Colocasia esculenta, Eleocharis dulcis, Nelumbo nucifera, Sagittaria sagittifolia, Trapa bispinosa, and Typha angustifolia possessed carbohydrate mainly in their storage and reproductive parts. Starch morphology, total starch, and amylose content of these six freshwater plant species were determined. Their functional properties, i.e., starch crystallinity, thermal properties, and rheological behaviour were assessed. Large starch granules were in N. nucifera rhizome (>15 μm), medium-sized was N. nucifera seed (8-18 μm), while the rest of the starches were small starch granules (<8 μm). Shapes of the starch granules varied from oval and irregular with centric hilum to elongated granules with the eccentric hilum. Eleocharis dulcis corm starch had significantly higher total starch content (90.87%), followed by corms of C. esculenta (82.35%) and S. sagittifolia (71.71%). Nelumbo nucifera seed starch had significantly higher amylose content (71.45%), followed by T. angustifolia pollen (36.47%). In comparison, the waxy starch was in N. nucifera rhizome (7.63%), T. bispinosa seed (8.83%), C. esculenta corm (10.61%), and T. angustifolia rhizome (13.51%). Higher resistant starch was observed mostly in rhizomes of N. nucifera (39.34%)>T. angustifolia (37.19%) and corm parts of E. dulcis (37.41%)>S. sagittifolia (35.09%) compared to seed and pollen starches. The XRD profiles of macrophytes starches displayed in all the corms and N. nucifera seed had A-type crystallinity. The T. bispinosa seed had CA-type, whereas the rest of the starches exhibited CB-type crystallinity. Waxy starches of C. esculenta corm had higher relative crystallinity (36.91%) and viscosity (46.2 mPa s) than regular starches. Based on thermal properties, high-amylose of N. nucifera seed and T. angustifolia pollen resulted in higher gelatinization enthalpy . Starch properties showed equally good potential as commercial starches in starch-based food production based on their starch properties and functionality.Several aquatic macrophytes such as  Zea mays (maize), Manihot esculenta (cassava), and Solanum tuberosum (potato) resulted in their extensive utilization in food industries. However, other plants besides those mentioned above may possess potential and promising alternative starch sources.Starch plays a vital role in food and nonfood industries, e.g., pharmaceutical, paper, textiles, biomedical, and polymer, because of its gelling characteristics, thickening, water binder, and food system stabilizing capacities . ResearcOryza sativa, is a human staple diet [Nelumbo nucifera), Chinese water chestnut (Eleocharis dulcis), water caltrop (Trapa bispinosa), taro (Colocasia esculenta), and arrowhead (Sagittaria sp.) for starch-based food. The research conducted showed that starches from macrophytes could also be a promising candidate as an energy source in the food-related industry. Water chestnut corm flour as a thickening agent and dusting powder in food preparation [Over the years, aquatic plants' usage has become increasingly important; for example, rice, ple diet . Detaileparation , arrowheparation , 5. Taroparation . Lotus sparation . Most ofparation –11, and paration .Research on starch isolated from freshwater macrophytes such as cattails, arrowhead, yellow nutsedge, and duckweed and their physicochemical properties are also available and less prevalent , 14. AltInvestigating the aquatic macrophytes starches, among others, is to create awareness of their various uses and economic values. For those involved in aquatic macrophytes, it can be part of their added income generation. This study also investigated the potential use of aquatic macrophytes starches in other applications in a starch-based industry. Thus, the present study was to systematically evaluate the starch structure, composition, functional properties, and also their resistant starch (RS) content isolated from selected commonly consumed aquatic macrophytes such as taro, lotus, and water chestnut and rarely consumed, e.g., arrowhead, water caltrop, and cattail in Malaysia.E. dulcis, S. sagittifolia, and C. esculenta; rhizomes of N. nucifera and T. angustifolia; seeds of N. nucifera and T. bispinosa; and pollen of T. angustifolia were peeled, washed, and isolated for starches.Two kilograms (2) kg of edible storage organ from five macrophytes species; corms of w/v) sodium metabisulfite was added into the slurry and left for 30 minutes before filtering using 100 μm nylon mesh cloth. The filtrated starch was centrifuged at 8000 rpm at 20°C for 20 minutes. The supernatant was discarded, and the pellet was oven-dried at 40°C for 24 hours. The dried starch was ground using mortar and pestle, sieved (250 μm), labelled, stored in a tightly closed container, and kept dry in a desiccator (10% relative humidity).Native starch was isolated following a method described by Vasanthan  with a sA small amount (0.2 mg) of starch powder was placed on a microscope slide (25.4 mm × 76.2 mm) by using a spatula. The starch was stained with 0.25% Lugol's solution. The slide was then covered with a coverslip and observed under a compound light microscope  equipped with a camera set , polarized filter and analyzer. Images of starch granule and hilum were observed and captured. The granule sizes were measured using the ImageJ software .Structural characteristics of the starch granules were examined with scanning electron microscope Jeol JSM-6400  and analyzed with an energy dispersive X-ray analyzer (EDS) PGT Spirit at an acceleration of 20 keV. Samples of starch were mounted on aluminium specimen stubs with double-sided adhesive tape and sputtered with a 20-30 nm gold layer using a sputter coater before observation.Macrocomponents  and resistant starch were determined using the Megazyme assay kit with given procedures . Microcomponents, i.e., protein, lipid, and phosphorus, were determined the content by following the Official Method of AOAC International .θ of 5°-45° using X-ray diffractograms . Traces were obtained using a Cu-Kα radiation detector with a nickel filter and scintillation counter operating under the following conditions: 40 kV, 30 mA, scattering slit 25 nm, K-Alpha1 wavelength 1.78901 Å, K-Alpha1 wavelength 1.7929 Å, Ratio K-Alpha2/K-Alpha1 0.5, and scanning rate of 0.02°/min. The degree of crystallinity of samples was estimated and analyzed following the method of Zhang et al. [Starch powders were scanned through the 2g et al. .μL capacity aluminium pan with the addition of 70% distilled water to achieve starch-water suspension. The DSC analyzer's calibration was conducted using indium, and an empty aluminium pan was used as a reference. Sample pans were heated from 25 to 120°C at the rate of 10°C/min. Onset temperature (To), peak temperature (Tp), conclusion temperature (Tc), and gelatinization enthalpy (ΔH) (J/g dry starch) were determined in triplicate.Thermal properties of starches were studied using differential scanning calorimeter, DSC . Starch  was placed into a 40 w/v) suspension of native starches were prepared by dispersing a suitable mass of dried starch granules in distilled water by a ratio of 1 : 17 with constant stirring. The viscosity (mPa s) and shear stress (Pa) were determined following the method by Chrungoo and Devi [Rheological properties of starches suspended in distilled water were determined by rotational rheometer . 6% (and Devi .p < 0.05) using the SPSS 16.0 Statistical Software Program, IBM, Chicago, IL.The data recorded in all the tables were mean values and standard error. Analysis of variance (1-way ANOVA) was performed for the data and, if significant, followed by a post hoc Duncan's multiple range test (DMRT) , medium-sized, 10-25 μm (maize or corn starch), and small, 3-8 μm (rice starch). From the starch classification, N. nucifera rhizome possesses large starch granules while N. nucifera seed has medium-sized starch granules that ranged 8.11-17.78 μm. The corms of C. esculenta, E. dulcis and S. sagittifolia, T. bispinosa seed, T. angustifolia rhizome, and pollen have small starch granules ranging 0.4-13.44 μm. The size of starch granules affects starch granules gels and paste performance as the larger the granule, the faster it swells, due to less molecular bonding than smaller granule [μm), which resulted in faster gelatinization range (56-69°C). In contrast, the smaller granules of regular corn (5-25 μm) resulted in a slightly slower gelatinization range with 62-80°C . In this present study, a large starch granule of N. nucifera rhizome gelatinizes faster than others. Besides, Pomeranz [C. esculenta corm and T. angustifolia had predominantly polygonal and irregular shapes with few oval shapes. In contrast, the larger granules normally were observed with predominantly longitudinal and rod-shaped such as in N. nucifera rhizome. Tester et al. [C. esculenta corm and N. nucifera rhizome) due to the fusing of different granules developing simultaneously within a single amyloplast during biosynthesis [Starch granules of plant species varied in size from 1 mm up to 100 mm, for taxonomic discrimination to be possible. ectively . PomeranPomeranz . The grar et al.  reportedynthesis . The resT. angustifolia seed starch  even though the layer not as distinct as reported in potato.Besides, some starch granules may still attach to other nonstarch components like fiber, lipid, or protein fragments despite undergoing isolating process, as shown in d starch . Accordi to grow , which cT. angustifolia pollen and 17.23% of E. dulcis corm starch. A higher total starch was in corm samples, including E. dulcis (90.87%), C. esculenta (82.35%), and S. sagittifolia (71.71%), whereas the T. angustifolia pollen has a significantly least starch content (7.02%). Based on previous studies, Typha sp. generally had low starch contents ranging between 13.01% and 14.5% compared to other commercial starch such as Zea mays (22.40%) [N. nucifera seed had high-amylose content with 71.45%, whereas T. angustifolia pollen and S. sagittifolia corm were categorized as regular starches with an amylose content of 36.47% and 19.80%, respectively. The rest were classified as waxy starch, ranging from 7.63% in N. nucifera rhizome to 13.51% in T. angustifolia rhizome. According to Eltaboni et al. [N. nucifera seed starch of the present study. In addition, a wide range of amylose content was observed in 46 lotus roots starches from 2.31% of Lianhu wild lotus to 60.52% of Jianxuan-35 hao lotus root [N. nucifera seed and T. angustifolia pollen also possess a higher amylose content. The high amylose of N. nucifera seed starch can be applied as a gelling agent or in the biodegradable plastic film industry. The chemical properties of the less-branched amylose molecule also provide beneficial effects to human health. Meals prepared with high amylose slow the rate of digestion, as it possesses the higher crystallinity which generated a postprandial glucose response in the attributed blood and lessened the fasting concentration of triacylglycerol and cholesterol [N. nucifera seed starch may reduce the blood glucose and insulin level and enhance the body's fat burning.The starch paste behaviour and functionality depend on the composition of amylose and amylopectin and the microcomponent as such affects the final food quality. 