Specimens (n = 80/group) were cut and sintered at 1500°C for 2 h. The specimens were hydrothermally degraded in an autoclave (134°C–1.8 kg/cm2) for 20 h in saline solution (0.5 g/L) and oral mouthwash solution . After hydrothermal degradation, the samples were immersed in containers with coffee or red wine for 14 days to determine their color stainability. The results showed that the ZrOp had a higher bending strength than the ZrTrans before and after hydrothermal aging. In ZrOp and ZrTrans, the roughness increased after hydrothermal degradation. ZrOp samples had a higher Ra roughness than the ZrTrans samples. Roughness did not change after immersion in coffee or red wine. The X-ray diffraction (XRD) results showed that ZrOp samples underwent a tetragonal to monoclinic phase transformation, while ZrTrans samples were unchanged. Both ZrOp and ZrTrans samples changed color after immersion in coffee and red wine.The objective was to evaluate the bending strength, phase transformation, roughness, and color stainability by coffee and red wine of opaque and high translucency yttria-stabilized zirconia before and after hydrothermal degradation in saline solution or oral mouthwash. Presintered zirconia blocks with medium opacity (ZrO Restorative and prosthetic techniques in dentistry have undergone significant changes in recent years with increasing patient demands. Until the last decade, during dental treatment, patients were only concerned with functional rehabilitation. Currently, patients wish that dental treatments should also provide good esthetic results. To meet the new requirements, advanced dentistry techniques and restorative materials have been developed , 2. AmonTetragonal zirconia partially stabilized with 3% mol yttria (3Y-TZP) has a flexural strength of 1000 to 1300 MPa –6, whichDetails of processes involved in phase transformation and the kinetics of zirconia degradation are described by Chevalier et al. . The phaThe phase transformation of zirconia is slow at room temperature but can be accelerated by heat treatment between 200 and 300°C. Kim et al.  studied t ⟶ m transformation. Conventional zirconia showed a higher level of surface degradation than highly translucency zirconia.Silva et al.  studied 3 by removing Y ions from zirconia. This behavior is reversed when zirconia is exposed only to hot water, indicating the influence of pH and fluoride. The authors found that the degree of susceptibility to degradation may be related to grain size since zirconia with nanometric grains was more susceptible to degradation than zirconia with micrometric grains.Mukaeda et al.  studied 2O3. For the analysis, the specimens were polished or sandblasted with alumina (Al2O3). X-ray diffraction analysis showed that the tetragonal phase was present in all specimens. It was found that the surface of Y-TZP with 5 mol % of yttria blasted with alumina had a roughness Ra parameter 16 to 26 times larger than a polished surface. The Ra parameter of Y-TZP with 3% mol of yttria was 38 times larger than that of Y-TZP with 5% mol of yttria. Blasting of 3 mol% Y2O3 ZrO2 and 5 mol% Y2O3 ZrO2 zirconia reduced the flexural strength by 23% and 37.5%, respectively.Amarante et al.  studied Consumption of colored beverages such as coffee, wine, coke, and tea affects the color stability of composite resin dental restorations. Coffee has a high ability to change the color of natural teeth. Red wine can affect the color stability of composite resin due to its red color . Ban 1818 analyzThe literature data –16 show The objective of the present work is to evaluate and compare the hydrothermal degradation of 3Y-TZP and 5Y-TZP in terms of phase transformation, mechanical properties, roughness, and color stainability after immersion in a beverage (coffee and red wine).2O3) were used in this work. The first group (ZrOp) of presintered blocks was produced from the 3Y-TZP commercial powder 3YSB-E® , has conventional translucency, and is indicated for extensive dentistry prostheses. The second group (ZrTrans) of presintered blocks was produced from the commercial powder Zpex Smile® , which has high translucency and is indicated for restoration of anterior teeth. The specifications of these materials are summarized in Two commercially available presintered blocks (40 × 19 × 6 mm) of yttria-stabilized tetragonal zirconia (Y-TZP) ceramics with two concentrations of yttrium oxide (Y2O3), density, and thickness  in zirconia transmittance. They showed that samples made with powder Zpex Smile® have higher transmittance. The transmittance of 3Y-SBE, Zpex, and Zpex-4 decreases approximately linearly with the specimen thickness, whereas zirconia Zpex-Smile has a sublinear decrease, which is expected due to the optical isotropy of the cubic phase. Based on Fonseca et al. [2O3) as high translucency zirconia (ZrTrans group). The presintered blocks were supplied by ProtMat Materiais Avançados . The compaction pressure and presintering temperature cannot be disclosed due to confidentiality reasons.Fonseca et al.  evaluatea et al.  results,Eighty zirconia specimens of each type of presintered zirconia blocks (ZrOp and ZrTrans) were cut and submitted to subsequent grinding, surface polishing, and sintering. The sintering was performed in an NBD 1700°C furnace  at 1500°C for 2 h, using a heating and cooling rate of 5°C/min.Characterization after sintering: density, surface roughness, phase identification (X-ray), color, 4-point bending, and grain size;Hydrothermal degradation in an autoclave;Characterization after hydrothermal degradation: surface roughness, phase identification (X-ray), color, and 4-point bending;Beverage immersion followed by surface roughness and color measurement.After sintering, the sequence of characterization and processing of the specimens was the following:N = 20/zirconia type) were characterized , color, 4-point bending test, and grain size) as-sintered state. The samples in the second subgroup (N = 60/zirconia type) were immersed in three solutions , mouthwash solution with 0.02% sodium fluoride without alcohol mouthwash solution (N = 20), and mouthwash solution with 0.02% sodium fluoride and 21.6% alcohol (N = 20) for hydrothermal degradation followed by characterization).After sintering, the samples suffered shrinkage (25 × 1.5 × 2 mm). The samples were ultrasonically cleaned and separated into two subgroups. The samples in the first subgroup , the sample size for the 4-point bending test was 25 × 2.0 × 1.5 mm, and during sintering, a shrinkage of the order of 25% occurs, and the samples were cut with approximately 27 × 3.0 × 2.0 mm.2. One group of samples (N = 20) was kept as sintered. The hydrothermal degradation was performed for 20 h, four times longer than the required times adopted in ISO 13356-15 standard [For hydrothermal degradation, the samples were heated at 3°C/min up to 134°C and at a pressure of 1.8 kg/cmstandard .N = 20).  ND: not subjected to hydrothermal degradation (N = 20).  SS: immersion in saline solution 0.5 g/L (N = 20).  F: immersion in oral mouthwash solution  (N = 20).  FA: immersion in oral mouthwash solution  . With the purpose to evaluate the effect of beverage on roughness and color change, after hydrothermal degradation, the samples were immersed in coffee or red wine at 39°C for 14 days. Considering the type of zirconia and the kind of hydrothermal degradation, the samples after sintering were divided into 8 groups (N = 5/group) was calculated by correlating the bulk density with the theoretical density (ρT = 6.05 g/cm3). The same samples were used for X-ray diffraction, roughness measurement, color, and finally grain size measurement.The bulk density was measured in distilled water using Archimedes´ principle. The relative density (N = 5/group) was performed using X-ray diffractometry (XRD) before and after hydrothermal degradation. The instrument was a PANalytical X'Pert PRO diffractometer equipped with a Cu-Kα radiation source, with an angular step of 0.02°. HighScore Plus software version 3.0e (3.0.5) 2012 from PANalytical was used to determine the crystalline phases. The diffractogram data were compared to those of the ICDD  and COD-2012  PDF2-2004 databases. The Rietveld method was employed to quantify the phases and analyzed the crystal structures.The identification of the crystalline phases (N = 5/group) of the specimens was measured before and after degradation using a noncontact coherence scanning interferometry (CSI) technology model NewView 7100 . Five measurements per specimen were performed. Three roughness parameters were measured . Although the parameter Ra is the most analyzed in the literature, our previous results showed that among the various roughness parameters, the parameters Ra, Rz, and PV are those that exert the greatest influence on dental implant properties. Three roughness areas per sample were measured.The surface roughness  to reveal the zirconia grain boundary. The samples were covered with platinum coating for imaging in a scanning electron microscope . An intercept procedure according to ASTM E112 and Feret's diameter method through automatic image analysis using Image-Pro Plus 6.0 software (Media Cybernetics Inc.) was used to measure the grain size. This procedure was used previously .The ASTM C 1161 standard also defines the presence of a chamfer or rounding of the edges of the 4-point bending specimens. In the present work, the first option was chosen. The four long edges of each specimen were uniformly chamfered at 45°. To perform the chamfer on the edges, an adjustable table with 45° was adapted .N = 15/group) were performed using a universal mechanical testing machine EMIC model DL-10000 . A loading rate of 0.2 mm/min and a cell with 1 kN was used. The bending test was performed following the recommendations of the ASTM C 1161-08 standard [Four-point bending tests (standard .L) of 20 mm and a loading span of 10 mm was used. The width (w = 8 mm) and thickness (t = 1.5 mm) of each specimen were measured to determine the flexural strength (σ) according to the following equation:P is the maximum load recorded during testing.A custom four-point flexure fixture having a support span  and after hydrothermal degradation , three bar-shaped samples from both zirconia types (ZrOP and ZrTrans) were immersed in containers with coffee or red wine for 14 days to determine the color stainability. After immersion, the samples were washed with ultrasound in distilled water for 3 min and the color spectrum was analyzed. The color of the sample still moist to simulate the oral environment was identified using an Easyshade Vita V  digital spectrophotometer and the VITA Toothguide 3D-MASTER scale. The color of the specimens was measured against a black background using a standard DayLight ICI .L∗, a∗, and b∗ color parameters. The parameter L∗ is the lightness coefficient, ranging from black (=0) to white (=100); a∗ is the shade of redness on positive values and greenness on negative values; and b∗ indicates yellowness on positive values and blueness on negative values. Color difference ΔE between the control group  and the color of zirconia after hydrothermal aging before and after immersion in coffee or red wine was calculated as follows:L∗ = L∗ control − L∗ experimentalΔa∗ = a∗ control − a∗ experimentalΔb∗ = b∗ control − b∗ experimentalΔThe results obtained with Easyshade V make it possible to interpret the color information in the VITA 3D-Master scale system. The Easyshade Vita spectrophotometer is based on the CIELab system on a black background. Each sample was chromatically measured three times, and the average values were calculated. Color quantification was expressed according to E) was calculated by the following equation:The color change (ΔE) was classified into 3 clinically relevant intervals as follows: ΔE < 1 (undetectable color change), 1 < ΔE < 3.3 (acceptable color change), and ΔE > 3.3 (unacceptable color change).Color change  and immersion in coffee and red wine do not affect