The accumulation of plastic wastes in different environments has become a topic of major concern over the past decades; therefore, technologies and strategies aimed at mitigating the environmental impacts of petroleum products have gained worldwide relevance. In this scenario, the production of bioplastics mainly from polysaccharides such as starch is a growing strategy and a field of intense research. The use of plasticizers, the preparation of blends, and the reinforcement of bioplastics with lignocellulosic components have shown promising and environmentally safe alternatives for overcoming the limitations of bioplastics, mainly due to the availability, biodegradability, and biocompatibility of such resources. This review addresses the production of bioplastics composed of polysaccharides from plant biomass and its advantages and disadvantages. Over the past two centuries, the significant growth of the world population and its consumption habits have led to several negative impacts on the environment. The development of a society with more sustainable production/consumption mechanisms should consider scenarios such as deforestation, water pollution, soil silting, and solid waste accumulation. Regarding plastic wastes, they represent approximately 12% of the composition of the world’s solid waste [Despite technologies and bioproducts  being an alternative for the mitigation of such environmental problems, a total replacement of synthetic plastics from petrochemical origin can hardly be considered in the short or even long term. On the other hand, certain applications of bioplastics may represent areas of large-scale potential replacement ; for exaBioplastics can be classified into materials derived directly from natural polymers (agro-polymers), with or without modifications , polymers produced by microbial fermentation , and biomaterials chemically synthesized from renewable raw materials . BPE is derived from the polymerization of ethylene from bio-ethanol, bio-nylons are produced via diacids from biomasses, and bio-polyurethanes are fabricated from the incorporation of polyols of plant origin . HoweverBioplastics from agro-polymers are derived from natural polymers such as polysaccharides  and proteins  that generally involve intra and intermolecular interactions and cross-links (crosslinking) between polymeric constituents, forming a semi-rigid three-dimensional polymeric network which retains the solvent ,9.However, large-scale production of bioplastics for different applications is limited by high costs, in comparison to synthetic plastics derived from fossil oil, and concerns over functionality . DiffereThe production and use of bioplastics instead of synthetic plastics (non-biodegradable and oil-based ones) reduce emissions of polluting gases and provide materials from renewable and/or biodegradable sources, availability of raw materials, and a promising alternative for the destination of solid biomass residues. Regarding environmental problems such as the greenhouse effect ), a 50% reduction in GHG emissions by 2050 is required for avoiding a 2 °C increase in the global temperature. Biomaterials such as bioplastics and biofuels are considered one of the mitigating measures in relation to global warming ,20,21,22This review focuses on the different possibilities of bioplastics production from starch and lignocellulosic fibers, their advantages and disadvantages, and the procedures for obtaining natural polymers from plant biomass. Therefore, considering the development of several studies on the production of bioplastics from lignocellulosic fibers (from fractionation of the components or in nature and modified), in addition to the different applications that these bioplastics present, a review study on the characteristics (properties) of bioplastics and the processes for obtaining these polymers are justified.d-glucose  branches of amylopectin reduce the degree of organization of the polymer ,25. AmylNative starch molecules are linked through intermolecular interactions of the hydroxyl group and the oxygen of amylopectin and amylose. The amylopectin and amylose are joined by hydrogen bonds, which make it insoluble in cold water. However, the molecules can undergo significant changes when exposed to gelatinization temperatures, provoking the breakage of hydrogen bonds between starch components from the supply of thermal energy in an aqueous solution . In addiAnother process that can occur mainly with amylose molecules is retrogradation, or starch retrogradation, according to which a gelatinized solution shows interactions between amylose molecules and an increase in the ordering degree of hydrogen bonds. Therefore, the amylose chains crystallize with the formation of a double helix ,31, wherBioplastics production from thermoplastic starch, or