22.40%) , 27. The(22.40%) . Normal .40% , 27i et al. , starch tus root . A starclesterol . ConsequIn contrast, waxy starch with higher amylopectin which possesses branched and long chain length greater than 30 chains yielded higher molecular weight. Thus, this branched chain hindered each particle from reassociating and formed an ordered structure that resulted in weaker hydrogen bonding and the strength of the gel . AmylopeT. bispinosa seed (26.47%) followed by T. angustifolia pollen (15.70%) starches, whereas the least was from S. sagittifolia corm with 3.06%. Higher lipid contents were in T. angustifolia rhizome and pollen  and N. nucifera seed (2.96%). According to Tester et al. [T. angustifolia pollen and rhizome. Starch-lipid compositions used in several applications, such as stabilizers and thickener agents, reduced starch stickiness, dough conditioners, enhanced freeze-thaw stability, detain bread, and biscuit staling and bread crumb softener [The minor components analysis showed higher protein accumulated in r et al. , proteinr et al. . The prer et al. . Howeverr et al. . Svihus r et al.  reportedsoftener .N. nucifera and T. angustifolia . These values are comparable with C. esculenta (35.19%) and Trapa sp. (36.80%) starches from previous studies [T. bispinosa seed with 6.92%, whereas S. sagittifolia corm starch had a comparable value of RS (35.39%) and non-RS (37.37%). Besides, C. esculenta starch had significantly higher non-RS compared to others. Generally, high-amylose starch possessed high RS; however, in the present study, the N. nucifera seed had higher digestible starch (44.36%) compared to its RS (27.94%). The present study showed that RS was higher mostly in the rhizome part compared to others due to their B-type crystallinity. Densely packed B-type and CB-type crystallinity patterns are poorly susceptible to hydrolysis containing higher RS compared to A-type [sculenta .19% and rapa sp. .80% staro A-type . The varo A-type  reportedo A-type . Baghurso A-type  reportedo A-type θ ≈ 17°and 18°, and strong diffraction peak at 2θ ≈ 15°and 23°, whereas the B-type pattern showed pronounced peak diffraction peak at 2θ ≈ 15° and 17°, as well broad diffraction peak at 2θ ≈ 23°, with smalls peak around 15°, 20°, 22°, and 24° 2θ [A-type if closer to A-type and CB-type if closer to B-type, or prominent C-type if the proportion of A- and B-type allomorphs are equal [The XRD profiles of aquatic macrophytes are presented in d 24° 2θ . The C-tre equal . Accordire equal , the X-rre equal .N. nucifera displayed A-type with the presence of peaks intensity at 2θ ≈ 15°and 23° and strong doublet around 17°and 18° 2θ  which results in CA-type similar to the water caltrop species  of previous studies [T. angustifolia pollen starch exhibited CB-type crystallinity with peaks at 5°, 20°, and 24° 2θ (5.96). Both B- [Based on the present study, corm samples and seed of d 18° 2θ , consist studies , 52–54.  Both B- , 56 , followed by T. bispinosa seed (35.59%). There was a lower relative crystallinity in T. angustifolia pollen (15.27%) and rhizome (15.56%). The value of relative crystallinity is directly proportional to the amylose content. It expends higher relative crystallinity in the waxy starch of C. esculenta corm and T. bispinosa. The lower amylose content reduced the disruption of crystalline nature and the amorphous region within the starch granules [A relatively higher crystallinity was in granules .Tp), and conclusion (Tc) temperatures of the aquatic macrophytes starches ranged 41.62-58.74°C, 74.62-96.02°C, and 99.89-119.59°C, respectively (H) ranged 3.85-19.95 J g−1. Higher To and Tp were observed for T. angustifolia rhizome starch (58.73°C and 96.02°C), while the lower results were obtained for T. angustifolia pollen starch (41.63°C and 74.62°C), respectively. The higher Tc value was observed for S. sagittifolia corm (119.58°C), T. angustifolia rhizome (119.56°C), and C. esculenta corm (119.54°C) starch, while the lower Tc was for T. angustifolia pollen starch (99.89°C). On average, the gelatinization temperature range (Tr) and PHI values of the native starches' samples were 36.45°C and 0.61, respectively. Temperature ranges from 39.57°C in T. bispinosa seed to 39.41°C in N. nucifera seed. The starch granules size, crystallinity degree, amylose-amylopectin ratio, and the amylopectin branch's size influence the To and Tp values [Tp were in T. angustifolia rhizome, 58.73°C and 96.02°C, respectively. The formation of amylose and lipid complex in starch is insoluble in water. A higher temperature is required to dissociate the formation and increase the individual granules' swelling to diffuse out the amylose from swollen granules [Tc was observed higher in most of the smaller granules of E. dulcis corm (119.58°C), T. angustifolia rhizome (119.56°C), and C. esculenta corm (119.54°C). The small-sized granules contain a more significant number of granules per unit weight, which needed higher temperatures to disintegrate the starch particles into paste [H) reflects the loss of molecular order within the granules. The high ΔH lowers the starch crystallinity degree . PHI measured the gelatinization uniformity. The ΔH is generally associated with double helices of amylopectin chains. A higher amylopectin content result in higher ΔH. However, the present study showed that higher ΔH and PHI were in starch with higher amylose content such as N. nucifera seed  and T. angustifolia pollen , respectively. A higher enthalpy transition is needed to uncoil the long chain of amylopectin possessed by those starches. The present study showed a broad range of temperature Tr (33.00-39.57°C), which were comparable with the previous study of commercial starches such as corn (32.2°C), sweet potato (38.94°C), and potato (39.87°C) [S. sagittifolia corm starch for Tp (101.5°C) and Tc (116.30) values. According to Yu and Christie [ectively . In contp values . In this39.87°C) –62. In aChristie , broadenChristie .Colocasia esculenta corm (46.2 mPa s) and N. nucifera rhizome starch (40.9 mPa s) possess higher viscosity in the first cycle with the shear stress of 71.71 (Pa) and 63.35 (Pa), respectively  due to low-amylose content, as it inhibits the swelling of granules, thus lowering the viscosity [T. bispinosa seed possesses the lowest viscosity and shear stress (8.8 mPa s/13.72 Pa) despite having high amylopectin content. According to Singh et al. [T. bispinosa seed starch contribute to its low viscosity.Rheology is the study of the deformation and flow of food properties. According to Nurul et al. , starch ectively . Both poiscosity . Also, Th et al. , higher T. angustifolia (cattails) and S. sagittifolia (arrowheads) have comparable potentials to commercial aquatic macrophyte starches from N. nucifera (lotus), E. dulcis (Chinese water chestnut), T. bispinosa , and C. esculenta (taro) in food formulation. Although the least starch was isolated from T. angustifolia pollen, its higher amylose content (36.47%) provides excellent human digestive tract benefits. Higher RS content was in tuber parts, i.e., rhizome and corm, than in the seed and pollen of freshwater macrophytes. Lower RS was found in N. nucifera seed starch (27.94%) compared to others despite having higher amylose. Starch isolation procedure of T. angustifolia needs to be improvised, especially on the starch washing to prevent the impurities affecting the functional properties. Simultaneously, the procedure also must be cost-effective and efficient to be commercialized in the large-scale industry. This functionality of the native starches can later be modified and improved physically, chemically, and enzymatically which enhanced its properties and to produce novel molecules and hence can be applied in a broad range of food and nonfood applications. The starch properties in aquatic macrophytes studies showed equally good potential as the commercial starches in starch-based products.Starches from


The Key incident monitoring and management system program (KIMMS) program collects data for 19 quality indicators (QIs) from Australian medical laboratories. This paper aims to review the data submitted to see whether the number of errors with a higher risk priority number (RPN) have been reduced in preference to those with a lower RPN, and to calculate the cost of these errors.Data for QIs from 60 laboratories collected through the KIMMS program from 2015 until 2018 were retrospectively reviewed. The results for each QI were averaged for the four-year average and coefficient of variation. To review the changes in QI frequency, the yearly averages for 2015 and 2018 were compared. By dividing the total RPN by 4 and multiplying that number by the cost of recollection of 30 AUD, it was possible to assign the risk cost of these errors.per year in Australia cost the healthcare industry 27 million AUD. If the RPN data is used, this cost increases to 66 million AUD per year.The analysis showed a drop in the overall frequency of incidents (6.5%), but a larger drop in risk (9.4%) over the period investigated. Recollections Errors with a higher RPN have fallen more than those with lower RPN. The data shows that the errors associated with phlebotomy are the ones that have most improved. Further improvements require a better understanding of the root cause of the errors and to achieve this, work is required in the collection of the data to establish best-practice guidelines. Pre- and postanalytical errors are now widely accepted as being the most common source of error in laboratory medicine  , causes and harm (or poor patient outcomes)  is derived from the product of the frequency of failures detected, the relative ability to detect failures, and how serious are their consequences (harm). This approach allows resources to be deployed most effectively by prioritising the most significant errors Sixty Australian medical laboratories, either as an individual laboratory or a group of laboratories using the same laboratory information system (LIS) (known as participants), code episodes that have errors associated with them; the code used indicates the nature of the error. Each type of error is known as a quality indicator (QI). From 2015 until 2018, KIMMS collected data for 19 Quality Indicators (QIs). Participants extract the frequency of each QI from their LIS and enter this information manually via the Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP) data entry portal. The information is uploaded into the KIMMS database. A report is produced using the RCPAQAP QDS program. The QDS program was produced in house in 1995, initially for chemical pathology programs, and extended for use by the KIMMS program in 2011. The report includes the frequency of each QI as submitted by the participant and the RPN for each QI.To calculate the RPN, the KIMMS Advisory Committee assigned a numerical value to the likelihood of finding the error  and the et al. were combined to calculate the percentage of episodes collected by KIMMS  and an estimate of the amount of pathology performed by the public system  by Pilbeam The data is reported to KIMMS each quarter. The period covered in this report is from 2015 to 2018, during which time the QIs did not change. The RCPAQAP QDS software can extract the data for each participant by QI. The results for each QI were reviewed, and any outliers removed. Any single result that was more than ten times different from the previous and following quarters result was considered an outlier.The results for each QI were averaged for each quarter, and these results were averaged for the four-year average and coefficient of variation (CV). To review the changes in QI frequency, the yearly average for 2015 was compared to the yearly average for 2018. All calculations were performed using Microsoft excel 2016.i.e. 11.80 AUD to 29.50 AUD  and the number of outliers (O) are also recorded. The last 5 QI’s shown in Medicare reports 38 million episodes were funded in 2017/2018 and Pilbeam The CVs for the other fourteen QIs vary from 6 - 32%. It is not possible to know why some vary more than others. However, there is a tendency for those QIs with fewer results recorded to have higher CVs.The yearly breakdown for the 14 QIs and the RPN for each of these is shown in per 1000 episodes. By 2018, this had grown to 910,438 errors from 45,433,742 episodes, which is a rate of 20.0 incidents per 1000 episodes, an overall reduction of 6.5%. Over the same time interval, the RPN fell from 233 per 1000 episodes to 211 per 1000 episodes, which is a 9.4% fall. A breakdown of the changes for each QI is shown in In 2015, there were 696,409 errors reported