the color stability of the ceramics. The ZrOp samples made with 3Y-TZP sintered and not subjected to hydrothermal degradation were the control group.Considering that several tests were performed to characterize the samples, the statistical analysis of the results was different according to the tests. The 4-point bending strength results were analyzed by the Weibull methodology. The statistical analysis for density, grain size, and roughness was performed with one-way ANOVA followed by Bonferroni and Tukey tests at a significance level of 0.05. The statistical analysis of colors was performed using the Origin-7 software .L∗, a∗, and b∗ parameter. The Shapiro–Wilk test was applied to assess the normality of the distribution. A one-way nonparametric analysis of variance test  and the Tukey test were applied to determine whether significant differences existed among the groups. Mann–Whitney test was used as a post hoc. The statistical differences in color (ΔE) among samples before and after immersion in coffee or red wine were compared using one-way ANOVA and the Tukey test. Statistical analysis of colors was performed using the Origin-7 software  and SPSS Statistics for Windows .Descriptive statistics (mean and standard deviation) values were calculated for each CIE The results of relative density of sintered samples were superior to 98.5% of theoretical density for both groups (ZrOp and ZrTrans), and no significant statistical difference was observed between both groups.2O3) had a higher grain size (1.6 ± 0.8 µm) than the ZrOp group (0.8 ± 0.3 µm).t-ZrO2 (space group P42/nmc); monoclinic zirconia, m-ZrO2 (space group P21/c); and cubic zirconia, c-ZrO2 (space group Fm-3m). Furthermore, 2-m) on the surface. The ZrOp group has only the tetragonal phase (ZrO2-t), and the ZrTrans group has a 35% tetragonal phase and 65% cubic phase (ZrO2-c). A joint analysis of the X-ray diffraction results with micrograph analysis  did not show the total transformation of t-m phases after hydrothermal degradation for 20 h in different aqueous solutions. The ZrTrans group had 36% of the untransformed tetragonal phase. A similar was observed by Amarante et al. , althougThe 3Y-TZP ZrOp samples, whose main crystalline phase was the tetragonal phase, showed considerable hydrothermal degradation in the liquid environments. The monoclinic phase content was 21% in the ZrTrans-FA group and 27.3% in the ZrTrans-SS group. The highest (30.8%) martensitic transformation t-m was observed for the group of samples ZrTrans-F.2 ceramics stabilized with Y2O3 can degrade in the presence of acid pH and fluorides, and the microstructure influences the degradation. An explanation for this behavior would be the formation of YF3, which induces the tetragonal-monoclinic phase transformation. Marcos et al. [Mukaeda et al.  evaluates et al.  showed t+ and OH− radicals are strongly linked to the surface. When the surface is more acidic than the medium, the surface has negative charges, and the zeta potential is negative. When the surface is more basic than the medium, the zeta potential is positive.The ceramic surface charges are generated by the adsorption of ions from the solvent on the surface of the zirconia. The contact of some ceramic materials with water induces water decomposition, and HIn cases where the surface charges are generated by the adsorption of ethoxide ions from the solvent (bound by the surface zirconium and the oxygen of the ethoxide group) on the surface of the zirconia, it appears that when the bonding of the ethoxide ion and OH radicals strongly linked to the surface of the zirconia (the water decomposes), there is a stretching of the bonding of the OH group attached to the surface of the zirconia and the disappearance of vibrations.The sample surface morphologies before and after hydrothermal degradation are shown in Figures 2) for 20 h in different environments  and oral mouthwash . After hydrothermal degradation, the ZrOp samples had a higher Ra roughness parameter than the ZrTrans samples. This result shows that zirconia ZrTrans has greater stability than zirconia ZrOp.The results of surface roughness measurements are shown in t ⟶ m). This result indicates that there was a diffusion of liquid to the inner layers, which, in turn, induced the phase transformation and increased the surface roughness. The conventional zirconia (ZrOp) presents greater degradation than the translucency zirconia (ZrTrans).Analyzing together the hydrothermal degradation and the roughness for the YTZP group, we verified that the surface roughness was higher for the degraded group, which presented tetragonal-monoclinic transformation , which, despite the increase in roughness, did not suffer the pullout of the monoclinic grains. Samples from the ZrTrans group show a loss of flexural strength after degradation, and the phase transformation was not detectable by X-ray diffraction. The lower mechanical resistance of the ZrTrans group than the ZrOp group may be associated with the cubic phase present in the material and the heterogeneous grain size.Another possibility is martensitic transformation on the surface during hydrothermal degradation. In this case, compressive residual stress occurs due to the volume difference between the monoclinic and martensitic phases. The residual stress decreases crack growth and flexural resistance increases. This seems to be the case for the ZrOF value was lower than the F critic). Samples from different ZrTrans groups had a statistically significant difference . The flexural strength of ZrTrans samples was reduced after hydrothermal degradation.For the Zr-Tr group, there was no significant difference between the phase volume fractions after hydrothermal degradation and bending did not influence the phase transformation. It was found that there was a reduction in the bending strength of the degraded Zr-Trans group samples. In this case, the lower strength may be related to defects on the material surface and roughness. As expected, the bending strength of the Zr-Tr group was lower than that of the Y-TZP group for all subgroups.P-value >0.05). After degradation, the bending strength of Y-TZP zirconia increases. This variation was not statistically significant, being a little more pronounced for the Y-TZP-FA zirconia. Possibly, the greater bending strength is due to the higher volume fraction of the tetragonal phase after hydrothermal degradation, associated with the presence of alcohol in the fluorine composition.ANOVA showed that there is no statistically significant difference among the subgroups Y-TZP-ND, Y-TZP-SS, Y-TZP-FA, and Y-TZP-F. The F value was less than the critical F value , it is observed that the bending strength decreases as the roughness increases, except for the subgroups ZrOp-SS and ZrTrans-FA. For the ZrOp-SS subgroup, a hypothesis for such behavior may be due to the percentage of tetragonal phase present, around 79%, greater than the percentage of the other ZrOp subgroups.L∗, a∗, and b∗ values (SD) for each shade specimen group.The results of the color stainability tests after immersion in coffee or red wine for 14 days are summarized in The results of the statistical color analysis are summarized in Due to the lack of a technical standard to perform zirconia degradation tests, the comparison of results is impaired. Researchers carry out their tests with specimens prepared in different ways and immersion environments with different compositions, pH, and temperatures. Despite this difficulty, comparisons were made between the results of this study and those available in the literature. Paravina et al. , 24 descThe results obtained in the present work corroborate those obtained by Barutçugil et al. . They anThe results of the present work showed that it is important for dentists to take special care in recommending the use of zirconia and to guide their patients regarding the intake of colored drinks, especially coffee and red wine.2O3 (ZrOp) had only the tetragonal phase (ZrO2-t) and high translucency zirconia with 5 mol % Y2O3 (ZrTrans) had a tetragonal phase (36%) and a cubic phase (64%). After hydrothermal degradation, ZrTrans did not have a significant phase transformation and ZrOp underwent a tetragonal to monoclinic phase transformation.After sintering, conventional translucency zirconia with 3 mol % YBefore and after hydrothermal aging, ZrOp zirconia had a higher bending strength than ZrTrans.Sintered ZrTrans zirconia had a higher Weibull modulus than ZrOp. After hydrothermal aging, the Weibull modulus of ZrOp increased and the Weibull modulus of ZrTrans decreased.The surface roughness of Zr-Trans increased after hydrothermal degradation.Hydrothermal degradation and immersion in coffee or red wine changed the color of conventional and highly translucency zirconia.There was not a significant relationship between roughness and color stainability in conventional and high translucency zirconia.The results of sample characterization before and after hydrothermal aging showed that:


Human brown adipose tissue (BAT) has gained considerable attention as a potential therapeutic target for obesity and its related cardiometabolic diseases; however, whether the gut microbiota might be an efficient stimulus to activate BAT metabolism remains to be ascertained. We aimed to investigate the association of fecal microbiota composition with BAT volume and activity and mean radiodensity in young adults.18F-fluorodeoxyglucose (18F-FDG) positron emission tomography-computed tomography scan (PET/CT) after a 2 h personalized cooling protocol. 18F-FDG uptake was also quantified in white adipose tissue (WAT) and skeletal muscles.82 young adults  participated in this cross-sectional study. DNA was extracted from fecal samples and 16S rRNA sequencing was performed to analyse the fecal microbiota composition. BAT was determined via a static Akkermansia, Lachnospiraceae sp. and Ruminococcus genera was negatively correlated with BAT volume, BAT SUVmean and BAT SUVpeak , whereas the relative abundance of Bifidobacterium genus was positively correlated with BAT SUVmean and BAT SUVpeak . On the other hand, the relative abundance of Sutterellaceae and Bifidobacteriaceae families was positively correlated with 18F-FDG uptake by WAT and skeletal muscles . All the analyses were adjusted for the PET/CT scan date as a proxy of seasonality.The relative abundance of Our results suggest that fecal microbiota composition is involved in the regulation of BAT and glucose uptake by other tissues in young adults. Further studies are needed to confirm these findings.ClinicalTrials.gov no. NCT02365129 (registered 18 February 2015).The online version contains supplementary material available at 10.1007/s40618-022-01936-x. Brown adipose tissue (BAT) is a tissue that dissipates energy through the action of the uncoupling protein-1 (UCP1) in rodents and in humans . ConsequFirmicutes and Bacteroidetes are found in higher abundance (> 75%) compared to Proteobacteria, Verrucomicrobia, and Actinobacteria (< 25%)  prior to the positron emission tomography/computed tomography (PET/CT). They transported the fecal sample in plastic sterile containers inside a portable cooler until arrival at the research centre. Fecal samples were stored at −80 °C until the extraction of deoxyribonucleic acid (DNA). A QIAamp DNA Stool Mini Kit  was utilized to extract DNA following the manufacturer’s instructions, and samples were incubated at 95 ºC to ensure lysis of both Gram-positive and Gram-negative bacteria. The quantification of DNA was performed using a NanoDrop ND1000 spectrophotometer . We measured absorbance spectrophotometrically at A260/280 nm and A260/230 nm ratios for determining DNA purity. The A260/280 ratio is used to determine protein contamination , whereasWe amplified DNA extracted by polymerase chain reaction (PCR) with primer pairs, 16S Amplicon PCR Forward Primer: 5’CCTACGGGNGGCWGCAG, and 16S Amplicon PCR Reverse Primer: 5’GACTACHVGGGTATCTAATCC targeting the V3 