and safety. The osteopaths who provided the treatment were experienced and trained for the NICU setting, thus leading to issues with the generalizability of our results. Finally, despite the promising trend, due to the retrospective nature of this study, the database did not contain detailed information about ventilatory and cardiovascular parameters within the OMT context; hence, it is not possible to draw conclusions on OMT biological effects in this cohort.Our study has introduced a new research question about OMT efficacy on TIV reduction, as well as its possible biological implications. Therefore, adequately powered RCTs should assess the BPD incidence and rate of NIV failure in infants with a GA < 32 weeks treated with OMT to evaluate its effects. Moreover, the results of this study show the safety and feasibility of OMT even at early stages, as well as its positive influence on preterm infants’ respiratory adaptation, thus suggesting plausible effects on national healthcare service.


Label-free quantitative proteomic (LFQ) and widely targeted metabolomic analyses were applied in the safety evaluation of three genetically modified (GM) maize varieties, BBL, BFL-1, and BFL-2, in addition to their corresponding non-GM parent maize. A total of 76, 40, and 25 differentially expressed proteins (DEPs) were screened out in BBL, BFL-1, and BFL-2, respectively, and their abundance compared was with that in their non-GM parents. Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis showed that most of the DEPs participate in biosynthesis of secondary metabolites, biosynthesis of amino acids, and metabolic pathways. Metabolomic analyses revealed 145, 178, and 88 differentially accumulated metabolites (DAMs) in the BBL/ZH58, BFL-1/ZH58, and BFL-2/ZH58×CH72 comparisons, respectively. KEGG pathway enrichment analysis showed that most of the DAMs are involved in biosynthesis of amino acids, and in arginine and proline metabolism. Three co-DEPs and 11 co-DAMs were identified in the seeds of these GM maize lines. The proteomic profiling of seeds showed that the GM maize varieties were not dramatically different from their non-GM control. Similarly, the metabolomic profiling of seeds showed no dramatic changes in the GM/non-GM maize varieties compared with the GM/GM and non-GM/non-GM maize varieties. The genetic background of the transgenic maize was found to have some influence on its proteomic and metabolomic profiles. Since the large-scale commercialization of GM crops began in 1996, the corresponding planting area has expanded rapidly worldwide while species and transgenic traits of GM crops have been constantly enriched. The planting area of GM crops with multiple transgenic traits continues to increase, accounting for 42% of GM crops worldwide . TherefoPreviously employed directional detection methods, such as polymerase chain reaction (PCR) and enzyme-linked immunosorbent assay (ELISA), specifically and accurately detect exogenous genes and proteins. Newly developed nondirectional detection methods, such as omics and especially proteomics and metabolomics, detect proteins and metabolites very closely related to the endpoint phenotypes , making cry gene, encoding Cry protein showing a broad insecticidal spectrum, has been widely used [epsps gene, encoding 5-enolpyruvate shikimic acid-3-phosphate synthase (EPSPS), is most widely used in GM crops [cry3Bb, cry1Ab, and cp4-epsps genes), BFL-1, and BFL-2 . These selected GM maize varieties show high insect resistance and excellent herbicide resistance, which has good application prospects. As storage and edible tissues, seeds contain abundant protein and metabolites that are more suitable and necessary to be studied. Based on these omics data, the profile changes of the proteins and metabolites will be elucidated and compared between three GM maize varieties and their non-GM parents, between GM maize varieties, and between non-GM maize varieties. It is conducive to promoting the development, seed production and preservation of these GM maize varieties, and the stable promotion of these GM maize industrialization.The insect resistance and herbicide resistance of GM crops are the main and popular features . The cryely used . As for GM crops ,25,26. PSeeds of the GM maize varieties BBL, BFL-1 and BFL-2, and their non-GM parents, ZH58 (with strong resistance to drought and various diseases such as powdery mildew) and ZH58×CH72 , were studied. The information of the studied maize varieties are listed in A genomic DNA extraction kit  was used to prepare genomic DNA from maize seeds. Event- and gene-specific PCR were applied to confirm the identity of the GM maize varieties based on genotype. The sequences of the primers used and the PCR product sizes are listed in Maize seeds were ground in liquid nitrogen and incubated in lysis buffer, then reduced with10 mM Dimercapterol (DTT) . The suspension was sonicated on ice and centrifuged. The protein was precipitated by precooled acetone. After centrifugation, the protein pellets were air-dried and resuspended in 100 mM tetraethylammonium bromide (TEAB)  pH 8.0 containing 8M urea. The protein samples were reduced with 10 mM DTT and then alkylated with 50 mM iodoacetamide (IAM) . After repeatedly precipitated by acetone, centrifugated, air-dried and resuspended in 100 mM TEAB (pH 8.0) containing 8M urea , the total protein concentration was measured using the Bradford method .w/w). Digestion was performed at 37 °C for 16 h. After digestion, the peptides were desalted using C18 columns and dried with a vacuum concentration. Three biological replicates of the seeds of different maize varieties were used for proteomic profiling.Trypsin  and protein from each sample were mixed at ratio of 1:50 (The dried peptide sample was reconstituted with a 0.1% formic acid (FA)  aqueous solution and then centrifuged at 15,000 rpm for 10 min. Then, the sample solution was analyzed by HPLC–MS. The detailed analysis procedure is presented in the g for 10 min, the extracts were absorbed using a CNWBOND Carbon-GCB SPE Cartridge  and filtered before UPLC–MS/MS analysis. Six biological replicates of the seeds of different maize varieties were used for metabolic profiling.Maize seed grains of each variety were