from 32,447,679 episodes, equal to a rate of 21.4 errors et al  may result in more than one report being amended. All of these reasons can lead to inconsistent results for a participant.The importance of setting and monitoring QIs has been emphasized but as yet there have been few publications about the impact of this approach on reducing error rates although, generally speaking, monitoring does lead to improvement , which has been driven by a greater focus on phlebotomist training  As a benchmarking tool for risk, KIMMS, in its current form, is not useful. The KIMMS program assumes constant harm and the likelihood of detection. With the introduction of changes such as technology, training and processes, there may be an increase in the ability to detect incidents for an individual site, which would reduce the RPN for that QI. The KIMMS program will not reflect this improvement. A laboratory better able to detect an incident will show an increase in frequency and thus an increase in RPN. The KIMMS program is unable to differentiate the two, and thus, measurement of individual risk compared to other participants is not valid.i.e. is the expectation that there will be an increase or decrease in the frequency of the QI. To calculate the risk, the laboratory should alter the ease of identity rating and perform its own calculation. Any known changes should have been documented and any unexpected changes investigated thoroughly. It is an unexpected change that is most likely to lead to the biggest increase in risk to the organisation.The value of the KIMMS data is as a monitoring tool in a specific site. Each laboratory needs to monitor their own risk for each QI over time. When a process change is made, the expectation of change in the KIMMS data should be recorded, Technologies available to laboratories to help with detection of errors include the use of label producing software to label tubes and record what has been collected, temperature monitoring devices that can be used during transport, and instruments to measure the levels of haemolysis, lipemia and icterus , sample type, test requested, source of the sample , ward type, phlebotomist employer and requestor . Provided more than five participants match the search criteria, participants will be able to compare themselves to their peers. This will allow laboratories to investigate their situation. Similarly, participants in the KIMMS program should be able to add information regarding how errors are detected allowing for more accurate calculation of RPN.In conclusion, the use of RPN data to calculate the cost of errors to the pathology sector may prove to be a better indicator of the true cost of errors. There is a need for an accurate cost of a recollection to be calculated, both in the hospital and community domain in Australia. The data shows that the errors associated with phlebotomy are the ones that have most improved. There is a bigger fall in in RPN than in frequency, indicating that the errors with a higher RPN have fallen more than those with lower RPN, however, the changes are not uniform. Further improvements require a better understanding of the root cause of the errors and to achieve this, work is required in the collection of the data to establish best-practice guidelines.


Back muscle stiffness at the L4 level was found to be the largest in the thoracic and lumbar regions (p < 0.05). The back muscle stiffness of males was significantly larger than that of females in both lying and standing postures (p < 0.03). SWE stiffness was found to be significantly larger in standing posture than lying among subjects (p < 0.001). It is reliable to apply SWE and TUPS to measure back muscle stiffness. The reported data on healthy young adults in this study may also serve as normative reference data for future studies on patients with scoliosis, low back pain, etc.Muscle stiffness in the spinal region is essential for maintaining spinal function, and might be related to multiple spinal musculoskeletal disorders. However, information on the distribution of muscle stiffness along the spine in different postures in large subject samples has been lacking, which merits further investigation. This study introduced a new protocol of measuring bilateral back muscle stiffness along the thoracic and lumbar spine  with both ultrasound shear-wave elastography (SWE) and tissue ultrasound palpation system (TUPS) in the lying and standing postures of 64 healthy adults. Good inter-/intra-reliability existed in the SWE and TUPS back muscle stiffness measurements (ICC ≥ 0.731,  Multiple musculoskeletal disorders can take place in the spine of human beings, including the spinal curvature deformity of adolescent idiopathic scoliosis  and chroThe mechanical property of muscle stiffness is an essential factor for maintaining muscle function. It is related to muscle performance during exercise  and the 3) to calculate the muscle elasticity (assumed as E = 3ρc2)  and good inter-rater reliability  for both measurement instruments were identified in this study (p < 0.05). Higher intra-rater reliability of TUPS than SWE except at T7 level, and higher inter-rater reliability of TUPS than SWE were also found.Good intra-rater reliability [p < 0.001, ηp2 = 0.292) and level , and significant interaction effect among three factors  were found.The measured muscle stiffness by TUPS is summarized in p < 0.001, ηp2 = 0.292).The results of post-hoc comparison revealed that the TUPS stiffness was significantly larger in male subjects than that of female subjects for all five levels (p < 0.05), significantly increased from T11 to L1 level (p < 0.05), and significantly increased from L1 to L4 level (p < 0.05). The muscle stiffness at L4 was found to be significantly largest (p < 0.05); meanwhile, the muscle stiffness at T11 tended to be the smallest, but did not reach a significant level.The TUPS stiffness was found to be significantly different among the five different levels , except the two pairwise comparisons of T3 vs. L1 and T7 vs. T11. More specifically, the muscle stiffness significantly decreased from T3 to T7 level . Meanwhile, upon looking into the TUPS stiffness at each level, significantly larger TUPS stiffness at T3, L1, and L4 during standing posture than lying in male subjects existed, and a reversed trend of significantly larger TUPS stiffness at T3, T7, T11, and L1 during lying posture than standing in female subjects existed.No significant difference in TUPS stiffness between the two postures was found . More specifically, the percentage change at the L4 level appeared to be the largest , and that of T7 was found to be the smallest .As shown in p = 0.030, ηp2 = 0.074) and posture , and significant interaction effect only between gender and posture  were found.The measured muscle stiffness by SWE is summarized in p = 0.003, ηp2 = 0.074).The results of post-hoc comparison revealed that the SWE stiffness was also significantly larger in male subjects than that of female subjects for all five levels .The SWE stiffness in lying posture was found to be significantly smaller than that of standing posture for both genders and for all five different levels , no other significant difference between the two genders was found.As shown in No significant difference in SWE stiffness among the five different levels was found .p < 0.001). Significant main effects of posture (p = 0.001), level (p < 0.001), and gender (p < 0.001), and no significant interaction effect among these factors were found. The soft tissue thickness was also found to be significantly larger in standing posture than lying posture at five levels (p = 0.001). Similar to the distribution of muscle stiffness at different levels, the soft tissue thickness was also found significantly decreased from T3 to T7 level, significantly increased from T11 to L1 level, and significantly increased from L1 to L4 level (p < 0.001). The soft tissue thickness at the L4 level was found to be significantly largest (p < 0.001), and the thickness at the T7 level was found to be the smallest (p < 0.001).As shown in p = 0.018), L1 in the standing posture , and L4 in the standing posture . Low correlations between the two measurement techniques were observed at the remaining levels and postures, but the correlations were not significant.To our knowledge, this is the very first study investigating the distribution of back muscle stiffness along the spine, with the stiffness measurements from both the SWE and TUPS, in healthy young adults. Several significant effects of posture, level, and gender on back muscle stiffness were identified in this study. The relationship and reliability of the SWE and TUPS measurement techniques were also investigated and established.Good intra-rater and good inter-rater reliability for both measurement instruments of TUPS and SWE were observed in this study. This is in accordance with previous studies on the reliability of the TUPS ,31,34 ann = 64), the results of this study could also act as a normative database for future studies on scoliosis, low back pain, and other spinal musculoskeletal disorders.This study has uncovered that regardless of the lying or standing posture, the back muscle at the L4 level has the largest TUPS stiffness value among the thoracic and lumbar regions that covered the commonly affected sites of scoliosis and low back pain. This helps explain why chronic low back pain has been commonly found in the L3-L4 region in previous studies ,29. The The TUPS stiffness was found to decrease from T3 to T7, and then increase from T11 to L4 level. This is in line with previous studies suggesting that the muscle stiffness at L4 was larger than L1 in patients with low back pain , patientUnlike TUPS, no statistically significant difference in levels in SWE was observed in this study. This might be explained by the different underlying mechanisms of evaluating muscle stiffness by TUPS and SWE. While TUPS could not differentiate the multiple layers of soft tissues, SWE could specifically locate a certain muscle area by choosing the region of interest (ROI) on an ultrasound image. Most previous studies have compared the difference between lying and upright positions and/or between resting and contraction conditions of a single muscle group ,43. UnfoBack muscle stiffness of male subjects was found to be larger than that of female subjects in both lying and standing postures as evaluated by TUPS and SWE. This accords with previous studies on muscle stiffness of knee extensor in healthy young athletes  and knee3) to be a constant value when calculating the stiffness [SWE stiffness was found to be larger in standing posture than lying posture, while significantly larger TUPS stiffness at T3, L1, and L4 during standing in male subjects and that at T3, T7, T11, and L1 during lying in female subjects were found. Meanwhile, significant percentage changes in muscle stiffness from the lying to the standing posture was found for TUPS measurement, but not for the SWE measurement in this study, even the pattern/trend of changes appeared to be the same. The finding of significantly larger TUPS stiffness at the L4 level during standing in male subjects was in line with a previous study on male patients with low back pain . The certiffness , and TUPtiffness . The softiffness . AdditioThe different changes in TUPS stiffness from lying to standing postures between male and female subjects might be due to the different anatomical structures between the two genders. The TUPS used the tissue deformation during the compression-release cycles to acquire the stiffness . It is rThis study observed significantly moderate correlations between the SWE and TUPS measurement techniques at the T3 level in the lying position, L1 level in the standing position, and L4 level in the standing position only. This might be caused by the different underlying mechanisms to measure muscle stiffness by the two techniques. Additionally, while