and V4 hypervariable regions of the bacterial 16S rRNA gene . All PCR3 reads per sample. All samples surpassed a cut-off of 10,000 reads. Samples were standardized to equal size of 30,982 reads using “phyloseq” [“Dada2”  R 28] p p28] pachyloseq”  R [28] pTaxonomic affiliation of phylotypes was assigned using the “classifier” function from Ribosomal Database Project (RDP), based on the naive Bayesian classification  with a p18F-FDG PET/CT scan, in which their shivering threshold was determined. Briefly, participants arrived in fasted condition (≥ 6 h), having avoided alcoholic or stimulant beverages within the last 12 h, and having refrained from any moderate physical activity within the last 24 h, and vigorous activity within the last 48 h. They wore standardized clothes  and entered a warm room (22.1 ± 1.6 ºC) where they kept seated for 30 min. Later, they entered a cool room (19.8 ± 0.5 °C) and sat down in a chair, where we put them a water-perfused cooling vest . Each participant’s shivering threshold was then determined being seated and following a personalized cooling protocol, as described elsewhere  p p18F-FDG “psych” –43, we p2.Among the 92 participants with a complete analysis of fecal microbiota composition, only 82 participants had BAT measurements; therefore, these 82 participants were finally included in the analyses. Table Verrucomicrobia phylum and its lower taxonomic levels  were negatively correlated with BAT volume  was positively correlated with BAT SUVmean  was negatively correlated with BAT volume  was positively correlated with BAT SUVmean  was negatively correlated with BAT SUVmean  was negatively correlated with BAT volume  was positively correlated with the SUVpeak of the descending aorta  was positively correlated with all skeletal muscles SUVpeak  were positively correlated with all skeletal muscles SUVpeak  were positively correlated with subcutaneous WAT triceps SUVpeak , whereas the relative abundance of Bifidobacterium genus was positively correlated with BAT activity. Moreover, Bifidobacteriaceae and Sutterellaceae families was positively correlated with 18F-FDG uptake by WAT in the tricipital area and skeletal muscles. These findings suggest that fecal microbiota composition is involved in glucose metabolism by BAT and other tissues including WAT and skeletal muscles in young adults.This study shows, for the first time, that the relative abundance of Akkermansia, Lachnospiraceae sp., and Ruminococcus genera was negatively correlated with BAT volume and activity. It has been previously shown that the bacteria belonging to Akkermansia and Ruminococcus genera produce short-chain fatty acids (SCFAs), as acetate, to activate BAT thermogenesis and promote WAT browning via triggering the G-protein-coupled receptor (GPR) 43 in mice [Akkermansia, Lachnospiraceae sp., and Ruminococcus genera, are inversely correlated with BAT 18F-FDG uptake.The role of gut microbiota composition in BAT activation and metabolism has been investigated in mouse models –20, but  in mice –20. Howe in mice . Indeed, in mice . Accordi in mice . Therefo in mice , 45, shoBifidobacteriaceae and Sutterellaceae families with 18F-FDG uptake by WAT and skeletal muscles, whereas the relative abundance of Bifidobacterium genus, and at higher taxonomic levels, was positively correlated with BAT 18F-FDG uptake. Scientific evidence has shown that SCFAs produced by gut microbiota regulate glucose homeostasis and improve insulin sensitivity [We also observed a positive correlation of the relative abundance of sitivity , 47. Thisitivity , 47. Thisitivity , 47. How18F-FDG PET/CT might not estimate accurately the cold-induced BAT metabolic activity, despite being the most widely used technique. Moreover, it will be of scientific interest to investigate whether fecal microbiota composition is related to BAT activity measured at other room temperatures. As for the strengths of this study, we should stand out that we sequenced the microbiota composition using the latest technology (Illumina platform) and annotations were made with RDP until genera taxon.The cross-sectional design of this study precluded us from establishing cause-effect relationships. Our study population includes young adults without relevant disease or comorbidity; thus, our results cannot be extrapolated to older or unhealthier populations. Importantly, SCFAs were not measured and could be of interest for future studies. Further, although BAT takes up glucose from circulation, intracellular fatty acids are the main substrate of brown adipocytes in humans . Hence, Akkermansia, Lachnospiraceae sp. and Ruminococcus genera with cold-induced BAT volume and activity in young adults. Contrarily, the relative abundance of Bifidobacterium genus was positively correlated with BAT activity. Moreover, the relative abundance of Bifidobacteriaceae and Sutterellaceae families was positively correlated with 18F-FDG uptake by WAT and skeletal muscles. Altogether, these findings suggest that fecal microbiota is involved in the regulation of glucose uptake by human BAT and other metabolic tissues, but future studies are needed to confirm these findings and to elucidate underlying mechanisms.This is the first study showing a negative correlation of the relative abundance of Supplementary file1 (DOCX 523 KB)Supplementary file2 (DOCX 16 KB)Below is the link to the electronic supplementary material.


The knee is one of the most frequently affected joints in sports trauma, and anterior cruciate ligament (ACL) injury and meniscal tears are the most common lesions. ACL reconstruction (ACLR) remains the treatment of choice for patients willing to return to their previous activity. There are different surgical techniques and different possible usable grafts. The graft used for ACLR surgery undergoes a bone incorporation process and an intra-articular remodelling named ligamentization until it reaches characteristics similar to the native ligament. After the first incorporation stage, the remodelling process is divided into an early stage that could last 4 weeks, a proliferative stage that lasts 4 to 12 weeks, and a final stage of ligamentization that could last over 1 year. The period of return to sport (RTS) after ACLR, which is becoming shorter and shorter, can be a high-risk period for athletes due to the risk of graft failure. This systematic review aims to define the phases of the ligamentization process considering graft type and fixation techniques, as well as the graft’s anatomopathological and biomechanical characteristics, to evaluate a criterion-based rehab progression and maximize patient outcomes for an RTS respecting graft biology. The rehabilitative program has to promote and optimize the graft remodelling and incorporation processes; moreover, it has to accommodate physiological graft healing and avoid overloading. An early RTS and noncompliance with the biological characteristics of the graft in the various phases are associated with a high incidence of re-injury. High sport injury rates have been reported. The knee is one of the most frequently affected joints in sports trauma for its central role in supporting large and rapidly changing external loads during activity. An anterior cruciate ligament (ACL) injury and meniscal injury are the most common knee lesions, and ACL reconstruction (ACLR) remains the treatment of choice in patients willing to return to previous activity.The graft used for ACLR surgery undergoes a bone tunnel incorporation process and an intra-articular remodelling named “ligamentization” ,2,3. TheThe intra-articular remodelling process produces graft adaptive transformations; however, it does not have the same biological and mechanical properties as native ACL ,4,5,6,7.This study aims to define the phases of the ligamentization process considering graft type and fixation techniques, as well as the graft’s anatomopathological and biomechanical characteristics, to evaluate a criterion-based rehab progression and maximize patient outcomes for an RTS concerning graft biology.The review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The literature search was carried out on Pubmed, Medline, Cochrane Library, and Google Scholar.The keywords used were as follows: “ACL graft healing”, “ACL graft remodelling”, “ACL graft ligamentization”, “ACL graft incorporation”, and “ACL reconstruction return to play”.Two reviewers (M.D. and N.C.) independently screened titles, abstracts, and full texts. Discrepancies between the reviews were thoroughly examined on the full-text screen to avoid inadvertent exclusion. At this stage, a consensus debate mediated by a third reviewer (G.D.C.) overcame potential discrepancies.Of the 5726 studies collected , 5447 were discarded after reading titles, 128 duplicates were removed, and 90 were discarded after abstract review. The full text of the remaining 61 studies was examined in greater detail. Forty-three studies were finally included in the review.According to the definition of a rehabilitative program after surgery and the correct timing for a return to activity after a lesion, it is important to know the graft specifics and biological transformations after ACLR ,7,8,9,10The human graft remodelling process could last 1 year. The initial phase is characterized by graft necrosis and reduction in cellularity without vascularization; during the subsequent stages, there is cell proliferation followed by a ligamentization process with comparable acquired proprieties of the native ligament. Graft integration depends on its variety, its placement, its way of fixation, and its micro-movements within the bone tunnel. There are different techniques for ACL reconstruction and fixation. Some involve the creation of a complete bone tunnel at the tibial or femoral level, while others involve a tibial half tunnel and a femoral half tunnel. Lastly, there are hybrid techniques in which a femoral half tunnel and a complete bone tunnel are created; in the latter, the neoligament is blocked with suspension systems at the femoral level and with an interference screw at the tibial level according to the technique.The graft could be an autograft taken from the patellar tendon, quadriceps tendon, hamstring tendon, or peroneus tendon, an allograft from human cadavers and animals, or a synthetic graft even if it is destined for revisions. The graft taken from the patellar tendon needs 6 weeks to be incorporated; it goes through a necrosis stage followed by bone incorporation ,9,10,11.Autografts made up of the semitendinosus tendon and/or gracilis tendon, unlike the patellar graft, have a greater incorporation timing of about 8–12 weeks. Even in this case, there is the first stage of mineralization of the tendon surface followed by bone growth at the most external portion of the graft; finally, there is complete graft incorporation within the bone tunnel with the progressive restoration of collagen fibre continuity with bone (sharp-like fibres).In addition, allografts from semitendinosus and gracilis tendons need 6–9 months for incorporation and a subsequent longer recovery period. Two fundamental aspects are important for the use of allografts: the immunological effect because the implanted graft could be recognized as non-self, and the sterilization system used, with X-rays to avoid infective processes ,5,6,11.The remodelling process is divided into an early stage that could last 4 weeks, a proliferative stage that lasts 4 to 12 weeks, and a final stage of ligamentization that lasts 12 weeks to 1 year [The determinant aspects for the remodelling processes are the patient , sports activity, mechanical and surgical factors , pharmacological factors (NSAIDs delay the remodelling process), and, above all, the subsequent rehabilitation program .The first stage (early stage) constitutes graft degeneration. Fibroblast necrosis is reported in the middle of the graft with a subsequent inflammatory response. Cellular necrosis produces the release of cytokines and