another natural polymer , is completed with the deposition of the gelatinized filmogenic solution on a non-adherent surface. The solution is then dehydrated (in an oven for example), thus facilitating retrogradation due to the increase in intramolecular interactions between polymers from the reduction of the volume in the polymeric matrix. This procedure is known as Casting .Apart from casting, other conventional methods of large-scale industrial production  are applied for bioplastics manufacture ,34,35,36Regarding biocomposites, extrusion can be even more efficient, since both melting and mixing occur in a one-step process, which decreases polymer and reinforcement degradation, improves efficiency and suitability for industrial applications that require continuous processing ,39. HoweTg) [Polysaccharide-based bioplastics are brittle, non-continuous, rigid, and fragile when formulated with no additive ,45,46,47Tg) ,49,50, bThe formulation of starch-based solutions with plasticizers increases water vapor permeability (WVP), elongation, and reduces tensile strength. Daudt et al.  reportedw/w based on starch) of glycerol to 1.6 MPa for 30% (w/w based on starch). The same trend was observed with the replacement of glycerol for sorbitol as a plasticizer. The bioplastics with 20% and 30% of sorbitol showed, respectively, 22.3 and 11.2 MPa of tensile strength. Consequently, the reduction in the mechanical resistance increased elongation, and the use of 20% and 30% of glycerol resulted in 2.8% and 59.8% elongations, respectively. Bioplastics plasticized with glycerol showed lower resistance capacity and higher elongation than those plasticized with sorbitol at the same plasticizer concentration. The explanation for such differences lies in the smaller size of the glycerol chain, which promotes a higher plasticizer capacity in relation to sorbitol, i.e., glycerol shows a greater ability to interact with the matrix polymers and a larger amount of water is retained [Dias et al.  observedretained ,54.Many of the properties and characteristics of starch are required for the use as coating or packaging material , availability, relatively simple extraction process, and low cost) ,59,60,61Other important features of starch-based bioplastics or any other polymer are color and transparency, related to marketing and consumer’s acceptance for a given product, depending on the bioplastics application. Starch-based bioplastics have the disadvantages of hydrophilicity, poor mechanical properties, low water vapor barrier property, and low freeze stability during bioplastics formation ,63,64,65w/w) [w/w) in relation to the starch mass  . Differew/w)  and Diasw/w) , a comparch mass . The stuA low tensile strength and high elongation in starch arrowroot-based bioplastics, and improvement occurred in the tensile strength of starch-based bioplastics blending with gelatin  Table 1Table 1. Renga pinnata starch presented different properties using as plasticizers glycerol (G), sorbitol (S), and glycerol/sorbitol (GS) mixture  [w/w, starch basis) showed reduced tensile strength with increasing plasticizer content (49 to 10 MPa), in addition to increased flexibility (3 to 25%), and water vapor permeability (WVP) (6.75 to 7.59 × 10−10 g m−1 s−1 Pa−1) [The concentration and type of plasticizer can influence the bioplastics properties. Plasticizers increase the interstitial volume in the polymer matrix, which results in a reduction in the number of polymer-polymer bonds and thus affects mechanical ,80, therh basis) . The ten−1 Pa−1) . Other s−1 Pa−1) ,85 and i−1 Pa−1) .The chemical modification or the starch molecule derivatization may represent an approach aiming to improve the physicochemical and barrier properties of the native starch grain . Some ofIn the study by Abel et al. , the inc−7 g.m/m2.h.Pa. While the tensile strength on the DS of 1.1 was 6.57 MPa, and the solubility and WVP did not change either. However, acetylation resulted in bioplastics with improved properties compared to native starch [Different degrees of acetylation and plasticizers can alter the mechanical properties, solubility, and water vapor barrier of starch-based bioplastics . The dege starch . The impe starch ,91.Starch oxidation can be performed with hypochlorite, hydrogen peroxide, permanganate, dichromate, persulfate, and chlorate are common. In this reaction the OH groups of glucose are replaced by carbonyl and carboxyl groups, usually on the carbon of number 2, 3 and or 6 . BioplasBy comparison, starch acetylation may result in a more hydrophobic and resistant bioplastic than oxidized starch-based bioplastics. This is due to the chemical nature of the hydroxyl substitution groups, that is, acetyl is more hydrophobic than carbonyl and carboxyl groups. Therefore, acetylated starch bioplastics hold less water