TUPS could not differentiate the multiple layers of soft tissues, SWE could specifically locate a certain muscle area by choosing the region of interest (ROI) on an ultrasound image. The muscle contraction and the overlying tissue might influence the SWE and TUPS stiffness measurements. The observed correlation may also contribute to the presented results and explain the difference in muscle stiffness as measured by the two techniques at the same location. For example, the TUPS stiffness values ranged between 104 kPa and 303 kPa, while SWE stiffness values ranged between 17 kPa and 37 kPa. This implies that when applying these two techniques to evaluate the muscle stiffness, the relative changes in measured values might be more meaningful for muscle assessment than that of absolute values.The results of this study will not only enlarge our understanding of back-muscle stiffness, but also provide us with insights about the possible cause and mechanism of scoliosis and low back pain. The findings of this study inspire future efforts to investigate if the observed change in muscle stiffness is a physiological phenomenon or the cause of pathologies of scoliosis and low back pain. The results may also serve as normative data about back muscle stiffness in healthy young adults, which could be useful in lots of healthcare areas in the future. Attention should be paid to the fact that the normative values might be different for different age groups, and only healthy young people aged between 18–30 years were evaluated in this study. The obtained values on muscle stiffness could be treated as a reference, but it might not be appropriate to directly generalize such values to patients with scoliosis or lower back pain. This study can be the first step for further studies investigating the distribution of back muscle stiffness along the spine in different populations, age groups, and patient groups. As the introduced experimental protocol has been evaluated to be reliable, this study also enables future studies to apply similar protocols on patients with scoliosis, low back pain, and other spinal musculoskeletal disorders.Good knowledge of the mechanism of the SWE and TUPS measurement techniques and careful consideration of the available experimental/clinical settings are needed to enable the best practice for the two techniques. It is recommended to apply the SWE to measure the muscle stiffness when differentiating and evaluating different layers of muscles and different regions of the same muscle, since the region of interest (ROI) of SWE can be easily customized to various shapes and sizes at various locations during the measurement. With the advantages of being portable, with a wireless connection, and occupying a small space, the TUPS would be more helpful to generally evaluate the muscle stiffness at certain anatomical locations, especially for screening purposes in labs/clinics with limited space or even in an outdoor environment ,40. The While mapping the muscle stiffness at the thoracic and lumbar regions could already provide plenty of information, the data on cervical and sacral regions were not involved in this study. Future studies could consider expanding this mapping strategy to provide a more comprehensive picture of spinal muscle stiffness. During the experiment, subjects were instructed to stand symmetrically and put equal weight on both feet, supplemented by the observation of accessors. Future studies could consider putting pressure sensors and/or a pressure mat under the subject’s feet to control the symmetric weight distribution more objectively. While subjects were instructed to breathe naturally during the experiment, it should be noted that the influence of breath dynamics on the measured results remained unclear. Future studies are needed to understand this issue. The muscle activity was unfortunately not measured as a covariable to explain muscle stiffness changes, which can also be considered in future investigations.It shall be noted that the SWE and TUPS measurements might be sensitive to other factors besides the mechanical properties. A recent paper reported that indirect tissue stiffness measurements are often sensitive to the mechanical properties, geometrical dimensions, and tensional state of the tissue . From a This study mapped the back muscle stiffness along the thoracic and lumbar spine, with both SWE and TUPS, in both lying and standing postures in healthy male and female adults. It identified that both SWE and TUPS are reliable in measuring back muscle stiffness. Significant effects of level, gender, and posture on back muscle stiffness were identified. This may provide some insights regarding the underlying mechanism of why the common sites of low back pain take place at a certain spinal region and facilitates future research on other spinal musculoskeletal disorders.


The pathogenesis of partial-thickness macular defects and the role of Müller glial cells in the development of such defects are not well understood. We document the morphological characteristics of various types of partial-thickness macular defects using spectral-domain optical coherence tomography, with the focus on tractional and degenerative lamellar holes, and discuss possible pathogenic mechanisms.A retrospective case series of 61 eyes of 61 patients with different types of partial-thickness macular defects is described.Partial-thickness macular defects are caused by anteroposterior or tangential traction onto the fovea exerted by the partially detached posterior hyaloid and epiretinal membranes, respectively. Tractional elevation of the inner Müller cell layer of the foveola—without  or with a disruption of this layer —produces an elevation of the inner layers of the foveal walls (nerve fiber layer to outer plexiform layer [OPL]) and a schisis between the OPL and Henle fiber layer (HFL). With the exception of outer lamellar holes, the (outer part of the) central outer nuclear layer and the external limiting membrane remain nondisrupted in the various types of partial-thickness defects. Degenerative lamellar holes are characterized by cavitations between the inner plexiform layer and HFL of the foveal walls; many cases have lamellar hole-associated epiretinal proliferation (LHEP). Proliferating cells of the disrupted Müller cell cone may contribute to the development of LHEP and fill the spaces left by degenerated photoreceptors in the foveal center.It is suggested that morphological characteristics of partial-thickness macular defects can be explained by the disruption of the  Müller cell cone in the foveola and the location of tissue layer interfaces with low mechanical stability: the boundary with no cellular connections between both Müller cell populations in the foveola, and the interface between the OPL and HFL in the foveal walls and parafovea. We propose that the development of the cavitations in degenerative lamellar holes is initiated by traction which produces a schisis between the OPL and HFL, and enlarged by a slow and chronic degeneration of Henle fibers and bipolar cells.Trial registration retrospectively registered, #143/20-ek, 04/03/2020 The fovea is a pitted invagination in the inner retina which overlies an area of elongated thin photoreceptors. The foveal pit develops by a radial displacement of the inner retinal layers away from the path of the incoming light; this results in the formation of the central foveola surrounded by sloping foveal walls. The structural stability of the fovea is provided by Müller glia . Two difVarious macular diseases are associated with anteroposterior or tangential tractions exerted by contractile epiretinal membranes (ERM) and/or the partially detached posterior vitreous which may cause a disruption of the foveal integrity resulting in the formation of partial- or full-thickness macular defects. A full-thickness macular hole (FTMH) develops by disruptions of both the Müller cell cone and the external limiting membrane (ELM). The common feature of most types of partial-thickness macular defects is a tractional or degenerative disruption of the normal shape of the foveal pit; the (outer part of the) central outer nuclear layer (ONL) and the ELM are not disrupted and keep the foveal walls together which prevents the formation of a FTMH. Partial-thickness macular defects are grossly classified into macular pseudoholes, foveal pseudocysts, tractional lamellar holes, degenerative lamellar holes, and outer lamellar holes; mixed types of tractional and degenerative holes were also described –10. TracThe aims of the present study were (i) to describe the morphological OCT characteristics of various types of partial-thickness macular defects, with the focus on the comparison of the morphologies of tractional and degenerative lamellar holes, and (ii) to discuss possible mechanisms of the pathogenesis of tractional and degenerative lamellar holes, including the roles of Müller cells and of tissue layer interfaces of low mechanical stability in the pathological processes. Because other types of partial-thickness defects may also display a schisis between the OPL and ONL of the foveal walls , we inclThis is a retrospective, single-center chart review. The study followed the ethical standards of the 1964 Declaration of Helsinki and its later amendments. The protocol was approved by the Ethics Committee of the Medical Faculty of the University of Leipzig . The ethics committee is registered as Institutional Review Board at the Office for Human Research Protections . We retrospectively reviewed charts of patients with partial-thickness macular defects who were referred to the Department of Ophthalmology, University of Leipzig, Germany, between February 2009 and August 2019. Patients with a lamellar macular hole or other types of tractionally induced structural alterations of the fovea in at least one eye were included in the study. Exclusion criteria were FTMH (with the exception of one case of a FTMH with LHEP) and degenerative myopia, defined as axial length of > 26 mm with presence of a pathological myopic maculopathy. Cross-sectional images of the macular area were obtained with SD-OCT . Best-corrected visual acuity (BCVA) was determined with a Snellen chart and is given in decimal units.All patients were Caucasians. SD-OCT images of the macular region of one eye of 14 patients with a tractional lamellar hole were investigated Figs. a‒e. ThreTractional lamellar holes are characterized by a disruption of the Müller cell cone in the foveola and an elevation of the inner layers of the foveal walls (NFL to OPL) which causes a schistic splitting of the foveal walls and parafovea between the OPL and HFL; obliquely arranged bundles of Henle fibers traverse the schistic cavities Fig. a, b. NorIt was described that a tractional lamellar hole can develop from a macular pseudohole . This waThe lamellar hole shown in Fig. Foveal pseudocysts are characterized by a tractional disruption of the foveal structure resulting in cyst formation in the foveola and foveal walls; the traction is exerted by contractile ERM Fig. a and/or In the cases shown in Fig. Figure Macular pseudoholes are produced by traction exerted by contractile ERM which causes a thickening of the foveal tissue. Many cases of macular pseudoholes do not show a schistic splitting of the foveal walls Fig. i; howeveDegenerative lamellar holes are characterized by cavitations of the foveal pit into the lower foveal walls; the foveal walls above the cavitations are elevated Fig. a‒f. The The SD-OCT scans shown in Fig. Figure Figure It was described that LHEP at the inner surface of the foveal walls may be connected with Müller cells in the foveola , 16, 21.As previously shown , 20, ERMThe fovea shown in Fig. Both degenerative and tractional lamellar holes are likely produced by a tractional disruption of the Müller cell cone and an elevation of the inner layers of the foveal walls. However, the