chemokines as chemotactic factors for host cells, resulting in stimulation of the neoligament as a scaffold.At the same time, those cytokines trigger a growth factor cascade that initiates the next stage ,15,16,17The cellular invasion begins at the outer part of the graft between the first and second weeks after surgery; cells derived from the native residual ACL, synovial fluid, and bone marrow elements are released during the bone perforation. During this stage, there is no revascularization. A study on rabbits evaluated, 6 days after ACL reconstruction surgery, the marked proline capture on the patellar tendon graft; after 48 h, there was a major marker deposition on the graft surface, demonstrating the presence of active cells. Furthermore, there was no marker deposition to the inner part of the graft with the prevalence of necrosis. This first stage is called the “degeneration stage” . MoreoveThe major risk during the initial stage is connected to the lack of graft incorporation within the tunnel and graft pull-out .Rehabilitation during this first stage should avoid the tensioning of the new ligament, even if the load is important to promote remodelling ; weight-Flexion recovery must happen quickly and gradually with passive and active exercises: during the first 2 weeks, 90° of knee flexion should be recovered, followed by 120° in the third week, and full flexion in the fourth week.Furthermore, quadricipital musculature should be strengthened; allowed exercises are isometric quadricipital contractions at 0°, 60°, and 90°, high saddle bicycle with low resistance, hell slides, straight leg raise, closed kinetic chain leg presses, and open kinetic chain extensions ,22.The second stage (proliferative stage) from the 4th to 12th week is dominated by elevated cellular activity and important extracellular matrix changes, which start during the earliest period after surgery. At this moment the graft has poor mechanical proprieties. Based on animal studies, we can provide two subphases at this stage: a proliferative subphase, characterized by cellular proliferation and reabsorption of the collagen matrix for the deposition of a new one with a vascularization-correlated process; a replicative subphase representing biochemical and histological modifications of the extracellular matrix  to produce the recovered mechanical graft properties.Evaluation in humans has shown reduced remodelling with partial substitution of fibres from cells and reduced necrosis. Vascularization is reduced and related to collagen destruction .Scheffler et al.  reviewedThe rehabilitation program during this period accepts load to stimulate the production of cellular and extracellular components, preserving graft stability. The rehabilitation goal should be a normal gait with complete knee flexion and extension; the gait could also be altered as a result of compensatory techniques used when the knee was sore immediately after surgery. This change in gait may be more subconscious at this point. It may be beneficial to use a mirror so that the athlete can see themselves and their irregular gait pattern. Another exercise to perform is a high-stepping gait cycle with a mirror, which can be used to make the patient understand the degree of hip and knee flexion that can be reached without feeling pain.Isometric muscle contractions can be replaced by isotonic muscle contractions to improve graft strength during the incorporation process and due to necrosis being succeeded by revascularization. Quadriceps strengthening can begin with wall slides progressing to mini-squats or progressive resistive leg press exercises; at this time, enough soft-tissue healing of the hamstrings should allow tolerance to perform gentle hamstring and gastrocnemius and soleus flexibility exercises. Squats with a closed kinetic chain should be performed on a solid surface before progressing to an unstable or labile surface. The athlete is instructed to flex the knees to approximately 25–30° and sustain the position to produce hamstring and quadriceps co-contraction. Squats may be performed on a tilt board that is tilted in either the medial/lateral or the anterior/posterior directions. Particular attention must also be paid to proprioceptive exercises.Lunges in multiple directions can gradually be included in the physiotherapy program. Higher-level lunges can be incorporated by lunging with a rotation, lunging onto a labile surface, or lunging with perturbation. When these lunges are tolerated, the patient’s attention can be focused on throwing or catching a ball indicative of the practised sport . This phase is marked by the advancement of the patient from tolerating simple functional activities to more advanced activities, enabling them to progress to complete leisure or sporting activities. They should have enough strength and balance by the end of 12 weeks to advance to regulated individual sports and leisure activities. This does not suggest that they will be entirely autonomous once they resume sports, but it does imply that they will be able to participate in supervised individual functional sports activities ,22.The third stage (ligamentization stage) starts 12 weeks after surgery. At this point, the graft undergoes adaptive remodelling to achieve the mechanical properties and structure of the native ACL. The native ACL is composed of aligned collagen fibres with different diameters. After the second stage, the graft is composed of disorganized fibres in space and diameters. Animal models show the normalized composition of cells in the graft at 3–6 months after surgery; vascularization is remodelled as the native ACL 6–12 months after surgery, and fibres reorganize themselves 6 to 12 months after surgery, despite their diameter showing a unimodal pattern. There is an increased production of collagen type III, which has fewer mechanical properties than collagen type I typical of native ACL ,6,7,8,9.After 2 years after surgery, the end of the revascularization process matches with a homogeneous graft MRI signal close to the native ACL .At 6 months after surgery, a graft implanted in human shows a reduction in collagen content compared to the original ligament, the interfibrillar spaces are occupied by an extracellular matrix, and clusters of fibrils are arranged parallel to the fibres; the presence of elastic fibres and similar-function macrophage cells, tenocyte cells, and fibroblasts is also observed.The reconstructed ACL is constituted by large-diameter collagen fibres similar to normal ligaments, along with small clusters of fibres of low diameter 12 months after surgery. Fibrils have a multidirectional organization which is parallel, oblique, and perpendicular to the main neoligament axis. The elastic system is well represented by elastic and oxalic fibres. An increased volume of the rough endoplasmic reticulum within cells demonstrates important protein synthesis ,24.The new ligament is very similar to the native ACL after 24 months; the small collagen fibrils are organized in more distended and closely packed fibres with a multidirectional organization, the interfibrillar space is reduced, and there is a small amount of extracellular matrix. Cells and the elastic system 2 years after surgery are almost the same as those observed at 12 months ,26.After 4 years after surgery, the graft is even more similar in collagen and fibres space orientation to the native ACL, with a further reduction in interfibrillar gaps and an increase in the elastic system. At 10 years after surgery, fibre arrangement is close to that observed at 24 months. The tendon is architecturally transformed almost completely into a native ACL; however, some fibres of the original tendon remain inside the graft .The end of the ligamentization process was indicated at 3 years after surgery by Rougraf et al. , at 1 yeEven the evoked potentials (EPs) become similar between patients subjected to LCA reconstruction and naïve patients, with a negative correlation between EP voltage and knee instability ,31.Moreover, there is a difference between animal and human models; reinnervation is observed in rabbit grafts after ACL reconstruction  but is aA low level of evidence is available for the reinnervation graft process; proprioceptive improvements after surgery are probably connected to central nervous system modifications or neuroplasticity. Patients with reconstructed ACLs show an increase in cerebral activity in the contralateral motor cortex, ipsilateral angular gyrus, and somatosensory cortex, whereas reduced activity was recorded in the ipsilateral motor cortex and cerebellar vermis ,40,41,42Biomechanical proprieties reached 1 year after surgery can be considered as 50–60% of those types of the native ACL . However, in recent years, various ACL repair techniques have been experimented with, providing excellent outcomes .During this third phase, the patient trains for a gradual return to full sports activity. If they pass the clinical examination and have no swelling or discomfort while undertaking daily activities, have a full range of motion, and have no instability, they can begin jogging in a straight line.When tolerated, bilateral plyometric exercises requiring a stretch/shortening period may be progressed to unilateral exercises. Exercises that stress single-limb postural control are given first on level ground and then progressed to an unstable labile surface. Improving the balance of a single limb can be initiated by maintaining the position of only one limb on a flat and level surface while moving the contralateral extremity through classic movement patterns such as flexion/extension and abduction/adduction. Once this has been demonstrated, inclined planes and proprioceptive platforms can be used. Running and jumping exercises, strength and endurance exercises, gait exercises, and valgus overload of the knee can be implemented.Exercises for the trunk and hips are recommended because most advanced activities need core stability to retain the centre of mass, balance, and postural control. The ability to effectively regulate the body’s centre of mass in response to forces produced by distal body parts during athletic competition is linked to core trunk training and stability .Return to playing does not mean full participation in competitive events; athletes are advised to resume practice activities and begin to prepare for competitive play gradually.The mean absence until the first match appearance after undergoing ACL reconstruction was 237.5 ± 76.1 days in Walden’s study , 232 ± 1However, return to match play is influenced by several nonmedical factors, such as coach selection, off-season holidays, and playing position.An early return to sport, <160 days, is associated with a high incidence of reinjury considering ligamentization and loss of physical performance timing.For a safe return to sport, we should consider the van Grinsven criteria  (no painHadley et al. showed that, for a safe RTS, patients must pass a checklist indicated in their work. Patients who successfully passed the checklist before returning to play experienced a significantly lower incidence of ipsilateral ACL injury as compared with patients who did not pass the checklist .The graft used for ACLR surgery undergoes a bone incorporation process and ligamentization process until it reaches characteristics similar to the native ligament.It is important to know the graft specifics and biological transformations after ACLR for the correct timing to return to activity after injury. The rehabilitative program has to promote and optimize graft remodelling and incorporation processes; moreover, it has to accommodate physiological graft healing and avoid overloading. An early RTS and noncompliance with the biological characteristics of the graft in the various phases are associated with a high incidence of re-injury.Further studies are needed to evaluate whether the graft’s microstructural characteristics and cellularity change after repair.