and consequently result in a more compact matrix with optimized bonds between polymers. Acetylated starch bioplastics exhibited a contact angle of 60.41° and tensile strength of 16.35 MPa, while the same properties for the oxidized starch bioplastic were 45.47° and 13.38 MPa .w/w starch). The tensile strength was 18.90 MPa (native starch), 15.66 MPa (6% propylene oxide), and 8.85 MPa (12% propylene oxide) [Hydroxypropylation in which the OH groups are replaced by hydroxypropyl ether results in the weakening of the interactions between the starch chains. Thus, as in the case of oxidation modification, starch modified with an ether group retains more water  when come oxide) . Effectse oxide) .Even though starch chemical modification in the manufacture of bioplastics can improve physicochemical and gas barrier properties, attention should be paid to the detriment of biodegradation properties . Starch Modified starch-based bioplastics showed a delay in anaerobic biodegradation, however, it is noteworthy that the degree of substitution of acetylated starch is >1.5, in which there is an impact on the biodegradation rate . BioplasAn alternative to improve the physicochemical and gas barrier properties of bioplastics, beyond ensuring biodegradation, is to join different chemical derivatizations. Advantage can be taken from the different potentials of each chemical modification. This approach is known as dual-modification , and canNatural polymers from lignocellulose have been used for improving the mechanical properties (limited application) of bioplastics ,99,100, Due to their potential application, components of lignocellulosic fibers from sugarcane bagasse, rice straw, flax, Kenaf, hemp, forest wood, and other sources have been widely used for reinforcement ,107,108.Examples of high availability of biological vegetal sources include generation of sugarcane bagasse  , banana Lignocellulosic fibers  can potentially be applied for the production of biomaterials and biomolecules such as bioplastics, thus reducing dependence on oil . Their uA mixture that uses natural biopolymers represents a source with potential for different applications. Among the different natural polymers, lignocellulosic residues from plant biomass are a resource for the production and improvement of the bioplastic’s properties, such as mechanical properties, in addition to the great availability of these fibers represent a possibility of cheaper bioplastics  and an alternative for the lignocellulosic waste management. Bioplastics produced from mixtures of more than one type of polymer can show improved properties in comparison to individual polymers .Cellulose is the most abundant natural organic compound on the planet, with an annual production of approximately 180 billion tons ,122. It The characteristics of cellulose are insolubility in water, high molar mass, and arrangement in nanofibers. Cellulose displays regions of poor organization and others highly crystalline, characterizing a semi-crystalline fiber. Due to such characteristics and the high resistance to enzymatic hydrolysis  , lignoceCellulose is biosynthesized not only by plants, but also by microorganisms such as algae, fungi, and bacteria ,127,128.Therefore, cellulose can potentially be used for the manufacture of biomaterials such as bioplastics, and in several areas and industries , nanotubes , forming an elongated structure, referred to as nanowhiskers), and nanolayers  .The literature reports improvements in the mechanical properties of biomaterials with the addition of cellulose nanowhiskers ,139,140.The amount of cellulose must also be considered in the production of cellulose-based bioplastics since its excess can cause agglomerations of cellulose granules in the polymeric matrix ,135,144,The main cellulose derivative produced from the etherification process (cellulose ether) is carboxymethylcellulose “CMC” ,153. TheRegarding microcrystalline cellulose “MC”, certain characteristics of CMC for the bioplastics development are solubility in water at different temperatures (use of water as a solvent), and reduction in the formation of particle agglomerates with other polymers ,155. TheStarch-based bioplastics with added MC and CMC resulted in bioplastics with improved tensile strength (up to 9 wt%) compared to pure starch bioplastic . HoweverCellulose acetate or acetylated cellulose (CA) , represeXylan-based bioplastics showed reduced solubility in water and food simulants (30.88% to 16.30%) after increasing the DS of nanocellulose (0 to 2.34) . In the The greater degree of hydrophobicity can result in a delay in the rate of biodegradation due to the reduction in the interaction of acetylated starch with water. The modification of cellulose may result in the need for different enzymes for hydrolysis, such as esterases, which