ground in liquid N2. Total metabolites were extracted with 70% aqueous methanol  at 4 °C. Following centrifugation at 10,000× The extracted metabolites were analyzed using an UPLC–ESI-MS/MS system . The analytical conditions were presented in the p ≤ 0.05 [p-value and fold change values of the univariate analysis were combined to further screen differential metabolites. Metabolites with ≥2 or ≤0.5 fold change and VIP ≥ 1 were considered differential metabolites for group discrimination [www.r-project.org, R Version1.6.2 4.0.2). KEGG pathway enrichment analysis of the DEPs and DAMs was carried out using the KEGG database  [Protein identification was performed against the UniProt Zea mays (maize) database supplemented with four foreign proteins, EPSPS, Cry1Ab, Cry3Bb, and Cry1F. All identified proteins were matched with at least one unique peptide at ≥95% confidence ,28. Protp ≤ 0.05 ,29,30 inmination ,32. A heay 2017) ,34.Maize seeds were ground in liquid N2. Total proteins were extracted with lysis buffer using an ELISA kit. The contents of foreign proteins Cry1Ab, Cry1F, Cry3Bb, and EPSPS were measured using ELISA kits according to the manufacturer’s instructions .The proteomic and metabolomic profiles of three selected GM maize varieties BBL, BFL-1, and BFL-2 and their non-GM parents ZH58 and ZH58×CH72 were studied, and their identities were first confirmed by event- and gene-specific PCR. Specific PCR fragments were only obtained from three GM maize varieties, as expected A.A total of 3577 proteins were successfully detected in the maize seeds using LFQ proteomics. The principal component (PC) analysis led to PC1 (50.60%) and PC2 (18.21%) being obtained as the two main components B. ClusteA total of 704 metabolites were successfully detected in the maize seeds using widely targeted metabolomics. The detected metabolites were diverse and could be classified into 12 classes, namely alkaloids (15.48%), amino acids and derivatives (10.65%), flavonoids (11.22%), lignans and coumarins (2.41%), lipids (18.89%), nucleotides and derivatives (5.97%), organic acids (6.96%), phenolic acids (12.36%), quinones (0.57%), tannins (0.14%), terpenoids (3.12%), and others (12.22%) A. The prThe number and regulation state of the DEPs in the different comparison groups are summarized in KEGG pathway enrichment analysis showed that the DEPs identified in the BBL/ZH58 comparison group are mainly involved in biosynthesis of secondary metabolites (ko01110) and biosynthesis of amino acids (ko01230), followed by diterpenoid biosynthesis (ko00904), amino sugar and nucleotide sugar metabolism (ko00520), and 2-oxocarboxylic acid metabolism (ko01210) A. The DEThe number and regulation state of DAMs in the different comparison groups are summarized in The DAMs identified in the BBL/ZH58 comparison group are mainly involved in ABC transporters (ko02010), followed by biosynthesis of amino acids (ko01230) and arginine and proline metabolism (ko00330) A. The DAThree DEPs, namely, EPSPS, B4FR99, and A0A804MXV9, were simultaneously identified in the three comparison groups and named co-DEPs A. These Integrated proteomic and metabolomic analyses showed that the DEPs and DAMs in BBL/ZH58 A, BFL-1/The ELISA data showed that the contents of three exogenous proteins Cry1Ab, Cry3Bb, and EPSPS were 3.35 ± 0.24 μg/g, 2.26 ± 0.01 μg/g, and 20.86 ± 3.41 μg/g in the BBL maize seeds, respectively; the contents of Cry1Ab, Cry1F, and EPSPS were 1.95 ± 0.01 μg/g, 39.46 ± 0.22 μg/g, and 3.79 ± 0.08 μg/g, respectively, in BFL-1 and 1.81 ± 0.07 μg/g, 33.72 ± 0.71 μg/g, and 3.49 ± 0.26 μg/g, respectively, in BFL-2. The proteomics data showed that Cry1Ab and EPSPS were identified as DEPs in BBL/ZH58, and Cry1F and EPSPS were detected as DEPs in BFL-2/ZH58×CH72, but only EPSPS was identified as a DEP in BFL-1/ZH58 .cry1Ab, cry1F, and cp4-epsps) but have the different genetic backgrounds, ZH58 and ZH58×CH72, respectively. In addition to the exogenous genes cry1Ab and cp4-epsps, BBL and BFL-1 carry the cry3Bb and cry1F genes, respectively, but have the same genetic background ZH58. Such an experimental design allowed us to analyze, compare, and mine the data from multiple perspectives.Different from previous studies focusing on non-edible tissues playing important roles during crop growth ,36,37,38cry1Ab, cry1F, and cry3Bb are Bt genes are exogenous, and the insecticidal proteins Cry1Ab and Cry1F are not involved in any known metabolic activity in plants. Cry3Bb was not even identified as a DEP, which may be due to methodological limitations. Herbicide tolerance is conferred by introducing the gene cp4-epsps, which encodes CP4-EPSPS, a key enzyme in the shikimic acid pathway. EPSPS is involved in the metabolic pathway for the biosynthesis of aromatic amino acids in microorganisms and plants [cp4-epsps gene insertion in genomic DNA being different in the various GM maize varieties, thus affecting different biological processes, or because of the influence of different genetic backgrounds.There were 76, 40, and 25 maize DEPs detected in the BBL/ZH58, BFL-1/ZH58, and BFL-2/ZH58×CH72 comparisons, respectively. A total of 145, 178, and 88 DAMs were found in the BBL/ZH58, BFL-1/ZH58, and BFL-2/ZH58×CH72 comparisons, respectively. None of these DEPs and DAMs were identified as novel toxins or allergens, only changed in abundance, consistent with previous reports ,43. The d plants ,45,46. NThree co-DEPs and eleven co-DAMs were identified in the seeds of the three GM maize varieties. The alignment of these proteins and metabolites to those screened out in previous studies is expected to form the basis for identifying screening markers of GM crops if they are frequently present in transgenic crops. Of course, this is dependent on sufficient research to accumulate more alternative indicators in backup databases to ensure reliability.The proteomic profiling of the GM maize variety seeds were not dramatically changed compared with those of their non-GM control. The metabolomic profiling of the GM/non-GM maize variety seeds were not dramatically changed compared with those of the GM/GM and non-GM/non-GM maize variety seeds. The genetic background of transgenic maize also has some influence on its proteomic and metabolomic profiling.