Mangifera indica) kernel, making it an alternative to obtain an ingredient from a non-conventional source with potential application in food and other industrial applications; however, reports on the use of new extraction techniques for this material are scarce. The main objective of this research was to evaluate the effect of ultrasound-assisted extraction (UAE) on the yield, chemical, techno-functional, rheological, and pasting properties of starch isolated from a non-conventional source such as a mango kernel. (2) Methods: Different power sonication conditions  and sonication time  were evaluated along with a control treatment (extracted by the wet milling method). (3) Results: Ultrasound-assisted extraction increases starch yield, with the highest values (54%) at 480 W and 20 min. A significant increase in the amylose content, water-holding capacity, oil-holding capacity, solubility, and swelling power of ultrasonically extracted starches was observed. Similarly, mango kernel starch (MKS) exhibited interesting antioxidant properties. The sol-gel transition temperature and pasting parameters, such as the breakdown viscosity (BD) and the setback viscosity (SB), decreased with ultrasound application; (4) Conclusion: indicating that ultrasound caused changes in physical, chemical, techno-functional, rheological, and pasting properties, depending on the power and time of sonication, so it can be used as an alternative starch extraction and modification technique, for example, for potential application in thermally processed food products such as baked goods, canned foods, and frozen foods.(1) Background: Starch is the main component of mango ( Mangifera indica) is a native of India. It is the second most traded tropical fruit worldwide and the fifth in terms of production [Mango  kernel [Eriobotrya japonica) [Artocarpus heterophyllus Lam.) kernel, longan kernel (Dimocarpus longan Lour.) kernel [Melicoccus bijugatus) [Litchi chinensis Sonn.) [Starch is one of the most abundant polysaccharides in nature and is the main source of carbohydrates for humans with a wide range of applications, in the food industry, chemical, pharmaceutical, textile, plastics, cosmetics as a colloidal stabilizer, thickening agent, gelling agent, water retention agent, encapsulating agent, adhesive, for the preparation of coatings and edible films . It is m) kernel , loquat aponica) , jackfru) kernel , Huaya (jugatus)  and lychs Sonn.) .The starch extraction process is mainly composed of the wet grinding method; in this case, the vegetable source is soaked in acid, neutral or alkaline media and the enzymatic method has been used to increase the yield of starches; however, these methods require a long extraction time, low yield and the use of pure enzymes for starch extraction makes the process costly ; for theDifferent authors have employed UAE for the obtention of starch from different sources, i.e., Sit et al. , investiStarch was obtained from the mango kernel by the conventional method (MKS-C) and employee ultrasound-assisted extraction (MKSU) with characteristics of a powder, a soft texture, and a light brown color. MKS-C presents an extraction yield of 42.05 ± 2.58%, closer than those reported for kernel starch in mango of Brazilian origin  and lowep < 0.05) with values between 45.2 and 54.0%, as shown in p > 0.05) when increasing the ultrasonic power values from 120 to 300 W, at the same sonication time. However, the MKS20-480 treatment produced a higher yield than the MKS20-120 and MKS20-300 treatments, which had lower potency values. That means that at high power values, the change in the sound field can produce violent vibrations and collapse by cavitation that stimulates the rapid swelling of the cell membrane, leading to a decrease in general resistance to mass transfer and an increase in the isolated starch content [The extraction yield increases with the UAE  increased amylose content. The higher amylose content was obtained at an extraction time of 20 min with values of 36.06 and 36.56 g/100 g starch at a power of 480 and 300 W, respectively. The results are consistent with those reported by Li et al. [Radix Puerariae. This result is mainly attributed to the molecular scission of the amylopectin chains caused by ultrasound extraction, which facilitates the leaching of amylose from the swollen starch granules, thus increasing the number of linear chains and the amylose content. Then, cavitation as the main effect of ultrasound is the cause of the increase in the starch extraction yield, and conditions such as sonication power and time are important parameters that affect this process. Consequently, the results of the amylose content can be explained by the difference in the cavitation mechanism induced by the different ultrasonic powers and times, which leads to the difference in the depolymerisation effect, as in this case where a higher value of amylose was obtained at a sonication time of 20 min and a power of 300 W.The ultrasound treatment significantly  [−1 was assigned to water molecules absorbed in the amorphous region [−1 are due to CH2 deformation and OH bonds, respectively [Analysis of the chemical groups of mango kernel starch (MKS-C and MKSU) was performed by FTIR in the range of 4000 to 550 cmC, C–OH) . The peas region  and the ectively . −1 is associated with the moisture content of the samples that is connected to the vibrations of adsorbed water molecules in the non-crystalline region [−1, which are assigned to the joined stretching vibrations of the C–O and C–C of the polysaccharide molecules [Then, the band at ~1640 cme region . The chaolecules .p < 0.05) for TPC suggesting that they are strongly bound to starch granules, surviving the different powers and ultrasonic times.p < 0.05) in comparison to MKS-C, which could be attributed to pyrolysis and release of hydroxyl radicals caused by bubbles in cavitation, and the formation of these hydroxyl radicals in water could cause the oxidation of some polar compounds [Eriobotrya japonica seed starch (0.49–2.85 µMol Trolox/g starch) [Similarly, the Trolox equivalent antioxidant capacity (TEAC) indicates that UAE is significantly reduced  . The resStarch WHC and OHC represent the ability to hold water and oil against gravity, respectively, depending on the molecular structure, morphology, amylose content of the starch granules, crystalline and amorphous regions within the starch, the size distribution of the granules and the type of modification .p < 0.05) with values of 85.71 and 92.85 g/100 g. This increase could be due to the affinity of starch granules for water molecules caused by cavitation, also, amylose content is directly related to WHC, because amylose tends to form chain-like aggregates through hydrogen bonds and hydrophobic interactions, increasing the water holding capacity of starch [Sagittaria sagittifolia L.) that demonstrated an increase in WHC upon application of trifrequency power ultrasound. Similarly, the OHC values ranged from 82.43 to 87.78 g/100 g in the case of sonicated samples, which were significantly higher (p < 0.05) than those observed in the MKS-C sample. The increase in OHC could be due to the breakdown of the starch structure by ultrasound treatment, resulting in increased capillary entrapment of oil molecules in the amylose–lipid complex, as reported by Wang et al. [f starch . These rf starch  for starg et al.  for ultrAnalysis of the characteristics of the starch–water system is of great importance in the food industry. Solubility represents the number of starch constituents leached into the swelling volume supernatant, while SP reflects the water absorption capacity of starch granules when heated under conditions of excess water . SolubilThe solubility and SP values of MKS and MKSU are shown in p > 0.05) on the SP of MKS at 65 °C; then, at temperatures of 25 and 90 °C, the differences were statistically significant (p < 0.05) except for samples MKS10-300 and MKS-120, this may be due to the low power levels and the ultrasonic time was used, resulting in a reduction in the interaction between chains, which reduces the integrity of the starch granules and decreases the SP. Samples MKS20-300, MKS30-300, and MKS20-480 showed an increase in SP different from MKS-C, these treatments were subjected to medium and high time and power levels; therefore, different ultrasonic times and powers have different effects. When combining a medium power level and high time, as in the case of MKS30-300, the highest SP values were found. The increase in SP of ultrasound-treated samples can be attributed to cavitation, which contributes to the breakdown of the crystalline structure of the starch granules, the disintegration of intermolecular bonds, and the change from order to disordered state of the internal matrices of the starch granules due to water absorption by amylopectin and therefore to the increase in swelling power of the granules [Ultrasound-assisted extraction has no significant influence (granules . Similarp > 0.05) in the solubility percentages for MKS-C, except for 65 °C, the MKS30-300 sample presented the highest solubility percentage. Previous research reported increases in solubility and hydration with ultrasound-assisted extraction of yam starch [In the same way as in SP, the solubility of MKS-C and the samples with UAE was determined; the results are shown in m starch . This maDynamic rheological measurements reveal the gelling ability of starch suspensions or pastes . Figure All samples exhibited two regions during heating: within the range of 40 to 75 °C, the modulus p > 0.05) with the MKS-C (81.70 ± 1.63), except for the sample MKSU20-480, which was treated at the maximum power level of 480 W. for 20 min, which presented a lower crossover temperature of 78.5 °C ; however, for most MKS with UAE, the PT is reduced compared to the MKS-C sample (83.80 °C), with the exception of the MKSU30-300 sample, where an increase of 0.3 °C was observed. The decrease in PT suggests that ultrasonic treatment reduces the resistance of starch to swelling as a result of the destruction of the ordered and crystalline molecular structure during the cavitation process.The pasting parameters of peak viscosity (PV), trough viscosity (TV), breakdown viscosity (BV), final viscosity (FV), setback viscosity (SB), and pasting temperature (PT) of the MKS-C and MKSU are presented in p > 0.05) with the application of UAE in values of 2.67–4.65 Pa·s, and the decrease showed a dependence on increasing sonication power. This result can be attributed to the fact that violent physical forces, such as shear forces, shock waves, microjets, and cavitation can induce the breakdown of long macromolecular chains that split into many short chains reducing the integrity and stiffness of the granules, resulting in a reduction in PV, as reported by Yang et al. [Furthermore, PV indicates the maximum viscosity reached during heating and is reached when the rate of granule swelling is equal decomposition of the granule . The MKSg et al.  and Yangg et al. . The lowg et al. , and thep > 0.05) than the control sample (MKS-C), indicating that MKSU had the weakest physical structure, which makes it more prone to collapse under heat treatment and shearing; therefore, ultrasound treatment strengthens the stability of starches under these conditions. A similar trend was observed in yam starch with ultrasound-assisted extraction [p > 0.05) from 3.34 Pa·s to 0.50 was evidenced for the MKS20-300 sample, indicating that ultrasound contributes to the depolymerization and degradation of long-chain amylopectin and leached amylose [Meanwhile, breakdown viscosity (BD) is the difference between PV and TV and measures the degree of disintegration of the organization of starch granules, low values of BD suggest a higher resistance of starch granules to mechanical agitation during heating . The BD traction , ultrasotraction , and chetraction . The set amylose . Decreas amylose .Ultrasound increases extraction yield and breaks down starch chains and amylopectin, as it increases amylose values compared to the conventional wet milling method; it also led to the acquisition of ingredients rich in phenolic compounds and interesting antioxidant properties. The techno-functional properties of water-holding capacity, oil-holding capacity, solubility, and swelling power were enhanced by ultrasound treatment when subjected to medium and high power and time levels, extending the potential industrial application of these starches in different food formulations. Ultrasound caused some conformational and microstructural changes in the starch granules because the sol-gel transition temperature decreased with high-power conditions. The pasting properties were influenced by ultrasonic treatment, these parameters are relevant to determine the behavior of starch in various industrial and food applications; therefore, the results suggest that ultrasound becomes an alternative methodology to obtain starches from non-conventional sources such as mango kernel with potential application in thermally processed food products such as baked goods, canned foods, and frozen foods.Sodium carbonate anhydrous (99.5% purity), sodium bisulfite (99.5% purity), and ethanol (99.5% purity) were purchased from Panreac . The Folin–Ciocalteu reagent, Gallic acid standard (>98% purity), and (±)-6-hydroxy-2.5.7.8-tetramethyl-chromane-2-carboxylic acid , were purchased from Sigma–Aldrich .Mango var. Corazón fruits were harvested to commercial maturity in the municipality of Santa Catalina, Bolivar, and transported to the laboratories of the Research Group of Complex Fluid Engineering and Food Rheology of the University of Cartagena, Colombia. The fruits were washed and disinfected with an aqueous solution of sodium hypochlorite at 100 ppm, and then manually peeled. After separating the seeds, they were washed and dried at 40 °C for 4 h in a hot air tray dryer to facilitate the separation of the kernel and the hull of the seed. The kernel was separated from the shell and sliced and then dried in a hot air tray dryer at 40 °C for 12 h. Finally, the size was reduced in a mill  together with a sieve to obtain flour with a particle size of less than 250 µm.g for 10 min to precipitate the starch. Finally, the starch was dried in a hot air tray dryer at 40 °C for 12 h.The extraction of mango kernel employees in the UAE was done following the procedures described by Mieles-Gómez et al. , and KarThe starch extraction yield was calculated based on the initial amount of dry weight of mango flour, as expressed in Equation (1):The apparent amylose content of the starches was determined using the iodine method according to Morrison and Laignelet . The amyw/w), dried, and IR spectra were recorded in the wavelength region between 400–4000 cm−1 with a resolution of 4 cm−1. Intensity measurements were made on the spectra by recording the heights of the absorbance bands from the baseline.The identification of the functional groups will be carried out by Fourier transform infrared (FTIR) spectroscopy in a medium spectrum range. FTIR spectra were recorded on an FTIR spectrometer  at room temperature. Briefly, small samples of starch were mixed in a starch: KBr ratio of 1:100 (w/w) and 190 μL of Milli-Q water were added to the sample. The samples were then left for 2 h in the dark at room temperature. The absorbance was measured at 760 nm using a Vis Genesys 10S UV spectrophotometer .The total phenolic content of the samples  was determined using the Folin–Ciocalteu method . BrieflyThe antioxidant capacity was measured following the method described by Re et al. , using tg for 15 min using a centrifuge . Finally, the supernatant was removed, and the wet starch was weighed after draining for 10 min.The water holding capacity (WHC) and the oil holding capacity (OHC) of the samples were determined following the method described by Yamazaki , modifieThe solubility and swelling power (SP) of the starches were measured using the method described by Jiang et al.  with somw/w) was carried out using a controlled stress rheometer , following the methodology of López-Barraza et al. [The rheological analysis of starch suspensions  in the linear viscoelasticity regime and a heating rate of 5 °C/min.