elevation of the inner layers of the foveal walls has partially different consequences on the contours of the cavities in the foveal walls in both types of lamellar holes. In most cases of tractional holes, the elevated inner layers of the foveal walls included the NFL to OPL; the elevation resulted in a schisis between the OPL and HFL Fig. a. The scIn degenerative lamellar holes, the shape of the cavitations of the foveal pit into the lower foveal walls varied among the individuals. Among the cases presented in Fig. Most types of partial-thickness macular defects are characterized by a deformation of the foveal pit due the tractional elevation or disruption of the Müller cell cone while the (outer part of the) central ONL and the ELM remain unaffected and keep the foveal walls together Fig. b‒d. In oWe propose that certain morphological characteristics of partial-thickness macular defects can be explained with the features of both Müller cell populations in the fovea and the localization of tissue layer interfaces with low mechanical stability: the boundary between the Müller cell cone and the HFL/ONL in the foveola, and the interface between the OPL and HFL in the foveal walls and parafovea Fig. a. The loUnder normal conditions, the structural stability of the fovea is provided by both Müller cell populations, i.e., the cells of the Müller cell cone and Müller cells of the foveal walls Fig. a 1]. Th. Th1]. TA schistic splitting of the foveal walls between the OPL and HFL in tractional lamellar holes, foveal pseudocysts, outer lamellar holes, and macular pseudocysts is produced by anteroposterior Figs. b‒h and/oThe present data may suggest that one function of the Müller cell cone is to provide the stability of the foveal structure by the prevention of an elevation of the inner layers of the foveal walls which may result in a schistic splitting of the tissue between the OPL and HFL in the foveal walls. We found in one eye a schistic splitting between the OPL and ONL in the peripapillary retina Fig. f; this mThe contours of the schistic and degenerative cavitations in the foveal walls are different in tractional and degenerative lamellar holes. In tractional holes, the schistic cavities between the OPL and HFL are tapered and have a more or less regular contour Fig. c. On theIt was suggested that tractional forces, exerted by contractile ERM and/or the partially detached posterior hyaloid, are the primary cause of tractional lamellar holes , 18, 20 The pathogenesis of degenerative lamellar holes is largely unclear. We found that degenerative cavitations display the widest lateral extensions at two levels: the OPL-HFL interface and the IPL-INL interface Fig. b, and thThere is no or less degeneration of Henle fibers in tractional lamellar holes; bundles of nondisrupted Henle fibers traverse the schistic cavities between the OPL and HFL Figs. a. BecausIn degenerative lamellar holes of several patients, the elevated inner layers of the foveal walls protruded nearly straightly above the foveal pit, and the base of the protruded walls was formed by the IPL Figs. , and 7b.It is unclear why Henle fibers degenerate in degenerative but not in tractional lamellar holes. Henle fibers are composed of photoreceptor axons which are surrounded by the outer processes of the Müller cells of the foveal walls , 5. AlthLHEP on the vitreal surface of the foveal walls and parafovea were found in eyes with degenerative macular holes Figs. , and 7b.LHEP is composed of a hyperreflective inner layer and a tissue of homogenous medium reflectivity between this layer and the hyperreflective NFL. The functional role and pathogenesis of LHEP are unclear. The main cellular constituents of LHEP were suggested to be glial cells and vitreal cells like fibroblasts and hyalocytes , 17, 42.In all cases described in this study, Müller cells in the foveola were connected to the middle part of LHEP. Both displayed a medium reflectivity. This may suggest that Müller cells of the foveola contribute to the formation of this part of LHEP. As indicated by the morphological connection between vitreous remnants and LHEP in the foveal tissue of the case shown in Fig. As previously shown , 41, traTractional and degenerative lamellar holes are produced by traction exerted by the partially detached posterior hyaloid and/or contractile ERM. One of the first steps of hole formation is likely a disruption of the Müller cell cone in the foveola or of the connection between the cone and the foveal walls. However, the different morphologies of the schistic and degenerative cavitations in tractional and degenerative lamellar holes, in association with (degenerative holes) or not  a degeneration of central photoreceptor cells, may suggest a partly different pathogenesis of both types of lamellar holes. The schistic splitting of the foveal walls in tractional lamellar holes is likely produced by traction which causes an elevation of the inner layers of the foveal walls. The location of the schisis can be explained with sites of tissue layer interfaces with low mechanical stability: the boundary with no cellular connections between both Müller cell populations in the foveola, and the interface between the OPL and HFL in the foveal walls and parafovea. A similar mechanism may also explain the formation of the schistic cavities in foveal pseudoholes, outer lamellar holes, and some cases of macular pseudoholes. We propose that the development of the cavitations in degenerative lamellar holes is initiated by traction which produces a schisis between the OPL and HFL, and enlarged by a slow and chronic degeneration of Henle fibers; this may cause a subsequent degeneration of the central photoreceptor cells and a retrograde degeneration of horizontal and bipolar cells. However, further research is required to reveal the etiologies and pathogenic steps implicated in the development of the different types of partial-thickness macular defects.


Introduction: Uterus transplantation (UTx) is a rapidly evolving treatment of uterine-factor infertility. We report the results of the first 10 UTx procedures performed at our institution. Methods: The program started in April 2016 as a two-arm study comparing the efficacy of UTx from live donors (LD) and deceased donors (DD). Results: Between April 2016 and April 2018, we performed five DD UTx and five LD UTx. Two grafts had to be removed early due to thrombosis. One graft was removed due to chronic rejection and previous herpes simplex infection at month 7. Graft survival is 70% at one year. Recipient survival is 100% at two years. Live donor survival is 100% at three years. Three live-births have been achieved, two from a LD and one from a graft from a nulliparous DD. Vaginal anastomotic stenosis occurred in 63% (5/8) of grafts. Self-expanding stents have shown preliminary suitability for the treatment of vaginal stenosis. Three recipients developed severe acute rejection. Conclusion: The interim results of our study demonstrate mid-term viability in 70% of grafts. The LD UTx produced two live births and the DD UTx produced one live birth. Nulliparous donors should be considered for donation. Uterus transplantation (UTx) has evolved from a purely experimental to a single method of treatment for women affected with absolute uterine-factor infertility (AUFI) ,2,3. AlbOur team obtained approval with the trial from the following institutions: 1) the Ministry of Health, Czech Republic , and 2) the Joint Ethics Committee of the Institute for Clinical and Experimental Medicine (IKEM) and Thomayer Hospital (number 2044/15 (NM-15-01)). We registered the trial at Clinical Trials Database (identifier NCT03277430). The study approval was for 20 UTx, 10 from LDs, and 10 from DDs.The trial was performed at the IKEM hospital, Prague, in collaboration with Prof. Michael Olausson, M.D., Ph.D., from the Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Additionally, a team of obstetricians and gynecologists from University Hospital Motol, Prague, collaborated in the first half of the trial. All retrieval and transplant procedures were carried out by a senior transplant surgeon and principal investigator of the study (J.F.).Requests for participation were received by phone or email. After initial phone screening, candidates were invited for a thorough evaluation. The final decision was made by a multi-disciplinary team. Candidate recipients who had no suitable LD were listed for a DD UTx. The nature of the study, including potential risks, was thoroughly explained to all study participants . Written informed consent with the trial and with the publication of the results of the trial was obtained from all graft recipients and LDs. In the Czech Republic, the principle of presumed consent with regards to multi-organ recovery from DDs applies. Additionally, as of December 2020, there is no special legislation regarding recovery of vascular composite allografts (VCA). However, approval of uterus procurement was still obtained from the DD’s next-of-kin in all cases.Inclusion criteria for a LD comprised the following: female 18–60 years of age, ≤4 childbirths, ≤1 caesarian section, and good general health assessed by the study team. The advantages of a LD are a planned procedure, detailed donor evaluation and selection, and shorter warm and cold ischemia time. On the other hand, it does burden the donor with the surgery, which may also result in complications.A DD provides a graft with longer vascular pedicles and is free of potential complications that could otherwise arise with a LD. After brain death (DBD), all DDs were evaluated according to the protocol of multi-organ donors. No donors are accepted after circulatory death. Eligibility criteria for a DBD comprised the following: general suitability for multi-organ donation, permission for uterus recovery, institutional review board approval, clinical trial registration, AB0 compatibility, negative cross-match, female 18–60 years of age, no previous hysterectomy, and no previous uterus malignancy. The full criteria of uterine DD are published elsewhere . A full Before a uterine donor candidate can be accepted, she requires a thorough assessement, which includes determining the quality of her uterine vessels. At our institution, computed tomography angiography (CTA) is used for evaluation of arteries, i.e., their course, diameter, degree of atherosclerosis, variant anatomy, etc. According to our preliminary results, CTA was insufficient in the evaluation of uterine venous outflow (uterine and utero-ovarian veins) in three of six uterine LD candidates. Whereas all of the LDs were assessed using CTA, only three of five DDs were evaluated in this manner. Magnetic resonance angiography (MRA) is reported to achieve better results in the assessment of uterine veins ,20. HoweInclusion criteria for recipients comprised the following: female 18–40 years of age, absolute uterine factor infertility based on congenital or acquired uterus absence, desire for a child, having a male partner and good general health.The uterus was transplanted in an orthotopic position in the lesser pelvis with arterial and venous anastomoses to the iliac vessels and vaginal anastomosis to the vault of vagina . VasculaTo prevent graft thrombosis, all recipients were treated with low-molecular-weight heparin (LMWH) in a prophylactic dose in the first postoperative month. The recipients received 100 mg of acetylsalicylic acid (ASA) daily during the entire post-transplantation period. The antibiotic/antimycotic/chemotherapeutic prophylaxis comprised ampicillin/sulbactam for 24 h, fluconazole for five days, and trimethoprim/sulfamethoxazole for four months (three times a week). Cytomegalovirus (CMV) prophylaxis follows the recommendation for “surveillance after prophylaxis” , i.e., 9The follow-up comprises four indispensable components: (1) clinical examination; (2) laboratory examination; (3) assessment of perfusion; and (4) cervical biopsies. The frequency of the visits is also defined per-protocol. The recipients are checked twice a week postoperatively in the first month, once every two weeks postoperatively in months 2–6, and once every three weeks in the further course. The visit involves a laboratory examination, a Doppler transvaginal or transabdominal ultrasound (US), and a clinical examination. The clinical examination consists of an abdominal examination and an inspection of the vagina and cervix to look for discoloration or pathological vaginal discharge. Doppler US is a crucial means of follow-up of the perfusion of the graft. Biopsies are planned for postoperative days 7 and 14, and later for months 1, 2, 3, 4, 6, 7, 8, 10, and 12 post-transplantation. During pregnancy, a per-protocol biopsy is performed at the gestational age of 20 weeks. In case of rejection, therapy is determined based on the severity of rejection . While bIn the course of two years, i.e., between April 2016 and April 2018, 10 recipients underwent UTx, namely five DD UTx and five LD UTx. Nine recipients suffered from Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) type I, and one recipient (Case 7) suffered from MRKHS type II (including agenesis of the right kidney). The mean age of the recipients was 28 ± 3 years . All transplantations were blood type compatible. The characteristics of the recipients and corresponding donors is provided in In all but one case, the arterial and venous anastomoses were sutured on the recipient´s external iliac vessels. In Case 1, the internal iliac artery and vein were used for right-sided anastomoses. In all but one case, the arterial anastomosis of the graft´s uterine artery was performed using the donor internal iliac artery patch or segment. In Case 1, the anastomosis was carried out directly with the ends of the uterine arteries. Venous outflow was established with two anastomoses in five cases: either two uterine veins or two ovarian/utero-ovarian veins depending on vein size, length and quality. All 4 venous outflow anastomoses were able to be carried out in the remaining five cases. In Case 8, an adjunct third venous outflow anastomosis was added to the two previous ones during venous thrombectomy on day 5. Detailed characteristics of the vascular anastomoses are shown in Operative details and post-operative complications including open or vaginal revision surgeries are listed in ©, Dr Franz Kohler Chemie, GmBH, Germany), and excision of all other organs are complete, the uterine graft is finally procured. In this way, there is no prolongation of the cold ischemia time (CIT) of life-saving organs. At the back-table, the graft is inspected for perfusion and vessel quality. A hysteroscopy ex vivo is performed on the bench, and the graft, including the vascular pedicles, is prepared for the transplantation. The mean age of DDs was 40 ± 18 years (range 19–57). The average duration of multi-organ procurement, including uterus, from a DBD was 6 h 46 min ± 65 min .Firstly, a transvaginal ultrasound is performed to rule out any pathologies of the uterus, such as tumors, scars, intraluminal adhesions, etc. . A mediaThe mean age of all donors was 46 ± 14 years (range 19–59) . The meaIn two cases (LD3 and LD5), adjunct oophorectomy needed to be performed in premenopausal women, resulting in preterm menopause, which was treated pharmacologically. Intra-operative iatrogenic ureteric laceration occurred in LD5. It was treated with a suture and placement of a temporary ureteric JJ stent. The LD4 suffered from urinary bladder hypotonia, which resulted in urinary retention. It was treated with a suprapubic catheter, which was inserted under local anesthesia. The urinary retention issue resolved three months after donation. The altruistic LD6 suffered from hypesthesia of the dorsolateral aspect of her calf in the early and late postoperative course. This was attributed to the defective application of compression stockings. The neural defect resolved slowly through therapy with B-complex vitamins. The three-year survival rate of our live donors was 100%.© assay) against human leukocyte antigens (HLA) class I ).Early graft loss occurred twice and mid-term graft loss occurred once. In Case 2, a hematoma was removed and the right uterine artery was re-anastomosed on day 1. Hysterectomy of the graft was carried out on day 7 for an arterial thrombosis that possibly occurred, according to explant histology, in part due to atherosclerosis. In Case 8, removal of a hematoma and thrombectomy of the left uterine vein were performed on day 5. Additional anastomosis of the right ovarian vein was also carried out. However, the graft had to be removed on day 15 due to complete thrombosis. Histology indicated hemorrhagic graft necrosis. Moreover, immunological examination on day 18 revealed positive T-FACS cross-match and the presence of de novo donor-specific antibodies (DSA)  infection of the graft was revealed in a protocol cervix biopsy on day 40. This infection was treated with i.v. and p.o. antiviral drugs. No growth of endometrium was noted on US and menstrual bleeding never started. A graft hysterectomy was performed on day 213 post-transplantation. Histology revealed complete fibrous obliteration of the cervical canal and the uterine cavity due to a possible combination of protracted rejection changes , vascular thrombosis, graft atherosclerosis and HSV infection. The 30-day graft survival rate or technical success rate was 80%, while the one-year graft survival rate was 70%. In Case 5, completion hysterectomy was performed after successful delivery on day 1109 post-transplant. Six of the remaining grafts are currently viable.All recipients are alive to this day. The two-year survival rate for recipients is 100%. To date, recipient Cases 1–4 have survived 4 years, Cases 5–9 have survived 3 years and Case 10 has survived 2.7 years. Details on graft and recipient survival are given in Seven out of 10 of our recipients were born with vaginal agenesis as part of the MRKHS. Six of them underwent a previous laparoscopic Vecchietti procedure in order to create a neo-vagina, and one (Case 5) underwent a dilation procedure. Three recipients were born with a vagina . One specific complication of UTx surgery is a stenosis of the vaginal anastomosis. Details on vagina type and the occurrence of post-transplant anastomotic stenosis are listed in In Case 1, the stenosis was first dilated by a gynecologist on day 267 and hemostasis was carried out for bleeding caused by a cervix biopsy. Additionally, the gynecologist twice attempted to cut and resect the vaginal stenosis using a diathermy knife. After the last attempt, the patient developed vesico-vaginal fistula; the gynecologist recommended a graft hysterectomy. The transplant team, however, disagreed with the plan, and on day 272, vesico-vaginal fistula closure was attempted by applying a suture trans-vaginally. Unfortunately, the fistula did not heal on a permanent urinary catheter. Therefore, open repair of the fistula, stenosis excision and a vaginal re-anastomosis were carried out on day 341. This procedure was performed by a transplant surgeon and an urologist. The patient healed without complications, yet the stenosis recurred and a stent was inserted on day 383. A total of two more stent insertions were required after the second surgery and vaginal re-anastomosis, after which there was no longer a need for a stent. In Case 5, repeated dilation and stenting was necessary only for the first 10 months post-transplantation. A scheduled transplant hysterectomy was performed five months after successful delivery. In Case 6, repeated dilation and stenting is still necessary to this day. In Case 7, a stent was also inserted; however, this graft was removed due to chronic rejection and HSV infection. The stenosis healed two months prior to the hysterectomy. In Case 10, repeated stenting contiues to this day. This recipient became pregnant after her fourth attempt and lost the child at week 20. After this miscarriage, the stent was inserted only once. After couple of weeks there is no need for further stenting, the vaginal anastomosis stays wide open.Uncomplicated urinary tract infection (UTI) was treated with antibiotics in 4 recipients , and repeatedly in Cases 1 and 3. In Case 1, UTI was associated with vesico-vaginal fistula. Description and time occurrence of infections, leukopenia, rejection episodes and renal impairments are listed in Leukopenia episodes were treated by adjusting existing, and potentially myelo-toxic, therapy as well as by administering filgrastim. In Cases 3 and 5, examination of a bone marrow aspirate was performed, revealing post medication suppression.The human leukocyte antigen (HLA) mismatch between the donors and the recipients, percentage of panel-reactive antibodies, acute rejection episodes and their treatments are presented in Chronic kidney disease (CKD) emerged in recipient Case 1 as early as day 27  0.83 mL/s). The patient gradually developed CKD G3A1 caused by nefrotoxic medication including calcineurin. Her renal function is permanently impaired and oscillating. Her maximum serum creatinine was 154 μmol/L and her minimum eGFR was 0.63 mL/s on day 1101. Her pregnancy passed without a significant worsening of CKD.Recipient Case 4 also developed CKD on day 104, and she has sustained a mild reduction in renal function . Recipient Cases 5 and 6 suffered from a decline in renal function on days 502 and 68, respectively, necessitating hospitalization and i.v. fluids. This occurred in both cases, however, during an episode of inter-current gastroenteritis and exhibited a prerenal etiology and temporary nature.©, Chiesi) and TAC twice daily was used in the remaining cases . Gynecologic data on transplanted uterine grafts, embryo transfers, pregnancies and livebirths are presented in All seven recipients with viable grafts underwent embryo transfers (ET). To date, five have become pregnant, of which two have suffered miscarriages (Cases 3 and 10) and three have given birth . There were no congenital malformations nor neonatal complications. None of the recipients are currently pregnant. The medication of the recipients before commencing ET and/or pregnancy was as follows: Case 1: TAC, Pr, AZA, ASA, Case 3: TAC, Pr, AZA, ASA, Case 4: TAC, ASA, Case 5: TAC, ASA, Case 6: TAC, Pr, ASA, Case 9: TAC, Pr, AZA, ASA, Case 10: TAC, AZA, ASA. A prolonged-release TAC once daily was used in Case 1 (EnvarsusIn Case 1 (LD UTx), the ETs were slightly delayed due to a vesico-vaginal fistula which required repair. She underwent seven unsuccessful ETs. Owing to numerous unsuccessful ETs, as well as gaps between the transfers, resulting in prolonged exposure to immune suppression, the recipient developed renal impairment. The eighth ET was successful and she gave birth to a healthy baby girl with a birthweight of 2115 g (10–50 percentile) and an Apgar score of 9-10-10. Apart from gestational diabetes treated with diet and placenta praevia marginalis the pregnancy was uneventful. In Case 3 (UTx from a nulliparous DD), the recipient underwent 11 ETs, three of which resulted in clinical pregnancy; however, all three of these ended in miscarriage for unknown reasons. She also suffered from three episodes of AR, the last of which was severe. In Case 4 (LD UTx), the recipient suffered from no complications at all (except for mild CKD). She underwent 11 ETs but failed to achieve pregnancy. A new ovum pick up will be necessary.Clostridium difficile colitis with perforated appendicitis [In Case 5 (UTx from a nulliparous DD), the recipient suffered from numerous late complications: vaginal stenosis, three episodes of mild AR, four episodes of leukopenia and ndicitis . She gotndicitis . After tIn Case 6 (LD UTx), the patient underwent five ETs. Pregnancy has yet to be achieved. She suffered from both moderate and severe episodes of AR. Surgery to remove