are common enzymes for native xylan hydrolysis (native xylan contains acetyl groups) . TherefoIncreasing the concentration of acetylated starch, with a consequent reduction in CA, occurred a higher rate of biodegradation . The purBacillus sp) was the only isolate capable of degrading more than 10% of the CA bioplastic. It is known that CA with a high degree of substitution is more resistant to biodegradation [From landfill 35 bacteria were isolated showing growth halo in CA emulsifying medium, however, few isolates degraded CA bioplastic with DS 1.7 . The strradation ,166. Forradation ,168.The hydrophilic character of the carboxymethyl groups on the surface of CMC represents an important aggravating factor in maintaining bioplastic integrity . The greA proof that CMC is highly biodegradable, susceptible to microbial enzymes, and soluble in water, is its use in methods to verify the cellulolytic potential of different microorganisms. In these methods, microorganisms are cultivated in media with CMC as the only carbon source, and the growth halo is indicative of the production and secretion of cellulolytic enzymes.Hemicellulose is a constituent of plant biomass; together with lignin and cellulose, they become the major constituents of the plant cell wall, forming a lignocellulosic complex. In this complex, it represents the second most abundant polymer in lignocelluloses ,173,174.Xylan is one of the constituents of hemicellulose present in different agroindustrial residues , besides forest residues and hardwood pulping ,178,179.Since hemicellulose is highly available, it is a promising source for obtaining chemicals and materials ,180,181,Citric acid was used as a crosslinking agent in xylan-based bioplastics blend with polyvinyl alcohol . A stronGordobil et al.  developeThe blending of hemicellulose with other polymers can improve the properties of biomaterials formed by hemicellulose. Several studies have reported the addition of biopolymers to hemicellulose-based bioplastics as a strategy to improve their mechanical properties. TM and low-density polyethylene (LDPE)) [As shown, different proportions of nanocellulose and plant raw materials of hemicellulose result in different tensile strength values, elongation, and elasticity or young modulus. According to the tensile strength data in  (LDPE)) ,192,193. (LDPE)) .The reasons for using cellulose as reinforcement  are due As in the case of starch and cellulose chain chemical changes, there are implications for the biodegradation of bioplastics based on modified hemicellulose, however, the information in the literature is limited. Therefore, it is highly recommended to evaluate the influence of polysaccharide modifications on biodegradation .Regarding the development of bioplastic materials with the addition of natural polymers such as lignocellulosic fibers, the steps that precede the formulation and modification stages of such materials must be considered, since the extraction and purification processes of the lignocellulosic fibers from the biomass are responsible for the economic viability of the fiber’s application, hence, the final material’s price. The processes will also define the quality and characteristics of the final materials because they influence the properties of the bioplastic films formed and their suitability for a particular application.The choice of biomass must be considered for manufacturing processes and further transformations of starch, due to its different characteristics and compositions. Tubers, for example, contain a very small amount of proteins and fats, which facilitates the isolation of starch . The mosThe unit operations for the extraction of starch start with disintegration—the plant cell walls are opened, thus exposing their starch granules . The nexThe industrial process of starch isolation separates starch from protein, usually using an alkaline solution ,204. DifHydrothermal processing with microwave-assisted extraction can optimize the process, since it is considered a green and safe technology for starch extraction, due to its ease of use, the possibility of using only water as extraction solvent, short extraction times, higher performance, and lower solvent consumption ,209. TheIn cost-effective and efficient isolation of cellulose from biomass, the cellulose source should ideally come from economically viable and easily accessible agro-wastes, as the amount of cellulose in various natural sources can vary, depending on the species and the lifetime of the plants. From a technological point of view, the evaluation of lignin content is crucial for the optimization of the pretreatment necessary for the extraction of pure cellulose pulp . Indeed,Initially, the material is subjected to a water-washing process for the removal of dirt/impurities and water-soluble