The present study aimed to determine changes in the properties of starch triggered by its long-lasting  retention with citric acid (5 g/100 g) at a temperature of 40 °C. The starch citrates obtained under laboratory conditions had a low degree of substitution, as confirmed via NMR and HPSEC analyses. The prolonging time of starch retention with citric acid at 40 °C contributed to its increased esterification degree (0.05–0.11 g/100 g), swelling power (30–38 g/g), and solubility in water (19–35%) as well as to decreased viscosity of the starch pastes. Starch heating with citric acid under the applied laboratory conditions did not affect the course of DSC thermal characteristics of starch pasting. The low-substituted starch citrates exhibited approximately 15% resistance to amylolysis. Starch and modified starch preparations are widely deployed in the industry. The most frequently applied methods of starch modification include the chemical ones. However, physical or enzymatic methods and their combinations also prove viable in this respect . Starch In recent years, there has been a growing interest in the use of citric acid. It is biodegradable and renewable, and also has been classified as safe for food uses because it is naturally derived via citrate fermentation. Starch can be esterified with citric acid in an aqueous suspension to produce low-substituted esters  or by roStarch esterification with citric acid is highly effective at high temperatures 120–150 °C), because these temperature conditions facilitate the formation an anhydride (highly reactive against starch) from citric acid in the first stage of the reaction 0 °C, bec. The estThe present study aimed to determine changes in the properties of starch triggered by its long-lasting  retention with citric acid at a temperature of 40 °C, with special attention paid to the possibility of producing low-substituted starch citrates.1HNMR technique is a highly reliable tool for ester bond detection in starch [The n starch ,12. Accon starch , methylen starch . In the n starch . The degThe low substitution degree of starch raises some concerns over the methodological correctness of the experiment. Theoretically, there is a possibility of physicochemical inclusion of free acid in spiral coils of starch chains, which would however distort the result of esterification degree determination with a chemical method. A solution is found via the analysis of molar masses of preparations determined after dissolution in two different solvents: dimethylsulfoxide (DMSO) or an aqueous solution of sodium hydroxide (NaOH). DMSO is deemed to be a solvent, which causes no changes in the molar mass of starch dissolved in it. This finding is confirmed by the results obtained by various methods from, which are similar ,14,15. D4 g/mol for fraction A and from 20.3 to 22.4 × 104 g/mol for fraction B and were similar to the Mw of the control sample (retained without the acid). Thermodynamic properties of aqueous solutions of maltodextrins from laser-light scattering, calorimetry and isopiestic investigations . Relativ2, it may be concluded that starch heating at 40 °C with citric acid had a several times stronger effect on its solubility in water than its heating without the acid. Presumably, the short-chain dextrins cleaved from amylopectin during acidic hydrolysis were highly soluble in water despite subsequent cross-linking with citric acid. Huang et al. [g et al.  also havg et al. . Olsson g et al.  also demg et al. .The swelling power of the starch heated without the acid approximated 23.5 g/g . Starch Potato starch forms pastes in a temperature range of 60 to 70 °C, and the heat of this transition approximates 17 J/g . The heaR2 and absolute slope “a”, observed in the case of analogous trend lines determined for starch samples heated with citric acid, points to the effect of this factor on paste rheology. The viscosity of pastes in the entire course of flow curves decreased along with extended starch heating with citric acid. A similar tendency was observed in the case of the rheological coefficients. The analysis of the occurring changes may lead to false conclusions that the paste viscosity decrease is attributable only to the acid effect on starch. However, the above-described chromatographic analysis indicates that there was no decrease in the molar mass of both types of starches (heated with and without acid addition) after their dissolution in DMSO. This decrease occurred only after starch dissolution and esterification in the NaOH solution, which proves the hydrolytic and, simultaneously, the crosslinking effect of citric acid on starch. Therefore, it can be concluded that the viscosity decrease was not due to the reduction in molar mass but rather to changes in the spatial arrangement of starch chains. The effect of the spatial arrangement of molecules on the properties of the analyzed substance is a well-known phenomenon [The rheological properties of pastes prepared from the analyzed starches were determined based on the plotted flow curves . The couenomenon .Starch susceptibility to enzymatic hydrolysis is determined mainly by its botanical origin ,27 and bThe research material included Superior Standard potato starch produced in 2019 at the Przedsiębiorstwo Przemysłu Spożywczego PEEPES in Łomża (Poland). Starch was modified with citric acid purchased at POCH SA Gliwice .Citric acid was dissolved in water, and then solution pH was brought to pH = 3.5 using 10 M NaOH solution. The solution was mixed with starch used in a dose to ensure acid content in the mixture at 5 g/100 g after drying. A moist mixture was carefully mashed through a screen, mixed, and conditioned for 12 h at room temperature. Afterward, it was divided into 6 portions that were left on trays in a drying cabined  at a temperature of 40 °C for 1, 2, 4, 7, 10, or 14 days. Each sample was rinsed six times with 65% ethyl alcohol. The produced preparations were dried in an air dryer  at a temperature of 35 °C for 12 h, ground in a laboratory grinder, and sieved through a screen with mesh size of 400 μm.The preparations produced analogously as the esterified preparations but without the addition of citric acid served as the control.2SO4, 1:500) were added. The mixture was filled with water to the volume of 300 mL and titrated with 0.05 M CuSO4 solution until its red-purple color disappeared. The degree of starch esterification with citric acid was expressed in grams of citric acid residues per 100 g of the preparation [Two grams of the analyzed preparation were weighed exactly to 0.001 g and mixed with 2 mL of distilled water and 50 mL of 1 N KOH solution. The mixture was heated in a boiling water bath for 10 min. After cooling, it was neutralized to pH = 8.5 using 5 N acetic acid solution. Then, 25 mL of borate buffer (pH = 8.5) and 0.3 g of an indicator  using a Bruker Avance II 600 MHz spectrometer. The analyzed starch preparations were dissolved in DMSO-d6 (20 mg in 0.6 mL). The analysis was conducted at a temperature of 25 °C [g, and the supernatant was injected into the columns. The system consisted