intrauterine adhesions is planned.In Case 9 (LD UTx), the patient suffered from one moderate and one severe episode of AR. A third ET led to pregnancy. Pregnancy-associated hypertension was treated pharmacologically. The patient gave birth to a healthy baby girl at a gestational age of 36 + 2, with a birth weight of 2300 g (10–50 percentile) and an Apgar score of 10-10-10. The patient has already undergone 2 ETs with the intention of having a second child.In Case 10 (DD UTx), the recipient had one episode of moderate AR. She went through six ETs. The second ET included two embryos. The fifth ET resulted in pregnancy, but it was discontinued through septic abortion for unknown reason at week 22.In this clinical trial, a total of 20 UTx procedures were intended. Ten of the uterine grafts were meant to be retrieved from live donors and another 10 grafts from deceased donors. The first 10 transplants of this study  were performed in women with MRKH syndrome and comprised five UTx from LDs and five UTx from DDs. Three recipients experienced graft loss. Three live births of healthy children were achieved, comprising two from LD UTx and one from nulliparous DD UTx.n = 10). However, we feel it is relevant to publish interim results since UTx is still a novel and rapidly evolving field. Moreover, the number of child births in our study (n = 3) is still relatively low. One patient had her graft removed after a successful delivery, and another desires a second child and is currently undergoing embryo implants. The remaining four recipients continue receiving embryo transfers. Regrettably, two of them have experienced miscarriages.The present study is limited by the relatively low number of UTx procedures  and Case 8 (LD UTx), graft loss was attributable to early vascular thrombosis occurring on day 7 and on day 15, respectively. In Case 8, additional immunological examination revealed a newly positive T-FACS cross-match and the presence of de novo DSA against HLA class I. This may suggest immune rejection involvement in the development of the thrombosis. The mid-term loss of the third graft on day 213 was related to an HSV infection. Our technical success rate of 80% is consistent with that of other studies ,15,17. TStricture of vaginal anastomosis was a relatively common and protracted complication. It occurred in five of eight (63%) viable grafts. None of the pre-transplant vagina type in MRKHS, i.e., own vagina, dilation or the L-Vecchietti procedure, seemed to affect the incidence of post-transplant stenosis. In fact, stenosis occurred in all three of these scenarios. However, stenosis occurred in all there recipients with a vagina , in only one recipient after dilation (Case 5), and in only one out of four recipients who received the L-Vecchiettti procedure (Case 6). The other there recipients who received an L-Vecchiettti neovagina were stenosis-free. The presence of stenosis did not appear to significantly affect conception or pregnancy outcomes. Indeed, all recipients who gave birth had stenosis . Nevertheless, the number of procedures is too low to be able to draw a definitive conclusion.In the largest series worldwide the rates of mid-term graft viability, vaginal strictures, graft rejections, miscarriages and livebirths were as follows. In the pioneering Gothenburg (Sweden) cohort by Brannstrom, Olausson et al., nine LD UTx have been accomplished and two graft losses have been experienced, one due to thrombosis on day 3 and another one due to infection on day 105 . During In a subsequent Gothenburg study, 8 robot-assisted uterus retrievals from LDs andopen UTx have been carried out, with mid-term viability in 6/8 cases . The intIn the study by Brucker et al. , four LD UTx have been done with full mid-term graft viability in all of the four recipients. Stenosis of the vaginal anastomosis was not reported and mild graft rejection happened in 2/4 recipients. One early miscarriage at eight weeks and four days of pregnancy was experienced. Two livebirths have been achieved in the first two UTx women, including the one with previous pregnancy loss .In the DUETS  by Testa, Johannesson et al., 20 UTx have been performed, 18 from a LD and two from a DD. Six graft failures occurred. In phase 1, 50% of recipients (5/10) had a technically successful uterus transplant, compared to 90% (9/10) in phase 2 . In the One challenging aspect of UTx is utilizing nulliparous grafts for transplantation. The main issue is that these grafts have yet to prove their ability to promote childbirth. The first UTx from a DD ever had used a nulliparous DD and this was also the second UTx case worldwide, carried out in Turkey in 2011. This case produced clinical pregnancy but ended in a miscarriage ,32. In oRecently, more than 70 UTx procedures and 23 livebirths from 21 recipients have been reported worldwide . UterineTen uterus transplants, comprising five from live donors and five from deceased donors, have been performed at our institution. The interim results of our study demonstrate mid-term viability for 70% of uterine grafts. Stenosis of vaginal anastomosis was encountered in five of eight grafts (63%) and necessitated repeated stent placement. Immunosuppression side effects, infectious complications and recurrent rejection may have led to significant delays in embryo transfers.Three live births have been achieved, two from a LD and one from a nulliparous DD. Therefore, nulliparous donors can be considered for donation; however, their potential needs further clarification. We also observed four miscarriages in two recipients. This preliminary report gives further evidence of the feasibility of uterine transplantation from both living and deceased donors.


Tungsten cemented carbide (WC-Co) is a widely applied material in micro-hole drilling, such as in suction nozzles, injection nozzles, and wire drawing dies, owing to its high wear resistance and hardness. Since the development of wire-electro-discharge grinding (WEDG) technology, the micro-electrical discharge machining (micro-EDM) has been excellent in the process of fabricating micro-holes in WC-Co material. Even though high-quality micro-holes can be drilled by micro-EDM, it is still limited in large-scale production, due to the electrode tool wear caused during the process. In addition, the high cost of precision micro-EDM is also a limitation for WC-Co micro-hole drilling. This study aimed to develop a low-cost desktop micro-EDM system for fabricating micro-holes in tungsten cemented carbide materials. Taking advantage of commercial micro tools in a desktop micro-EDM system, it is possible to reach half the amount of large-scale production of micro-holes. Meanwhile, it is difficult to drill the deep and high aspect ratio micro-holes using conventional micro-EDM, therefore, a cut-side micro-tool shaped for micro-EDM system drilling was exploited in this study. The results show that micro-holes with a diameter of 0.07 mm and thickness of 1.0 mm could be drilled completely by cut-side micro-tools. The roundness of the holes were approximately 0.001 mm and the aspect ratio was close to 15. Tungsten carbide (WC) is a materiel which is widely applied in military industrial composite, metallurgy, aerospace, and other important fields because of its excellent physical and chemical properties . Pure WCMicro-holes made from WC-Co are widely used as spraying nozzles, injection nozzles, and spinning nozzles, owing to their low wear and hardness . MachiniIn order to achieve semi-mass production of micro-hole drilling using EDM in WC-Co material, a low-cost desktop micro-EDM system was developed in this study. Off-the-shelf spindle electrode tools with diameters of 0.15 mm were used directly as microelectrode tools. These tools have proven to be commercially successful in low-cost mechanical drilling. Using these commercially available micro-spindle tools, it was possible to achieve the semi-mass production of a WC-Co material with micro-holes drilled via a desktop micro-EDM system. However, small diameter and long electrode tools with diameters less than 0.1 mm are not commercially available. Therefore, in this study, a WEDG unit was attached to the desktop micro-EDM system to fabricate micro-spindle tools with diameters less than 0.01 mm by using commercially available 0.15 mm tools. In order to produce micro-holes with a high aspect ratio, a single-side notch electrode method was applied to flush debris. The machining parameters, such as machining time, aspect ratio, spindle tool wear, and micro-hole quality, were investigated in this paper. It is expected that the desktop micro-EDM system will be potentially useful for drilling micro-holes in tungsten carbide materials.The micro-EDM with three axis computer numerical control (CNC) controllers has been commercialized in the industry market . The higThe desktop micro-EDM system was developed and designed in this research. The block diagram of the operation relationship of each unit is shown in The desktop micro-EDM system uses off-the-shelf spindle electrode tools. The micro-tool length and diameter are 5 mm and 0.15 mm, respectively, as shown in As described in the previous section, mechanical grinding process has been successful for the mass production of micro-spindle tools. The diameter was approximately 0.003 mm. However, it is still difficult to fabricate spindle tools with diameters less than 0.1 mm by using the grinding process, due to the mechanical grinding force . It is pThe conventional micro-EDM system is usually operated by numerical control (NC) or computer numerical control (CNC) controllers . In addiIn this study, two types of micro-spindle tools with diameters 0.15 mm and 0.035 mm were used to fabricate the WC-Co micro-holes by micro-EDM drilling. To achieve the semi-mass production of micro-hole drilling using micro-EDM, commercial micro-spindle tools with a diameter of 0.15 mm can be used directly, but there is no supply for diameters less than 0.050 mm. However, fine micro-spindle tools may be produced by the WEDG grinding process, as shown in The desktop micro-EDM system uses an RC discharge circuit and DC power with an open voltage of 80 V . The macThe surface observation of the micro-holes by Scanning Electron Microscope (SEM) is shown in Normally, transistor discharge circuits are used in commercial EDM because the discharge energy is controllable by adjusting the pulse generator and duty cycle . HoweverMicro-EDM encounters another critical problem for high-aspect ratio on deep micro-holes machining, especially when the diameter is less than 100 μm and the aspect ratio is larger than 10 . The cutA review of the research trends in micro-EDM about various electrode tools and their effects in the characteristics of micro-EDM are presented. A low-cost desktop micro-EDM system was explored and developed for rapid drilling of micro-holes through tungsten cemented carbide in this study. Using commercial electrode tools of 50 up to 150 μm, for about 2 to 4 min, it is possible to achieve semi-large-scale production of micro-holes. The desktop micro-EDM system is also able to drill micro-holes by mechanical drilling using a micro-spindle tool with a screw slot. Besides, the WEDG technology can even be employed for more meticulous micro-electrode and shaping tool fabrication. In addition to superb microelectrode tool fabrication, micro-hole drilling could be also done by the same machine. Compared to the nearly one million dollars and high prices of commercial micro-EDM systems, there are more potential applications for the drilling of tungsten cemented carbide in the low-cost desktop micro-EDM system developed in this study, which is able to produce roundness of a micro-hole of approximately 1 μm and a 9 times standard aspect ratio, enhanced to 15 times in high-aspect ratio. We hope that research and analyses on machining characteristics of double cut-side tool electrodes will be continued in the future.