extractives. The biomass compounds closely linked to cellulose, such as hemicellulose and lignin, are then removed. The complexity of the composition of lignocellulosic materials hampers the penetration of chemical agents, thus requiring a pretreatment for the breakage of the structure and facilitation of chemical processes, hence, economy.2S) in a digester to dissolve lignin and hemicellulose [Kraft pulping uses a mixture of sodium hydroxide (NaOH) and sodium sulfide , hydrogen peroxide (H2O2), ozone (O3), or peracetic acid [After pulping, the resulting material can undergo a bleaching step, or delignification, which uses different bleaching agents such as chlorine dioxide  of emissions of CO2 and other gases in the GHG (greenhouse gases) category [The carbon footprint refers to the measurement , compared to petrochemical plastics. Moreover, these negative impacts about the use of bioplastics or additives based on plant biomass are debatable, as the implications of the arable land use and water resources due to the cultivation and harvesting of these biomasses can be mitigated through the approach of reusing agro-industrial and urban wastes. In addition to reducing the environmental impacts mentioned above, the use of waste from the wood industry, crops, and urban is a management alternative to agro-industrial and urban organic solid waste.The application of native starch in bio-plastics resulted in reduced GHG emission (up to 80%) and nonrenewable energy use NREU (up to 60%) . These nThe life cycle assessment approach (LCA), blends with starch residues (waste from fries potato processing) depicted a reduction in the eutrophication potential (up to 40%), land use (up to 60%), GHG and NREU (reduction < 10% for both), compared to virgin starch . The redThis review has addressed the state-of-the-art of the production of bioplastics from polysaccharides from plant biomass, as well as the advantages and disadvantages of using starch and lignocellulosic components (as an additive and main component) for their development. Academic and industrial efforts have been devoted towards new and improved polymers, production methods, and sources for the obtaining of polysaccharides that can strategically reduce petroleum consumption in the production of plastic and replace partially the conventional synthetic and non-biodegradable plastic materials. Moreover, the production of bioplastics from plant biomass represents a model for the recycling and management of such waste with positive economic effects. However, the disadvantages  related to the production of bioplastics from polysaccharides must be studied towards the expansion of the fields of application of such materials. This study showed that the application of lignocellulosic fibers has a high potential for application in bioplastics, since they result in the improvement of the properties of bioplastics, in addition to being an alternative to reuse biomass with great availability.


Irreparable rotator cuff tears are common and difficult to treat. Techniques for “filling the loss of substance” require fixation to the rotator cuff stump (tendon augmentation) or to the glenoid (superior capsular reconstruction), which are complicated by the narrow working zone of the subacromial space. The main objective of this study was to determine whether a braided graft of gracilis (GR) and semitendinosus (ST) could fill a loss of tendon substance from an irreparable rupture of the supra- and infraspinatus, by fixing the graft to the greater tuberosity and the spine of the scapula.This was a cadaveric study with the use of ten specimens. The GRA and ST tendons were harvested, braided and reinforced with suture. An experimental tear of the supraspinatus (SS) and upper infraspinatus (IS) retracted at the glenoid was made. The GRAST transplant was positioned over the tear. The transplant was attached to the greater tuberosity by two anchors and then attached to the medial third of the scapular spine by trans-osseous stitching. The percentage of filling obtained was then measured and passive mobility of the shoulder was assessed. We proceeded to the same technique under arthroscopy for a 73 years old patient whom we treated for a painful shoulder with irreparable cuff tear. We inserted a GRAST graft using arthroscopy.The Braided-GRAST allowed a 100% filling of the loss of tendon substance. Mobility was complete in all cases.This technique simplifies the medial fixation and restores the musculo-tendinous chain where current grafting techniques only fill a tendinous defect. The transplant could have a subacromial “spacer” effect and lower the humeral head. The donor site morbidity and the fate of the transplant in-vivo are two limits to be discussed. This anatomical study paves the way for clinical experimentation. The rotator cuff has