of a series of columns: OHpak SB-G (guard), OHpak SB-806, and OHpak SB-804 Shodex (Japan). An aqueous solution of 100 mM NaNO3 was used as an eluent. Flow rate was 0.6 mL min–1, and the injection loop was 100 mL. The temperature of columns was set at 60 °C. The molar mass distribution of the starch was measured using refractive index (RI) detection. A calibration curve was plotted with pullulan standards  with known molecular masses  and glucose. Each standard (10 mg) was dissolved for 1 h in the eluent (4 mL) and measured in the same way as the samples. Molar mass distribution was used to calculate the molecular parameters: average molar mass  and dispersity (Ð = Mw/Mn) using Eurochrom  and Clarity  software.Distribution of molar masses of the examined starches was evaluated by modified HPSEC/RI methods Buksa et al. and Praznik et al. ,30. Prio4 g/mol, fraction “B” of 40.3 × 104 > Mw > 0.6 × 104 g/mol, and fraction “C” of Mw < 0.6 × 104 g/mol, and molecular parameters of each fraction were calculated.The molar mass distribution profiles were divided into 3 fractions: fraction “A” of Mw > 40.3 × 10In brief, 200 mL of an aqueous suspension containing 1 g of starch preparations or modified starch preparations per 100 g solution were prepared in a round-bottom flask. The flask was placed in a water bath with shaking at a temperature of 80 °C. It was kept under these conditions for 30 min until the water bath temperature had been obtained inside it. Afterward, the flask was cooled to a temperature of 20 °C, and water evaporated during heating was supplemented. Next, 50 g of the starch suspension were weighed into centrifuge tubes, which were then centrifuged in a Biofuge 28RS Heraeus Sepatech centrifuge at 14.500 rpm and 20 °C for 30 min. Next, the supernatant was decanted, and its dry matter content was determined with the air-dry method at a temperature of 105 °C. The precipitate left in the tubes was weighed .This determination was conducted using a DSC 822E differential scanning calorimeter  . Pre-tesAnalyses were carried out using an RS 6000 oscillating-rotating viscosimeter  for starch suspensions contained 5 g of starch preparations or modified starch preparations per 100 g solution that were heated at 96 °C for 30 min under continuous stirring. The properties of the prepared pastes were determined based on the flow curves .−1. A hot paste (38 g) was placed in a system of coaxial cylinders (Z38AL type) of an RS 6000 rheometer, then cooled, and relaxed at the measurement temperature for 15 min. The flow curves plotted were described using the following equations:τ—shear stress (Pa), y—shear rate (s-1), ocτ—yield point (Pa), cη—Casson’s plastic viscosity (Pa s).The flow curves were plotted for the pastes at a measurement temperature of 50 °C and a shear rate of 1–300 sA 0.36 g portion of starch preparations or modified starch preparations per 100 g solution was prepared in a conical flask, which was then kept at a boiling temperature for 5 min. The suspension was then cooled, evaporated water was completed to the weight of 38 g, and 34 mL of an acetate buffer (pH 4.5) were added. The flask was placed in a water bath with a shaker at a temperature of 37 °C, and 4 mL of an amyloglucosidase solution was added (enzyme to acetate buffer ratio was 1:100). After 20 min, and 1, 2, or 3 h , 1 mL of the hydrolysate was collected to a centrifuge tube and centrifuged at 5000 rpm for 5 min in an MPW 312 centrifuge. Then, 10 μL of the supernatant were collected from the centrifuge sample, transferred to a microcuvette containing 1 mL of a BIOSYSTEM reagent, stirred, and incubated at a temperature of 20 °C for 15 min. Absorbance was measured at a wavelength of λ = 500 nm using a CECIL CE 2010 colorimeter against a blank sample made of the reagent with the acetate buffer. The content of glucose was read out from the standard curve [Experimental results were subjected to a statistical analysis using Statistica 13.0 package . The statistical computations  enabled determining values of the least significant differences (LSD) and standard deviations.The experimental data achieved were then used to determine correlations between selected traits that were described with linear  equations.Starch heating with citric acid resulted in the production of low-substituted esters, whose degree of substitution ranged from 0.05 to 0.11 g of acid residues per 100 g of starch. The produced esters exhibited increased resistance (by approximately 15%) to amylolysis, being typical of RS4 type resistant starch. The comparison of molar mass distribution of these esters with control samples proves the existence of cross-linking bonds in the modified preparations. The prolonging time of starch retention with citric acid at 40 °C contributed to its increased esterification degree, swelling power, and solubility in water as well as to decreased viscosity of the starch pastes. Starch retention with citric acid under laboratory conditions did not affect the course of DSC thermal characteristics of starch pasting.


Considerable amounts of starch granules can be present in the atmosphere from both natural and anthropogenic sources. The aim of this study is to investigate the variability and potential origin of starch granules in ambient air recorded at six cities situated in a region with dominantly agricultural land use. This is achieved by using a combination of laser spectroscopy bioaerosol measurements with 1 min temporal resolution, traditional volumetric Hirst type bioaerosol sampling and atmospheric modelling. The analysis of wind roses identified potential sources of airborne starch  in the vicinity of all aerobiological stations analysed in this study. The analysis of the CALPUFF dispersion model confirmed that emission of dust from the location of storage towers situated about 2.5 km north of the aerobiological station in Novi Sad is a plausible source of high airborne concentrations of starch granules. This study is important for environmental health since it contributes body of knowledge about sources, emission, and dispersion of airborne starch, known to be involved in phenomena such as thunderstorm-triggered asthma. The presented approach integrates monitoring and modelling, and provides a roadmap for examining a variety of bioaerosols previously considered to be outside the scope of traditional aerobiological measurements.  