Pre-operative knowledge of hamstring graft size for anterior cruciate ligament reconstruction (ACL) is of clinical importance and useful in making appropriate decisions about graft choice. This study investigated if there is any correlation between anthropometric measurements such as height, weight, body mass index, thigh length, and circumference with the size of hamstring tendon graft in anterior cruciate ligament reconstruction.The anthropometric data of 50 consecutive adult males, who underwent primary ACL reconstruction using quadruple hamstring autograft, were collected prospectively. Data analysis using Pearson’s correlation test was performed and multiple logistic regression analysis was used to investigate any correlation not detected by Pearson’s test and to eliminate confounders.r = .464, P = .001, r = .456, P = .001, respectively) and semitendinosus graft length . While the patient’s age was the only independent factor which had a positive correlation with the quadrupled hamstring graft diameter , multiple regression analysis showed abdominal girth had a significant negative correlation with gracilis (P = .04) and semitendinosus (P = .006) graft thickness.Patient’s height and thigh length demonstrated a positive correlation with gracilis graft length (, these results provide preliminary support for the use of some anthropometric measurements in the preoperative planning and prediction of the hamstring graft length and diameter in anterior cruciate ligament reconstruction.This study demonstrated that some anthropometric measurements had a positive correlation with the hamstring graft length and diameter in male patients. Hence Rupture of the anterior cruciate ligament (ACL) is one of the most common encountered knee injuries . DeficieThe aim of an ACL reconstruction is to restore the function and biomechanics of the native ligament. Various grafts available for use in the reconstruction of the ACL and the hamstring is one of the most commonly utilized autograft , 4. A grPre-operative knowledge of the hamstring graft length and diameter is of clinical importance and may assist surgeons in making appropriate and informed decisions about the graft choices which may increase surgeon’s confidence and enhance patient’s evaluation and counseling regarding graft choice –10.Various studies exist in the literature regarding prediction of graft size. However, no consensus has been reached due to differences in results between the studies –13.This study investigated if there is any correlation between anthropometric measurements such as height, weight, body mass index, thigh length, and thigh circumference with the size of hamstring tendon graft in anterior cruciate ligament (ACL) reconstruction.We hypothesized that there is no correlation between some anthropometric measurements with the size of the hamstring tendon graft that is used in anterior cruciate ligament reconstruction among males.We prospectively collected anthropometric data of 50 consecutive patients with ACL deficiency confirmed by MRI studies pre-operatively and scheduled to undergo primary arthroscopic ACL reconstruction using a single-bundle quadruple hamstring tendon autograft, between September 2014 and January 2017. Approval for the study was obtained from our Institutional Review Board.All adult male patients with isolated ACL deficiency undergoing primary arthroscopic ACL reconstruction using a hamstring tendon autograft were included in this study. Female patients, children under the age of 18 years, patients who had undergone previous ACL reconstruction, multiple ligamentous injuries, patients treated using grafts other than hamstring, double-bundle hamstring graft reconstructions, single-bundle hamstring graft reconstruction, and patients with neuromuscular diseases were excluded from the study.Informed consent was obtained from all patients prior to their inclusion. The following data was collected from patients: age, ethnicity, height, weight, abdominal girth, thigh length, and thigh circumference. The abdominal girth, thigh length, and thigh circumference measurements were taken while the patients were supine and knees in full extension.Abdominal girth was measured by placing the tape around the abdomen at the level of the umbilicus. Thigh length was measured from the anterior superior iliac spine (ASIS) to the superolateral border of the patella. The thigh circumference was measured at a point 15 cm proximal to the superolateral border of the patella.Two senior board certified fellowship trained knee surgeons performed all operations using the same harvesting technique. Using a skin incision distal to the insertion of the tendons on the proximal tibia, both semitendinosus and gracillis tendons were harvested by a closed graft harvester. Graft length was determined from the tibia insertion including the pretibial periosteum to the tendon tail while tendon length was from the tibia insertion including the pretibial periosteum to the tendomuscular junction. Intraoperative measurements of each tendon were recorded by the operating surgeons after removal of the fat and muscle tissue attached to each tendon. The measurements included length of the full graft, length of tendon, its width, and thickness of the tendons in millimeters Fig. .Fig. 1a The hamstring graft was prepared using a single-bundle 4-strand technique with each end of the tendon whip stitched using the same non-absorbable size 2 ethibond suture. The final graft diameter was measured using the ACL reconstruction graft diameter measurement guide  and the diameter was defined as the smallest calibrated size in which the graft could pass through .IBM SBSS Statistics (version 24) software was used for statistical analysis. Pearson’s test was used to identify correlations between anthropometric measurements and graft dimension. For results with positive correlation, simple linear regression analysis was used to estimate the linear curves. Multiple logistic regression analysis was used to investigate correlations not detected by Pearson’s test and to eliminate confounders. The positive results were considered statistically significant if the A total number of 50 consecutive male patients agreed to participate in the study. There were 3 patients who had missing data of the final graft diameter. Table The mean length of the harvested gracilis tendons was 147.3 mm (± 37.1 SD). Whereas, the mean graft length was 273.9 mm (± 33.1 SD) with mean width of 4.7 mm (± 2.1 SD) and mean thickness of 1.8 mm (± .8 SD). On the other hand, the mean length of harvested Semitendinosus tendons was 172.1 mm (± 38.9 SD) and the mean graft length was 307.5 mm (± 31.9 SD) with a mean width of 6.0 mm (± 2.8 SD) and a mean thickness of 2.3 mm (± .98 SD). The whole, single bundle 4-strands, mean graft diameter was 7.3 mm (± .67 SD)  and semitendinosus graft length . In addition, it showed a weak significant positive correlation with semitendinosus tendon length   and semitendinosus graft length .Thigh length was found to have a significant positive moderate correlation with gracilis graft length . There was no statistically significant correlation between hamstring graft diameter and the remaining anthropometric measurements.Furthermore, patient age demonstrated a significant positive moderate correlation with the final graft diameter . Semitendinosus graft length measurement variations could also be explained by patient’s height and thigh length . Semitendinosus tendon length measurement variations were explained by height . Variations of final hamstring graft diameter could be explained by age   but not significant for semitendinosus tendon length (P = .143), a significant negative correlation between abdominal girth and gracilis graft thickness (P = .040) and semitendinosus graft thickness (P = .006) and a significant positive correlation between the thigh circumference and gracilis graft thickness (P = .019) but not significant for semitendinosus graft thickness (P = .262), whereas thigh length had a significant positive correlation on only semitendinosus graft length (P = .016). The age was found to have a significant positive effect on the final ACL hamstring graft diameter (P = .013)  Table . FinallyThe ability to predict the length of the hamstring graft pre-operatively is of great importance and may help the surgeon in the decision to achieve an acceptable diameter for the autograft in ACL reconstruction.This study demonstrated a positive correlation between the patient height and thigh length with semitendinosus and gracilis graft length; this positive correlation was also reported in previous literatures –17.In addition, we could not find a positive correlation between height and the final graft diameter; however, several studies have demonstrated such positive correlation among females , 18, 19.Furthermore, we found no correlation between BMI and the final graft diameter in males as the females were excluded in our study. In previous studies, one author reported that BMI was correlated to the graft diameter in females but not in male , anotherIt is interesting to note that, in our study, the patient age was the only independent variable that had a positive correlation with the final graft diameter. The previous studies had demonstrated a negative correlation with age as a predictor of final quadrupled hamstring graft diameter , 13, 23.Additionally, we were able to find a significant negative correlation between abdominal girth with gracilis and semitendinosus thickness as well as a significant positive correlation between thigh circumference and only gracilis thickness, which were not reported in previous literatures.Some of the limitations of our study include small sample size, exclusion of females, the measurement technique is challenging and may be inaccurate for a thin tendon with varying width and thickness along the length and having two different surgeons involved in graft harvesting and measurement, possibility of other confounding factor and statistical artifacts to add more, and variability of amount of tension applied on the graft during sizing has an effect on the final graft caliber measurements intra-operatively.This study demonstrated that some anthropometric measurements had a positive correlation with the hamstring graft length and diameter in male patients. Hence, these results provide preliminary support for the use of some anthropometric measurements in the preoperative planning and prediction of the hamstring graft length and diameter in anterior cruciate ligament reconstruction.