−1.The temperature profile starts with a 5 °C/min heating ramp from 50 to 95 °C, holds at 95 °C for 5 min, cools down at 5 °C/min from 95 to 60 °C, and finally is kept at 60 °C for 5 min. Throughout the assessment, the sample was kept under constant agitation at a deformation speed of 500 sThe pasting properties obtained were peak viscosity (PV), trough viscosity (TV), breakdown viscosity (BV), and final viscosity (FV), breakdown viscosity (BD) is the and Setback viscosity (SB).p < 0.05) between samples. All tests were performed in triplicate.Data were analyzed with a unidirectional ANOVA using Statgraphics software (version centurión XVI) to determine statistically significant differences (


DCD utilization rate was 59.5%. In the DCD group, median functional WIT, A-NRP and D-HOPE time was 43, 246, and 205 min, respectively. Early outcomes of DCD grafts recipients were comparable to those of matched DBD LTs. In DCD and DBD group, incidence of anastomotic biliary complications and ischemic cholangiopathy was 15% versus 22% (p = 0.73) and 5% versus 2% (p = 1), respectively. One-year patient and graft survival was 100% versus 95% (p = 0.18) and 90% versus 95% (p = 0.82). In conclusion, the association of A-NRP + D-HOPE in DCD LT with prolonged WIT allows achieving comparable outcomes to DBD LT.Prolonged warm ischemia time (WIT) has a negative prognostic value in liver transplantation (LT) using grafts procured after circulatory death (DCD). To assess the value of abdominal normothermic regional perfusion (A-NRP) associated with dual hypothermic oxygenated machine perfusion (D-HOPE) in controlled DCD LT, prospectively collected data on LTs performed between January 2016 and July 2021 were analyzed. Outcome of controlled DCD LTs performed using A-NRP + D-HOPE (  In liver transplantation (LT) using grafts from donors whose death has been determined by circulatory criteria (DCD), warm ischemia time (WIT) has a major impact on the outcome. Prolonged WIT has consistently been associated with an increased risk of primary non-function, ischemic cholangiopathy (IC) and inferior graft survival –5. In coHowever, mainly prompted by the favourable Spanish experience with the use of abdominal normothermic regional perfusion (A-NRP) to recover DCD liver grafts from Maastricht category 2 donors , DCD LT A growing body of literature supports the benefits of A-NRP for livers procured from Maastricht category 3 (controlled) DCD donors –17. In tIn the Italian setting, previous studies have shown that the association of A-NRP with ex-situ machine perfusion for controlled DCD liver grafts allows achieving good LT outcomes –24, whicThus, the aim of the study was to report our results with the use of A-NRP + D-HOPE for controlled DCD liver grafts with prolonged WIT. To assess the effectiveness of this approach, outcomes of DCD grafts recipients were compared to those of a matched cohort of DBD LTs, selected using propensity score matching.Prospectively collected data on adult (≥18-year-old) patients who underwent LT at our centre from January 2016 to July 2021 were retrospectively analyzed. Collected data included donor and recipient baseline characteristics, operational details, and prognostic scores , 27. The2 saturation ≤70% or systolic blood pressure ≤50 mmHg, whichever occurred first) 300 IU/kg heparin was administered. After 20-min electrical asystole, death was declared, femoral vessels were cannulated and descending aorta was occluded by an endovascular balloon or a surgical clamp, depending on theatre logistic, after which A-NRP was started. During A-NRP, pump flow was maintained ≥1.7 L/min/m2 and temperature at 35–36°C (2 and air flow) were adjusted to maintain PaCO2 between 35 and 45 mmHg, SaO2 about 96–98%, and SvO2 > 60%. If needed, packed red blood cells were transfused to maintain haematocrit ≥20%. Heparin boluses were administered based on activated clotting time values. Blood samples were obtained prior to A-NRP start, at 30 min and then hourly to adjust A-NRP parameters  and to assess liver injury and function. Target A-NRP duration was 4 h and it was never less than 2 h or more than 6 h. During A-NRP, liver viability assessment was based on a modified version of the criteria proposed by De Carlis et al.  macrovesicular steatosis or Ishak >1 fibrosis, good liver and abdominal viscera perfusion, and evidence of bile production. A liver biopsy was systematically obtained to rule out significant necrosis or macrovesicular steatosis. At the end of A-NRP, the liver graft was cold flushed with Celsior  solution through the arterial cannula and trough a portal vein tributary. Liver was prepared on the backtable immediately upon arrival at our transplant centre and subsequently underwent a minimum of 2 h of D-HOPE using the LiverAssist device , primed with 3 lt of Belzer MP solution . Temperature, portal vein and hepatic artery pressure were set at 8–10°C, 3–5 mmHg and 25 mmHg, respectively. D-HOPE was not used with the purpose of viability assessment and all grafts treated by D-HOPE were subsequently transplanted. At the end of recipient hepatectomy, the liver was disconnected from the device and brought to the operating table for implantation.Our procurement and machine perfusion protocols are depicted in  35–36°C . Target s et al. , includiIn DBD group, the liver was flushed with Celsior and preserved by static cold storage until implantation into the recipient. In both groups, the liver was flushed with chilled 5% albumin solution before implantation.As a rule, liver transplant was performed by the piggyback technique with portal reperfusion first. Following hepatic artery anastomosis, an end-to-end biliary anastomosis was performed using a 2.5 mm T-tube. In all patients graft histology was assessed on time-0 biopsies, which were systematically obtained at the end of transplant operation. Standard immunosuppression included basiliximab, tacrolimus, steroids and mycophenolate mofetil, and was not modified according to treatment group.Early outcome endpoints included rate of post-reperfusion syndrome , 31, traPost-reperfusion syndrome was defined as a drop in mean arterial pression ≥30% from the baseline for at least 1 min and within 5 min from reperfusion . EAD andBiliary complications  were diaVariables are presented as number (percentage) of median (interquartile range), as appropriate, and compared using Fisher’s, Chi-square and Mann-Whitney tests. To control selection bias, 1:2 propensity score matching without replacement and using the nearest method was used to select two patient cohorts with comparable characteristics. Variables included in the model were recipient age, body mass index (BMI) and model for end-stage liver disease (MELD) score, hepatocellular carcinoma (HCC) as an indication for LT, donor age and BMI, percentage of macrovesicular steatosis and presence of macrovesicular steatosis ≥15%. Standardized mean differences were used to assess balance obtained by propensity score matching. Patient and graft survival was analyzed using Kaplan-Meier curves. Statistical analysis was performed using R: a language and environment for statistical computing .n = 22; cat. 2, n = 4). A total of 37 category 3 DCD donors were signalled in our region during study period, of which 22 were transplanted by our centre. As per Italian regulations, livers from regional DCD donors were allocated locally to our centre, which is the only liver transplant centre in our region, and referred elsewhere only upon refusal by our unit. Four livers were refused based on donor characteristics and the organs were reallocated to other centres. Three of these grafts were successfully transplanted, whereas one was discarded during A-NRP due to elevated transaminases and lack of lactate clearance. Of the remaining 11 livers, 6 were discarded by our and all other Italian centres based on donor features, whereas of 5 offers initially accepted by our centre, 2 were subsequently discarded due to excessive functional WIT, and 3 during A-NRP. The reason to discard the liver during A-NRP was mainly elevated transaminases, which was associated to persistently elevated lactate levels in one case and evidence of gallbladder and bile duct necrosis in another. No liver was discarded based on histological findings. Overall utilization rate of livers from category 3 DCD donors was 25/37 (67.6%), whereas it was 22/37 (59.5%) if we consider only those transplanted at our centre.During study period, 810 adult LTs were performed, of which 26 using organs proceeding from a DCD donor  score and portal reperfusion time .Outcomes in the unmatched and matched cohort are reported in In the DCD and DBD group, EAD and grade 2/3 AKI rates were 5% versus 15% and 15% versus 22%, respectively, with no patient requiring renal replacement therapy after LT. Five (25%) and 8 (20%) recipients of a DCD or DBD liver, respectively, developed grade ≥3 complications and median comprehensive complication index was 16.5  versus 21.8 . Intensive care unit and hospital length of stay was 4  versus 4  and 10  versus 12  days, respectively. Two grafts were lost in the DCD group, which were the first and the second in our series. The first graft loss resulted from a hepatic artery injury that occurred during an attempt at performing hepaticojejunostomy for a late biliary fistula 97 days after LT. The vascular injury resulted from the severe inflammatory reaction caused by the biloma involving the porta hepatis and was deemed not amenable to repair. The second graft loss was caused by hepatic artery thrombosis occurring on postoperative day 2. Despite the graft was showing good function, large necrotic areas were apparent at computed tomography scan, so a decision was made to relist the recipient for urgent retransplantation. Both patients were successfully retransplanted.The rate of anastomotic biliary complications and ischemic cholangiopathy was comparable between groups . In partMedian follow-up was 40  and 15.5  months in the DBD and DCD group, respectively. Graft and patient survival was comparable between groups . In the This study shows that a combination of A-NRP followed by D-HOPE is effective in preserving grafts from controlled DCD donors with prolonged WIT and allows obtaining comparable outcomes to DBD LT. These results appear to be even more remarkable if some peculiarities of the Italian setting are considered. Besides the 20-min no-touch time, which is unique among countries with active DCD programs , pre-morOverall, our results confirm the benefits of both A-NRP and D-HOPE in controlled DCD LT. As compared to ultra-rapid recovery followed by static cold storage, use of A-NRP has been associated with better graft function, lower rate of overall biliary complications and ischemic cholangiopathy, and improved graft survival –17, 39. Undoubtedly, these favourable results also issue from accurate donor selection and liver function assessment during A-NRP. In our experience, four (12.9%) initially accepted grafts were discarded based on parameters obtained during A-NRP. Different criteria for liver viability assessment during A-NRP have been proposed in different countries , 45, 46.As LT outcomes are also influenced by recipient condition , 27, it Limitations of our study include retrospective single-centre design and limited numerosity. Given the exploratory nature of this analysis, formal sample size calculation was not made. Also, as the majority of DCD LTs were performed in 2020–2021, follow-up was shorter in DCD group. Although 6-months minimal follow-up should have allowed capturing the majority of biliary complications, late-onset complications could have been missed. We are aware that an updated definition of functional WIT has been recently introduced . HoweverIn conclusion, despite apparently prohibitive WIT, outcome of LT using livers from controlled DCD donors treated by a combination of A-NRP and D-HOPE is comparable to that of DBD LT, suggesting that a wider implementation of this approach could contribute improving the results of DCD LT and expand donor pool. Larger studies are required to confirm these findings, refine our evaluation process, and establish when and by which modality machine perfusion is indicated in this setting.