Networks of aerobiological stations have been set up across the world for the long-term monitoring of important outdoor aeroallergens  and planStarch is a polysaccharide produced by plants and serves as energy storage. It is synthesized in the form of granules that are insoluble in water at room temperature . The morOn the other hand, anthropogenic activity, such as the production and processing of cereal grains for human and animal use , can result in large emissions of airborne dust  that conNew aerobiological methods developed to increase the specificity of detections, e.g. identification based on molecular analysis , or to e22.1The study was conducted in the Autonomous Province Vojvodina (Serbia), located on the southern part of the Pannonian Plain, from 16 February to 6 October 2019. The Pannonian Plain is a region predominantly occupied by agriculture, particularly arable crops . There i2.22.2.1−1 of air through an orifice oriented towards the direction of the wind. The particles suspended in the atmosphere are impacted onto an adhesive tape that is mounted on a drum that rotates at 2 mm/h behind the 2 mm  ×  14 mm orifice. A 48 mm section of tape corresponding to 24-h sample is then mounted on a microscope slide and analysed under the light microscope at x400 magnification. The slides are scanned at horizontal transects and bioaerosols of interest are recorded and quantified at 2 mm segments, which corresponds to hourly samples . These data were used for validating measurements by real-time bioaerosol monitor.In order to examine characteristics of airborne starch granules in the studied region, all daily samples collected in 2019 were reanalysed by light microscopy to identify the hours when large numbers of starch granules were present. Thirteen daily slides from Novi Sad that contained notable amounts of starch granules were selected for further quantitative analysis; starch granules > 8 μm were counted along three longitudinal transects at x400 magnification and data were expressed as concentration (starch granules m2.2.2−1 of air through a fixed two-layered Sigma-2 inlet (The Rapid-E instrument (Plair SA) is a laser spectroscopy-based aerosol monitor. It continuously samples 2.8 L min-2 inlet . Each sa-2 inlet . The col-2 inlet .The Rapid-E was installed in Novi Sad next to a Lanzoni VPPS2000 sampler and operated in the “smart pollen mode”  which quThe classification algorithm is based on multi-input one-output convolutional neural network (CNN) that allowed combining multiple inputs from the Rapid-E device to perform classification. As described in 2.32.3.1u and v  measured at 10 Hz by using 3D ultrasonic anemometer (Young 81000 from Campbell Scientific Inc.) installed besides the bioaerosol samplers. The conversion was performed to calculate the meteorological angle representing wind direction, having in mind that 0° corresponds to the wind from the north. There is no representative meteorological station in Vrbas, and so we were unable to perform wind direction analysis for that location.Wind directions were analysed to search for the sources of the starch granules recorded at aerobiological stations. For four locations, Kikinda, Sombor, Sremska Mitrovica and Zrenjanin, we extracted wind data from automated weather stations belonging to the official observation network operated by the Hydrometeorological Service of Serbia and situated in vicinity of aerobiological stations . At the 2.3.2−1 and 18 m s−1 velocity. The geometric mass mean diameter was 10 μm and the geometric standard deviation was 4 μm.The Lagrangian puff model CALPUFF  has been33.1The analysis of aerobiological samples detected only a few clusters of starch granules packed within plant material, but numerous episodes when isolated starch granules were predominant. Temporal distribution of starch detections during 2019 is shown in 3.2Broussonetia and Ulmus pollen while a small percentage (∼5%) of Broussonetia, Morus, Platanus and Poaceae are misclassified as starch.Overall accuracy of the artificial intelligence classification model for the identification of 26 classes  was 65.3% for the validation dataset. Starch granules are identified with 82% accuracy, mostly being confused with A highly significant positive Pearson correlation coefficient  confirmed satisfactory performance of the airborne starch detections using the Rapid-E device, which allowed us to use 1 min resolution data during further analysis .Fig. 5Ac−3. Sudden increases in airborne starch are usually followed by sudden decreases. However, starch is recorded more frequently and with a notable quantity, during the minutes following the peak. The 1 min records are further explored to identify potential sources.Measurements of airborne starch at 1 min temporal resolution reveal that recorded starch episodes are often shorter than an hour  reaching up to 7143 starch granules m3.3Average hourly wind directions during hours with the highest number of starch granules recorded in Novi Sad indicated potential sources towards the north A. Northehttps://earth.google.com/) confirmed that, there are storage towers in the vicinity of each aerobiological station, i.e., Kikinda (0.8 km to the NNE and 1.5 km to the S), Sombor (4.5 km to the SSW-SW and 5 km to the SSE-SE), Sremska Mitrovica (1.3 km to the NNE and 2.8 km to the SE-ESE), Vrbas (1.3 km to the NW) and Zrenjanin (1.3 km to the SW-SSW and 2.7 km to the S-SSE) . Predominant wind directions at the specific station during high starch records were: WNW, N-NNE, S-SSE in Kikinda, SSE-ESE in Sombor, E-ESE in Sremska Mitrovica and SSE in Zrenjanin .A GoogleEarth search  could contribute to atmospheric concentrations of starch, the analysis of wind roses identified large sources of airborne starch in the vicinity of all aerobiological stations analysed in this study . We can see in the case of Sombor  and Zrenjanin  that wind roses did not implicate large potential sources of airborne starch to the WSW-SW as being responsible for intensive starch episodes, which suggests lower activity in those facilities at the time. This supports our hypothesis that starch emission is intermittent and depends on anthropogenic activity (i.e. processing grain), and the records of starch at the monitoring station depend on aligning the wind direction with emission processes. Although it is expected that the frequency of starch detections is going to be larger at sites closer to storage towers, more sources surrounding the site in different directions, like in Sremska Mitrovica, increase the odds that wind direction is suitable for transport and thus could result in more frequent detections. It should be noted that starch granules recorded in Zrenjanin were of notably smaller size, making them more susceptible for dispersion under a wider range of wind conditions.The CALPUFF dispersion model was used to investigate the possibility that starch granules emitted from the suspected source in Novi Sad  could be carried by northerly winds to reach the measurement station. For detailed analysis and comparison of the modelled and measured starch concentration, precise determination of the emission rate and time, source height, radius and diameter are required. Also, more details about the meteorological conditions  should be combined with the WRF model. Finally, it should be noted that the study area is complex with respect to terrain and for more precise quantitative assessment of particle dispersion buildings should be added to the CALPUFF model.