two functions: to rotate the head of the humerus (and consequently the whole upper limb) in the three planes of space  and to cWith aging, degenerative tears are frequently encountered. This cuff tear generally begins in the anterior part of the supraspinatus and then gradually extends to the infraspinatus .Due to the effect of muscular contraction, the tendon stump progressively retracts towards the glenoid. If not used, the muscle then undergoes atrophy and fatty degeneration . When faSome authors have proposed to perform this filling either with autologous grafts such as fascia lata , quadricHowever, these different grafts have important limitations such as the morbidity of the harvest, the inadequate thickness of the graft, the immunological or infectious risk, and the cost.In order to overcome these limits, we propose a reconstruction technique of the cuff which is original for two reasons.The first lies in the choice of grafts used and their preparation method. We have chosen to combine the use gracilis (GRA) and semitendinosus (ST) tendons by braiding them to form the GRAST graft. The removal of these tendons has low morbidity and they are usually sizable . The aimThe second point of originality is the attachments locations of the graft from the humerus to the spine of the scapula. This avoids complex fixation procedures to the stump or glenoid in the narrow subacromial space. Fixation to the scapular spine is also technically less demanding because it is practically subcutaneous.The main objective of this study was to determine whether a GRAST transplant can fill a tendon defect from an irreparable rotator tear of the supra- and infraspinatus, while being long enough to reach the spine of the scapula and the greater tuberosity of the humerus.This was a cadaveric study on ten specimens. The mean age at death was 78 years (72–91). Exclusion criteria were the presence of shoulder stiffness, deformity or signs of prior surgery. The study protocol was approved by our institutional review board (Comité Scientifique et Ethique de l’APHP) and was registered under the CNIL  number 13810*01. Anatomical subjects were used in accordance with the willingness to donate one’s body for teaching and medical research, expressed in writing during the donor’s lifetime. The subjects came from the Fer à Moulin Institute, 7 rue du Fer à Moulin, 75005, Paris, France, Assistance Publique des Hôpitaux de Paris (APHP). We proceeded to the same technique under arthroscopy for a 73 years old patient whom we treated for a painful shoulder with irreparable cuff tear. We inserted a GRAST graft using arthroscopy. The participant gave her informed written consent for the surgery, the submission and the publication of images in Fig. Subject was seated in a beach chair position, one shoulder and one knee in the field. The GRA and the ST were first harvested Fig.  through Once the two tendons had been harvested, they were placed parallel to each other and folded in half so that both tendons were the same length on each side. The result was four strands and a plication. Two traction sutures  were placed one centimeter apart and passed through the plicature. The graft was prepared by braiding the 4 strands to obtain the final GRAST graft.The dry GRAST was then measured with a digital caliper: thickness, width, length and dry volume. The transplant was then preserved in a saline cup.After 10 min of soaking in saline, the same dimensions were measured again on the wet GRAST.The shoulder was then approached by a superolateral approach to perform an acromionectomy first. The experimental tear was then induced by excising the entire supraspinatus tendon and the anterior part of the infraspinatus from their humeral insertion to the glenoid, thus simulating an irreparable tear. The dimensions of this defect were measured: antero-posterior, medio-lateral Fig. .The GRAST transplant was then positioned over the loss of substance and fixed with two anchors to the great tuberosity, as in a single-row repair. A suture is then passed from the remaining infraspinatus tendon and attached to the graft allowing the graft to cover the entire empty footprint left by the tear as well as incorporate the intact infraspinatus tendon into the repair. Fig. . The medAt the end of the procedure, the loss of residual material from the rotator cuff not covered by the graft was evaluated, as well as the percentage of antero-posterior and medio-lateral filling.Each measurement was repeated twice by two double-blind operators.The average length of the semitendinosus (ST) was 263 mm , that of the gracilis was 240 mm .The dry graft averaged 114 mm long , 13.6 mm wide , and 5.8 mm thick .The average hydrated transplant was 110 mm long , 15.6 mm wide , 7.7 mm thick . When its dimensions were reduced to a parallelepiped, there was an 85% increase in volume.  