Headaches have been studied and treated since nearly 7,000 BC because of their significant global impact. Current headache treatment modalities are various and have a wide variety of targets, but medications are the most common. Since conventional medical treatments have several side effects, alternative remedies such as osteopathic manipulative treatment (OMT) should be considered. OMT can assist in the management of various health conditions, such as low back pain, neck pain, and headaches. The purpose of this scoping review is to evaluate recent findings regarding the efficacy of OMT modalities in the management of headaches such as tension-type headaches (TTH) and migraines.This study was designed as a scoping review to gather evidence on the efficacy of OMT modalities in the management of headaches. Following PRISMA guidelines, four databases were used to search for articles published between 2010 and 2022 that reported the use of OMT and manual therapy for TTH and migraines. Databases used include Embase, PubMed, Medline, and Web of Science. The following keywords were used: treatment, therapy, Headache, migraine, craniosacral, muscle energy, myofascial release, trigger point, osteopathic, and manipulation. The initial search yielded 473 unique articles after removing duplicates. After screening based on the inclusion and exclusion criteria, and after further analysis, 15 articles were selected.Data reports of OMT and manual therapy efficacy and/or effectiveness in treating TTH and migraine were analyzed. Articles included were randomized control studies , one pilot study , and one case series , which were divided into TTH  and Migraine Headaches . All articles reported significant headache improvement in at least one measurement. Of all treatments analyzed, single technique interventions  and multiple technique interventions  were identified. Among the techniques used, Myofascial Release was the most common .The articles presented provide evidence of the significant benefits of manual therapy. Because of the limitations of traditional medicine, OMT can be used either as an alternative or adjuvant therapy for headaches. Evidence suggests the positive impact it can provide on headache management, but the number of randomized control trials and population samples should be increased to support its recommendation. This demonstrates how different osteopathic techniques can provide therapeutic effects on TTH, MH, and potentially other types of headaches. A preference for myofascial release was observed, which can be due to the fast relief from the physiologic effect on tissue movement.This review study demonstrates the benefits OMT has on decreasing headache frequency, intensity, and duration in TTH and migraines. OMT has shown to be beneficial, especially for patients seeking alternative non-pharmaceutical and non-invasive treatments. Further studies are needed to evaluate the effects of different OMT techniques, and different combinations of treatments, on other types of headaches. Headaches have been one of the most common and prevalent medical concerns affecting the human population worldwide . The preTTH is the most common headache type worldwide and has an etiology that arises from a constellation of emotional, environmental, and physical factors . It has Also classified as a primary headache, MH is the second most common type of headache which carries a greater physical burden on the population . MH appeAs one of the most common disorders, headaches have a wide variety of medications in an extensive and diverse pharmacology market . The MH OMT is a branch of medicine that follows four tenets: the unity of the human body, the body's ability to regulate and heal itself, the interrelationship of structure and function, and the use of rational treatment revolves around the total care of the patient . OMT incThe techniques used in these models include myofascial release (MFR), muscle energy, high velocity and low amplitude (HVLA), trigger point, balanced ligamentous tension (BLT), occipito-atlantal decompression (OA-D), and cranial therapy treatment. MFR techniques are specific maneuvers directed toward the body’s soft tissues, principally the muscles and fasciae . EvidencCombining these techniques can provide significant effects on the treatment of diverse conditions . For insMethodsA computerized search was performed to identify the efficacy of OMT treatment for TTH and MH. The databases PubMed, Embase, MEDLINE, and Web of Science were utilized with search terms related to OMT, headaches, TTH, and migraines.Search strategyFirstly, the inclusion and exclusion criteria were established before conducting the review. Articles were included if they (1) were in the English language, (2) were published from 2010 to 2022, and (3) included an abstract containing the keywords treatment/therapy, osteopathy/osteopathic manipulation treatment, or headache/migraine. Book review, print media, editorial, correspondence, short survey, erratum, conference abstract, and paper were excluded.Identification of studiesAn electronic search of PubMed, Embase, MEDLINE, and Web of Science was performed to identify effectiveness of OMT for TTH and migraines. An initial Boolean and keyword search that included " OR "("Muscle"" AND ""Energy"") OR " OR "("Trigger"" AND ""Point"") OR " OR "("Osteopath"*" AND ""Manipulat"*")) AND "("treatment"" OR ""therapy"") AND "("headache"" OR ""migraine"") was conducted.Data extractionThe Boolean and keyword search resulted in 2,072 articles, and 519 duplicates were removed. Of the 1,553 articles that remained, 1,080 articles were removed due to either (1) the abstract not including all keywords  or (2) being a book review, print media, editorial, correspondence, short survey, erratum, or conference abstract or paper. Additionally, any article not written in English was removed. Two readers assessed the remaining 473 full-text articles based on the inclusion and exclusion criteria, and a total of 19 articles were found to be eligible. Upon further screening, four did not include TTH or MH, leaving 15 articles for this review , which was used in 4 out of 6 studies -28. The Control and Comparison GroupsAll studies in this review utilized a control or sham group except a study by Arnadottir et al., who utilized an experimental crossover design . Two of Study PopulationThe majority of studies included in this analysis included both male and female research subjects and excluded participants under the age of 18 years old and over the age of 65 years old. One study excluded individuals under 20 years old, including an age range from 20 to 50 years old . All othLength of Treatment Session and Length of Overall StudyThe studies included in this analysis varied in their treatment protocol and the total length, ranging from as little as four weeks to as long as six months. One study lasted four weeks, consisting of Myofascial and trigger point treatment sessions that lasted 30 minutes and occurred once a week . AnotherStatistical ResultsThe studies assessing the impact of treatment with migraines used various criteria for quantification of results, such as the Headache Impact Test -6, Migraine Disability Assessment (MIDAS), or Headache Disability Index (HDI) -30. ThesTension-Type HeadachesTechniques UtilizedOsteopathic Manipulative Techniques (OMT) were used across nine studies to treat TTH. Of the OMT techniques used, three out of nine used MFR to treat TTH -33. Two Measuring InstrumentsA variety of instruments were used to measure the effectiveness of various OMT techniques in these studies. Most studies used multiple means of measuring treatment effectiveness. The most commonly used instrument for measuring treatment effectiveness was a headache diary, used by four out of nine studies on tension headaches ,33,36,38Control and Comparison GroupsSeven out of nine of our studies evaluating the use of osteopathic manipulation for TTH were randomized controlled trials (RCTs). One was a pilot study and one was a case series ,39. Of tStudy PopulationOur study populations included both male and female sex with varying age cut-offs depending on the study. Two studies were limited to ages 18 to 50 ,35. One Inclusion criteria for the type of TTH and length of diagnosis varied based on the study. Inclusion criteria for the majority of the studies were based on the diagnosis of TTH utilizing the International Classification of Headache Disorders criteria for TTH -34,36-38The studies included in this review took place worldwide. Two of the nine studies on TTH took place in Kerala, India ,35. AnotLength of Treatment Session and Length of Overall StudyThe studies varied widely in their total length, ranging from as little as five days to as long as 20 weeks. Only one study lasted five days, while one study lasted 4 weeks, one lasted five weeks, one lasted six weeks, three studies lasted 12 weeks, and one lasted 14 weeks -34,37,38The studies also varied in the length of each treatment session. One study utilized 20-minute sessions of cervical traction, cranial rhythmic impulse, and McKenzie exercises . AnotherStatistical ResultsAll studies reviewed revealed statistically significant changes in headache parameters of patients before and after OMT, through their various criteria for measuring effectiveness in treatment. One study, however, showed that both positional release therapy and medical therapy are equally effective at treating TTH .One particular study was able to present that direct and indirect MFR OMT treatments significantly decreased the number of TTH the studied population experienced within 20 weeks, with a confidence interval of 95% . This stAnother study looked at headache frequency, intensity, and pain threshold before and after intervention with positional release therapy, noting that headache frequency (p=.001), headache intensity (p=.002), and McGill score decreased significantly (p=.003) and local pressure pain threshold increased significantly (p=.003) after treatment . DespiteDiscussionThe purpose of this study was to identify the efficacy of OMT on TTH and migraine headache treatment. The effectiveness of OMT was based upon the presence and quantity of relief of symptoms associated with TTH and MH.Migraine Headaches Main findings: OMT techniques such as direct and indirect myofascial tissue release were most commonly evaluated in the studies on MH -27. MyofThe patient population of these studies ranged from 18 to 65 years old, with one study evaluating specifically female patients, who are diagnosed with migraines as indicated by the International Classification of Headache Disorders (ICHD) criteria . All stuMost studies in this review have shown a statistically significant difference in using OMT to alleviate migraines in patients. One study by Gandolfi et al., in particular, demonstrated no statistically significant difference in headache measurements in groups receiving myofascial and trigger point treatments, but a statistically significant decrease was noted in the use of relieving medications after OMT treatment when the study was conducted for four weeks . On the Implications: The treatment of migraines through OMT techniques revealed significant results with improved patient