−3 (Jay-Lin 2009), and assuming starch particles are spherical 10 μm in diameter, we can calculate the mass concentration of starch suspended in the atmosphere. The quantity of starch measured per hour on selected days in Novi Sad reached over 10000 starch granules m−3 which corresponds to about 0.008 mg m−3. Knowing that the peaks are usually recorded over shorter periods of time  the exposure concentration is even higher (e.g. maximum recorded 1 min concentration of starch granules was 0.025 mg m−3 on 29 March). In our study, we have quantified starch granules only as particles > 8 μm. However, smaller fractions were also present in our samples, which suggests the present study underestimates the total amount of airborne starch and its mass concentrations per hour. Environmental challenge chamber tests, with hourly concentrations lower than described in this study, showed that starch granules can trigger inflammation of the lower airways (−3) specified by the Scientific Committee on Occupational Exposure Limits (Based on the knowledge that the density of starch is 1.5 g cm airways . Occupat airways , while te Limits . In addiLolium perenne pollen grains. Whereas L. perenne pollen was only lightly labelled by Lol p 1 and Phleum pratenseThe quantity of starch granules detected here exceeded estimated quantities of airborne starch that could originate from airborne pollen, i.e. about 700 per pollen grain . AlthougIn addition, starch produced from contaminated stored cereals can contain a notable amount of aflatoxins  which arAs we have seen in the case of airborne starch, high resolution automatic bioaerosol detection can provide warnings in real-time of the negative effects of anthropogenic activity and thus support mitigation efforts for protecting public health. Furthermore, 1 min resolution data can give insights into natural phenomena such as thunderstorms and, therefore, greater understanding of the role of airborne particles of biological origin, such as starch and aeroallergens, in asthma exacerbations . The resStarch granules are only one of many "neglected" biological particles, which may have significance for animal and human health and the environment. For instance, real-time automatic bioaerosol samplers will allow the detection of many potent airborne pathogens, such as fungal spores, which are often not routinely monitored due to morphological similarities between taxa. On the other hand, the analysis by light microscope requires trained specialists , which i5In this study, we have investigated the variability and potential origin of starch granules in ambient air and provided a roadmap for examining a variety of bioaerosols previously considered to be outside the scope of traditional aerobiological measurements. The advantages of automatic techniques for bioaerosol detection over traditional monitoring can be clearly seen. Laser spectroscopy-based automatic bioaerosol measurements equipped with machine learning algorithms enable the identification and quantification in high temporal resolution of airborne particles of biological origin, such as starch granules, that are often overlooked during routine microscopic analysis. With proper training datasets and dense automatic monitoring networks, the spatiotemporal distribution of these neglected biological particles could be obtained. Such data can help answer crucial evolutionary questions about colonization processes and species diversity on earth.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Objective This study examined the effectiveness of different functional monomers in universal adhesives on zirconia/resin composite bond strength both before and after thermocycling. Four universal adhesives , one adhesive , and one ceramic primer  were used in this study.Materials and Methods Zirconia discs were prepared and embedded in acrylic. Specimens were polished and sandblasted with alumina. The specimens were randomly divided into two groups (24 hours and the thermocycled), and each group was divided into six subgroups (n = 10), according to zirconia surfaces treatments: no Tx, CCP + SB2, GPU, CTB, OBU, TNU. An Ultradent mold was located on top of the treated zirconia surface. The resin composite was filled into the mold and then light-cured. A universal testing device was used to determine the shear bond strength.Statistical Analysis The data were statistically analyzed using one-way ANOVA and Tukey's test.Results After water storage for 24 hours, the shear bond strengths were GPU > CCP + SB2 = CTB = OBU = TNU > no Tx (p < 0.05). After thermocycling, the shear bond strengths were CCP + SB2 = GPU = CTB = TNU > OBU > no Tx (p < 0.05).Conclusion The universal adhesives containing 10-MDP exhibited the best performance in the shear bond strength of the zirconia/resin composite interface both before and after thermocycling. In restorative dentistry and prosthodontics, zirconia has been widely used, particularly for inlays, onlays, crowns, bridges, and implant materials. Because of its biocompatibility, strength, and esthetics in dentistry, zirconia has increased in popularity.Universal adhesives have become a new trend in adhesive and restorative dentistry. It is further stated that universal adhesives can be used not only to bond to enamel and dentin but as adhesive primers on materials such as zirconia, silica-based ceramics, noble metals, base metals, and resin composites. The universal adhesives use phosphate and/or carboxylate monomers as their primary adhesive functional monomer. Acidic functional monomers are commonly utilized, including carboxylate monomers such as 4-methacryloyloxyethyl trimellitate anhydride (4-META) and phosphate monomers such as 10-methacryloyloxydecyl dihydrogen phosphate (10-MDP) or glycerol phosphate dimethacrylate (GPDM). These monomers have many positive attributes, including the potential to bond chemically to zirconia,Thermocycling is a technique for simulating the restorations' artificial aging process. This technique gives information on the bonding resin and zirconia adhesive failure due to the dissimilar coefficients of thermal expansion between the adhesive and zirconia. The aging process has been demonstrated using a variety of thermocycling regimens, however, Gale et al have described that a cyclic procedure of 10,000 cycles per year may be enough to indicate restorative adhesive failure.This laboratory study aimed to compare shear bond strength (SBS) of four universal adhesives G-premio bond universal (GPU), Clearfil Tri-S bond universal (CTB), Optibond Universal (OBU), Tetric N-bond universal (TNU) on the resin composite and zirconia interface both before and after thermocycling with standard control Clearfil ceramic primer plus (CCP) + single bond 2 (SB2) and negative control .n = 10) according to zirconia surface treatments: no Tx, CCP + SB2, GPU, CTB, OBU, and TNU. The predictor variable was adhesives/primer, which was a nominal scale . The specimens treated by CCP + SB2, a standard adhesive for zirconia/resin composite repair, as standard controls, while negative controls were no chemically zirconia surface modification.This was a randomized control group study using 120 fully sintered zirconia disc specimens  6.0 mm in diameter and 4.0 mm in thickness. At first, the specimens were embedded in polyvinyl chloride pipe with acrylic. The specimen's surfaces were polished with 600 grit silicon carbide abrasive paper . The specimens were sandblasted with 50 µm aluminum oxide  perpendicularly in the zirconia surface  to create micromechanical retention. All specimens were then ultrasonically cleaned  for 10 minutes in distilled water and then dried with oil-free air for 10 seconds from a triple syringe. The specimens were randomly divided into two groups , and each group was divided into six subgroups (n = 10). All of them, except standard and negative control, were treated with one adhesive according to their group using a microbrush, dried 10 seconds with oil-free air from a triple syringe, and then light-cured for 20 seconds . The standard control samples were first conditioned with CCP, dried 10 seconds with oil-free air from a triple syringe, subsequently treated with SB2, dried again for 10 seconds in the same method, and finally light-cured for 20 seconds. The negative control samples were no chemically zirconia surface modification.The samples were randomized into 12 subgroups  2.0 mm in diameter, and 2.0 mm in thickness was located on the zirconia pretreated surfaces to help to display the bonding region, filled with resin composite , and then light-cured 40 seconds.The bonded samples were stored for 30 minutes at room temperature and then were kept in distilled water at 37 °C in an incubator  for 24 hours; one half was then tested (24 hours) and the other half was thermocycled  for 10,000 cycles with different temperatures of 5 °C and 55 °C, with a reside time of 30 seconds in each bath and 5 seconds of a transfer time.A universal testing equipment  was used to measure the SBS with an external load tested in the direction parallel to the zirconia/resin composite interface at 0.5 mm/min of crosshead speed. The SBS was determined by dividing the force at which bond failure appeared at the zirconia/resin composite interface.Under a stereomicroscope  with a magnification of x40, the fracture pattern was identified to quantify the postloading failure mode percentage at the fractured zirconia/resin composite interface. The fracture mechanism was classified into three different types: adhesive failure at the zirconia/resin composite interface, cohesive failure within the zirconia or resin composite substance, and mixed failure was a result of a mix of the two.p < 0.05 was used to determine statistical significance in all of the analyses.During the study period, a collecting form was used to collect data and recorded into a statistical database  for analysis. The statistical analysis results, using one-way ANOVA and Tukey's test, were computed as appropriate.p < 0.05). After thermocycling for 10,000 cycles, the SBS values were: CCP + SB2 = GPU = CTB = TNU > OBU > no Tx (p < 0.05). Compared with water storage for 24 hours, the SBS values of the GPU, OBU and no Tx groups were lower after thermocycling for 10,000 cycles, but the SBS values of CCP + SB2, CTB, and TNU groups did not change significantly (p > 0.05).The SBS values of all test groups are presented inAt the fractured zirconia/resin composite interface, the failure mode was detected using a stereomicroscope , which Zirconia is chemically inert. Surface modification with zirconia is necessary to achieve micromechanical retention and/or chemical bonding.Phosphate and/or carboxylic monomers are included in commercially marketed zirconia surface modification agents. The commonly-used adhesives/primers include phosphate monomers, 10-MDP or GPDM, and carboxylic monomer, 4-META. These monomers are acidic bifunctional monomers with two functions, with the hydrophilic portion being the phosphate/carboxylic group and the hydrophobic portion being the vinyl group. Chemical bonds can be formed between the phosphate/carboxylic group and oxide layer of zirconia. The vinyl group can copolymerize with the resin monomer of the resin-based materials. Commercially manufactured universal adhesives and metal/zirconia primers contained acidic functional monomers that were efficient in improving the adhesion capacity of resin-based materials to zirconia.In this research, we used one zirconia primer (CCP) and four universal adhesives  containing phosphate and/or carboxylic monomers. The GPU has 10-MDP and 4-MET containing monomers. CCP, CTB, and TNU have 10-MDP containing monomers. OBU has GPDM containing monomers. After each of the primers and universal adhesives had been applied to the zirconia surfaces, the SBS' significantly improved compared with the no Tx groups. GPU showed the highest initial bond strength. In contrast to other universal adhesives and CCP, GPU contains both phosphate monomer (10-MDP) and carboxylic monomer (4-MET). These two acidic functional monomers could enhance the initial bond strength of zirconia/resin composite. There was a need to differentiate between the effects of other universal adhesives and GPU on SBS. However, the initial bond strength for CCP + SB2, CTB, OBU, and TNU was not significant in between groups. Both phosphate monomers, 10-MDP and GPDM, were successful in increasing the initial bond strength of resin composite to zirconia. For this, the no Tx group served as the negative control, as it showed the lowest initial bond strength. Similarly, Han et al, Seabra et al, and Celik et al reported that the use of universal adhesives proved successful in increasing resin composite and zirconia adherence.As part of the aging process, the SBS values of the GPU, OBU, and no Tx groups were lower after thermocycling for 10,000 cycles, but the SBS values of CCP + SB2, CTB, and TNU groups did not change significantly. Even after a long-term aging process, the bonding strength of zirconia/resin composites must be maintained. Thermocycling procedures were performed to compare the bond durability, according to aging. According to Gale et al, a cyclic method of 10,000 cycles per year may be sufficient to detect restorative failure.After the SBS test, the mode of failure distribution confirmed the bond strength data. All of the samples for the no Tx group showed the lowest bond strength and exhibited adhesive failures both after 24 hours and after 10,000 cycles. The samples for the 10-MDP containing monomers showed predominantly mixed failures both before and after 10,000 cycles of thermocycling. The samples for the GPDM containing monomers presented primarily mixed failures after 24 hours, but adhesive failures increased after 10,000 cycles of thermocycling. Cohesive failures in the zirconia and resin composite were not found, which mentions that the weakest bond in the bound specimen occurred at the zirconia/resin composite interface.Within the scope of this study's limitations, the universal adhesives containing 10-MDP monomers performed best in terms of zirconia/resin composite interface' SBS both before and after thermocycling. Moreover, the SBS of all universal adhesives using 10-MDP monomers has not been substantially reduced by artificial aging. The universal adhesives containing 10-MDP monomers have the potential to improve the clinical method of repairing zirconia fractures, using resin composite, both in terms of initial bond and long-term stability.


My collaboration with the journal “Oftalmologia” dates back to 1994, when I started my residency in Ophthalmology. I began by helping my supervisor at that time, Ioan Ştefăniu, MD, PhD, with the distribution of the journals. In 1996, I published my first article and in 1997, I became editor.I was taught about the structure and functioning of a medical journal by my predecessors, Prof. Paul Cernea, Assoc. Prof. Mircea Filip and Ioan Ştefăniu, MD, PhD. Under their supervision, “Oftalmologia” evolved to become an important name among the medical journals in Romania. To increase the international exposure of the scientific works published in “Oftalmologia”, at the initiative of Prof. Călin Tătaru, MD, PhD, in 2015, the journal started to publish articles in English and changed its name to “Romanian Journal of Ophthalmology”. Simultaneously, the online, free access version of the journal was launched, on www.rjo.ro. Despite a slower start, Romanian Journal of Ophthalmology has become internationally known, as it results from the more than 3000 monthly views from all around the world, as well as from the increasing number of citations of published articles.Authors from more than 25 countries from Europe, Asia, Africa, and Latin America have published their works in Romanian Journal of Ophthalmology over the years. Regrettably, the contribution of Romanian authors has decreased in the last years and there are issues of the journal in which more than 80% of the scientific work belongs to foreign authors. This year, we started the process of indexing the journal in Clarivate - Web of Science (ISI) database, which is still ongoing.To progress, every organization benefits from the periodical change of its managing team. This avoids routine and allows new ideas and perspectives to spring and drive the journal forward. I am confident that the new board of Romanian Journal of Ophthalmology will ensure its growth, enhancing its visibility and prestige. Mihail Zemba, MD, PhD,Editor in ChiefRomanian Journal of Ophthalmology


Recipient and donor characteristics were comparable between organ preservation groups. Cold ischemic time was significantly longer in the HMP group . The overall presence of DGF was comparable between groups (HMP group n = 10 (55.6%), SCS group n = 10 (50.0%)). Prediction of DGF was possible in SCS and HMP kidneys; StO2 at 10  and 30 min  after reperfusion, as well as NIR at 10  and 30 min  after reperfusion were significantly lower in DGF kidneys, independent of the organ preservation method. In conclusion, HSI is a reliable method for intraoperative assessment of renal microperfusion, applicable after organ preservation through SCS and HMP, and predicts the development of DGF.The aim of our study was to evaluate hyperspectral imaging (HSI) as a rapid, non-ionizing technique for the assessment of organ quality and the prediction of delayed graft function (DGF) in kidney transplantation after static cold storage , as well as hypothermic machine perfusion . HSI assessment of the kidney parenchyma was performed during organ preservation and at 10 and 30 min after reperfusion using the TIVITA Hyperspectral imaging (HSI) demonstrated promising results for the characterization of tissues and the assessment of physiologic tissue parameters ,2. In co2), near-infrared perfusion index (NIR), tissue hemoglobin index (THI), and tissue water index (TWI) , unless stated otherwise. Differences were tested using Student’s Data collection and statistical analysis were performed using Microsoft Excel 2010 , IBM SPSS Statistics , and GraphPad Prism 9 for macOS version 9.3.1 .p = 0.0002).We included 38 recipients of deceased-donor kidney allografts in our study. All donor organs were derived from donation after brain death. The most frequent kidney diseases were glomerulonephritis  and vascular nephropathy . The median dialysis vintage was 67 [16–181] months. The method of organ preservation was SCS in 20 (52.6%) cases and HMP in 18 (47.4%) cases. Recipient and donor characteristics, as well as surgical details, are given in p = 0.7568). Kidney allografts developing DGF were more likely to be from male donors. Furthermore, there was also a trend towards a higher recipient BMI and for recipients being male more frequently; however, this did not reach statistical significance  developed DGF (SCS Group n = 10 (50.0%), HMP Group n = 10 (55.7%), ificance . KDPI wan method .2 levels compared to SCS-preserved kidneys at back-table preparation, i.e., prior to dynamic organ preservation . During the study period, no graft loss occurred. All patients are alive and do not need of dialysis treatment.The follow-up of the entire study cohort was 8.8 [3.5–12.7] months. The length of hospital stay was 16 [4–42] days. Creatinine at discharge was significantly higher in the DGF group (3.01 [1.49–9.29] vs. 1.88 [0.70–3.92] mg/dL, Our study demonstrates that HSI assessment of human kidney allografts is feasible and reliable, regardless of the organ preservation method. As an easy, non-invasive, non-ionizing technique with a rapid application, HSI does not disturb the surgical procedure. In our study, we demonstrated that HSI can be utilized not only to predict DGF in SCS-preserved kidneys but also in HMP-preserved kidneys. Despite significantly longer CIT, HMP kidneys yielded comparable results on HSI assessment in the recipient, confirming the attributed positive effects of HMP on microperfusion .DGF not only affects the kidney allograft and the recipient in the immediate post-transplant period, but is also a predictor for the allograft’s subsequent course, which is frequently characterized by long-term detrimental effects, e.g., recurrent episodes of acute rejection, declining kidney function, and impaired graft survival . DespiteKidney allografts with measurably impaired microperfusion are prone to developing DGF . However2 and NIR 10 and 30 min after reperfusion. Furthermore, a significantly decreased TWI was evident in DGF kidneys 30 min after reperfusion. In kidneys developing DGF, vasoconstriction and renal edema may inhibit the capillary flow after reperfusion in the recipient, resulting in decreased oxygen and nutrient delivery, as evident in decreased NIR and StO2 values in HSI measurements. In primary function kidney grafts, vasodilation probably not only improves nutrient supply, but may also lead to an increased water content, as evident in increased TWI values. Since the higher values for TWI go along with higher values in StO2 and NIR, the increased water content is judged as a positive factor, and not as a sign for renal edema. For this difference in water content to become apparent in HSI measurements, a stable period of adequate perfusion appears to be necessary; therefore, we recommend additional HSI measurements 30 min after reperfusion.Our results confirm a significantly decreased microperfusion in DGF kidneys after reperfusion in the recipient, as assessed by StOAltogether, HSI offers valuable information on allograft microperfusion. Even in kidney allografts with a supposedly enhanced microperfusion after undergoing dynamic organ preservation, i.e., HMP, HSI detects significant differences in allografts with and without DGF. Nevertheless, there are some drawbacks to HSI assessment, as one needs to obtain a close, direct view of the organ, and transcutaneous measurements are not possible. Pictures are static, and a continuous sequence of moving images is not possible.Our study is limited to 38 kidneys without randomization, and was performed at a single center, which may introduce bias. Nevertheless, this is the largest study cohort analyzing HSI in human kidney transplantation after SCS and HMP. Due to the high DGF rate in our study, regardless of the preservation method, differences in HSI measurements according to initial graft function are clearly detectable despite the small sample size. HSI measurements at back-table preparation detecting differences in tissue water content or hemoglobin deposit might be promising for the prediction of DGF prior to transplantation, but this needs to be verified in larger samples. HSI assessment might also be applicable during oxygenated HMP for detecting kidney allografts at increased risk for developing DGF.A further possible field for HSI application might be the evaluation of the organ quality prior to procurement from the deceased donor. In this setting, the HSI technique might save resources by preventing the transplantation of organs of truly poor quality that are also not amenable to organ reconditioning. However, the surgical process during the procurement procedure would need to be adapted for the HSI measurements, with early removal of the kidneys’ fat capsule for direct view of the parenchyma.HSI is a reliable and simple tool for gathering information on the microperfusion of transplanted kidneys, regardless of the preservation method, and therefore adds substantial information to routinely performed sonography. Since the quality of the microperfusion is crucial for the detection of ischemia and reperfusion injury, and also predicts initial graft performance, HSI is a valuable addition to established organ quality prediction techniques, such as KDPI and zero-time biopsies.