outcomes. These outcomes were primarily based on the analysis of their validated quantifiable measures. It was found that OMT ,29, cranSince the studies were conducted in Europe, the results can be generalized to the population in Europe, but further studies are needed to be conducted in the US to determine whether the conclusions can be generalized to the US population as well.As the precise mechanism of action of the effect of OMT on migraines has not been defined, it has been hypothesized that it includes the rebalance of vegetative nervous system (VNS) nuclei and the reduction of pro-inflammatory substances . MigrainOverall, OMT has been shown to provide significant improvement in migraine management. A combination of OMT techniques, such as MFR and craniosacral techniques, can help reduce migraine intensity and frequency, and acute medication use, which can further contribute to the quality of life for patients suffering from migraines ,27. The Tension-Type HeadachesMain findings: OMT techniques such as HVLA, MFR, positional release techniques, cervical traction, McKenzie exercise, suboccipital soft tissue inhibition, and Myofascial trigger point focused massage techniques were performed on patients with TTH to evaluate their efficacy. Headache diaries were most commonly used to measure the effectiveness of these techniques ,33,36,38The patient population of these studies ranged from 18 to 65 years old, with some studies limiting the age range to patients of either 20 to 40 years old or 40 to 49 years old ,39. InclAll studies in this review have shown statistically significant differences in their respective measurements regarding the effectiveness of OMT on TTH. Both positional release therapy and medical therapy were shown to be equally effective at relieving TTH, shown by the decrease measured in headache frequency and intensity . Direct Implications: When reviewing the findings of each study regarding effectiveness in treating TTH, it can be deduced that intervention with OMT provided measurable instant relief of TTH in all scenarios. Relief was even found to be long-lasting, noting improvements in the patient’s posture over time as well, with treatments spread across a period . PositioSimilarly, for TTH, there is no definite mechanism for the physiological effects of OMT. OMT techniques, including MFR, provide direct relaxation of muscle tension in cervical muscles and fascia, resulting in relief. Therefore, this can indicate that TTH causes dysfunction of pericranial myofascial tissue, which can explain part of the pathophysiology of TTH . As AjimThese findings can be generalized due to the moderate sample size in most studies, along with the use of standardized measurements such as HIT-6 and statistical analysis to ensure that the results are statistically significant. Additionally, the studies range from various countries across the world, allowing these results to be generalized worldwide.Limitations of included studiesIn attempts to include relevant studies through the database search, the possibility of missing clinically significant and relevant studies cannot be excluded. The use of four databases restricted the articles to be used. Limited translational resources restricted us from the use of articles that were not written in English. The inclusion criteria allowed for OMT performed in Europe and Asia to be included, where medical training is not as standardized compared in the United States. Similarly, there is inherent variability in techniques among different OMT practitioners and in including studies that used physical therapists instead of licensed OMT physicians. The inclusive use of randomized controlled trials limited the study to further analyze evidence in other experimental trials. Furthermore, the lack of quality evidence analysis limits the study for clinical recommendations. Other potential limitations of the studies in this review include low sample sizes, short duration of the study, and heterogeneity of the populations sampled.Limitations of the review processFirst, this study focused on articles published only in the past 10 years. This limitation does not allow for all published data on the topic of OMT treatment on TTH and migraines to be analyzed and covered in concluding. Additionally, this review only included articles written in English, which may not be representative of the global prevalence and treatment of TTH and MH. Lastly, relevant articles may have been excluded due to limited databases utilized and strict inclusion and exclusion criteria.Future research considerationsThrough this scoping review, we hope to provide supportive guidance for future research studies in OMT. One limitation of selected studies that has been mentioned is the lack of diversity within the patient populations. Some studies were able to work within the constraints of small population sizes by utilizing crossover studies . FurtherSecondly, the database search identified a small number of articles executed in the United States. With the increasing rate of students graduating in the U.S. as Doctor of Osteopathic Medicine (D.O.), the unique effect of OMT should be further supported as management for diverse conditions. This review should be taken into account to expand the understanding and provide evidence of the benefits OMT can provide. Through the articles acquired, it can be observed how there are many hypotheses of OMT physiological effects and secondary pain relief effects. Further studies are needed to evaluate the mechanism of action of different OMT modalities on various conditions besides migraine and TTH headaches. Lastly, because of the lack of protocolized use of OMT in headache treatment, it will be significantly beneficial for a consensus to propose a standardized protocol of treatment.It can be concluded that OMT can be used through diverse techniques to provide significant improvements to headaches. Such benefits include decreasing headache frequency, intensity, and duration in TTH and migraines. The implementation of soft tissue techniques including MFR, suboccipital inhibition, and cranial therapies can not only assist in the management of migraine pain intensity and frequency but also in decreasing the use of medications. Furthermore, OMT has the potential to provide significant headache improvement as adjuvant therapy and has shown to be beneficial, especially for patients seeking alternative non-pharmaceutical and non-invasive treatments. Comparably, OMT techniques such as HVLA, positional release therapy, and MFR techniques can be used with significant efficiency for TTH management. Further studies are needed to evaluate the effects of different OMT techniques, and different combinations of treatments, on other types of headaches.


Arterial venous (AV) fistula is the first choice of vascular access to perform hemodialysis in the vast majority of suitable patients followed by arteriovenous grafts (AVG). An iatrogenic fistula can occur when a second vein adjacent to the graft is punctured and the needle traverses the vein. In normal circumstances, this has no clinical repercussions and does not need correction, and in prior reports, it has helped to maintain the patency of partially occluded grafts but rarely can lead to thrombosis of the graft due to reduced flow and pressure in the graft lumen. We report here what we believe is a unique approach to perform thrombectomy of an occluded graft in a 71-year-old patient on hemodialysis to avoid placement of tunneled hemodialysis catheters and complications associated with catheters. When the outflow of basilic vein in this patient was thrombosed and could not be traversed, we successfully used an iatrogenic fistula as main outflow vein for the graft and created an alternative vein for drainage thus avoiding placement of a tunneled catheter for hemodialysis. The basilic vein is the larger vein in diameter compared to the cephalic vein. It is a commonly used vein for creation of arteriovenous fistula (AVF) in the upper extremity . BasilicWe present a 71-year-old male with ESRD on hemodialysis for 6 months who was deemed not suitable for creation of a fistula due to his suboptimal vein size and therefore had surgical creation of right brachial-basilica AV graft. Eight months after placement of the AVG, he presented with complete loss of thrill over the AVG. A few weeks prior to that adequacy of hemodialysis access was declining during the InterAccess flow monitoring which was below 500 ml/min. Patient was referred for a fistulogram but was unable to follow up prior to thrombosis of access. An ultrasound duplex scan demonstrated thrombosis in the AVG and therefore patient was referred to us for declotting.We cannulated the graft in antegrade direction. Angiogram showed that the basilic vein was thrombosed . We coulAn iatrogenic fistula is a conduit created between the arteriovenous graft and nearby vein(s), described as a consequence of repetitive traumatic cannulation of the AV graft, which leads to establishment of an alternative pathway of venous outflow of the graft. The repeated cannulations can lead to a hematoma in the surrounding tissue. This results in creation of a fistula with near native veins and can remain asymptomatic and nonfunctioning. Thrombosis of the graft leads to increased intragraft pressure in the venous arm of the AV graft which leads to increased blood flow through the iatrogenic fistula , 6. The Common complications of fistulas and grafts in hemodialysis patients include thrombosis, infection, steal syndrome, pseudoaneurysms with risk of bleeding, venous hypertension, seromas, and heart failure. Thrombosis and infection occur more frequently with grafts than with fistulas but the patency advantage of fistulas over grafts is not found in people who are 65 years and older –9. ThromIn our case, the cause of thrombosis we suspect could be that the graft-to-vein fistula reducing intraluminal pressure in the graft played a key role in causing graft thrombosis . We suspThe iatrogenic fistula formation between AV graft and an adjacent vein is a rare but a reported cause of graft thrombosis. The prevalence of this complication is not well established, but the major contributing factor is repeated inadvertent concomitant cannulation of AV graft and adjacent vein in the presence of venous outflow stenosis. Careful selection of cannulation site and proper cannulation technique is extremely important to prevent this rare complication. Early detection and resolution of venous outflow stenosis are of high importance in preventing and treating this complication. These iatrogenic fistulas only manifest during periods of elevated graft pressure. Once the graft pressure is normalized, these fistulas have minimal hemodynamic effect, and some resolve spontaneously without the need of any specific treatment .In conclusion, although a traumatic graft-to-vein fistula is not a common hemodialysis access complication to occur, it can lead to graft thrombosis. Careful cannulation technique is important to prevent the development of iatrogenic fistulas. Endovascular techniques can be utilized to salvage this type of thrombotic traumatic AV fistulas using different outflow vein than the original vein the graft was anastomosed to.