and 34 mm long , i.e. an area of 853 mm2  in a rectangle . The GRAST graft was able to connect the greater tuberosity of the humerus to the spine of the scapula in all cases. Finally, the passive mechanical behavior of the GRAST does not interfere with the elevation of the arm.Our technique offers an intermediate solution between superior capsular reconstruction, which has become the primary treatment in many centers in the management of irreparable posterosuperior tears , along wCentering the head of the humerus in the glenoid is an essential prerequisite for the proper function of the shoulder, especially with forward elevation. Indeed, this allows the center of rotation of the humeral head to be maintained in an optimal position so that contraction of the deltoid causes rotation of the humeral head rather than proximal migration. In addition, it induces a tension effect on the deltoid fibres, which potentiates its strength when the elevation movement is initiated. The natural tendency of the humeral head is to migrate proximally under the action of the powerful deltoid. In the event of a massive tear in the cuff, this results in a reduction of the subacromial space. Since glenohumeral congruence is poor, only soft tissues  can oppose this migration. As in many other anatomical sites, there are two complementary solutions to prevent migration of a bone piece in a given direction: “traction” in the opposite direction and “abutment”. Traction is usually based on a ligament and/or tendon whose force vector is in the opposite direction to the movement to be prevented. This is similar to the cable of an anchor that prevents the boat from drifting under the action of the current. The stop, on the other hand, consists of placing an obstacle that will oppose the migration of the bone piece. In the shoulder, the only stop between the humeral head and the acromion is the supraspinatus tendon. It has therefore been suggested that proximal migration of the humerus could be prevented by sliding a subacromial spacer implant. This is the case for example with subacromial balloons , 17. HowHowever, this study is a cadaveric study and therefore has certain limitations.As with any anatomical study, the question of in vivo transposition arises. Indeed, one legitimate question is the clinical tolerance of such a transplant as well as the biological fate of the transplant. It is obviously too early to report the results of a clinical series, but a first look at early results can be seen with the case of a 73 years old patient whom we treated for a painful shoulder with irreparable cuff tear. We inserted a GRAST graft using arthroscopy. At 1 year’s follow-up, the graft appeared well incorporated with a reconstructed cuff appearance. Clinically, only intermittent residual pain persists, and it is interesting to note that the GRAST does not interfere with the elevation of the arm, which is almost complete Fig. . This isAfter a rotator cuff tear, inactive muscles tend to atrophy and degenerate into fat, visible on Computerized Tomography (CT) and Magnetic Resonance Imaging (MRI) . It woulA second limitation is the need to harvest from another anatomical site. As with any graft harvesting, this adds complexity to the technique and increases the risk of specific complications: infection, donor site morbidity, failure of the harvesting, residual pain. This limitation is important as more and more surgeons are over-specialized in shoulder surgery and are therefore unfamiliar with the removal of harmstring tendons. However, the removal of these tendons is commonly performed for cruciate ligament surgery. For surgeons who are used to this procedure, it takes only a few minutes and the scar is short. The rate of infection and specific complications is exceptionally low . The maiIn irreparable posterior cuff tears, the tendon defect can be filled by the braided GRAST, which restores the musculo-tendon continuity, and could have a humeral head lowering action and regain at least partially, the motor function of the supra- and infraspinatus and give patients back external rotation. This simple, fast, safe and inexpensive procedure could be an alternative to the proposed treatments, especially in patients not eligible for reverse arthroplasty or tendon transfer. This anatomical study opens the door to clinical experimentation.


The right posterior segment (RPS) graft was introduced to overcome graft size discrepancy in living donor liver transplantation (LDLT). However, it was very rarely used in pediatric patients. Here we presented 4 pediatric LDLT cases receiving RPS graft between January 2015 and April 2020 in our center. A total of 1868 LDLT procedures were performed in this period.Recipients included 1 boy and 3 girls with a median age of 45 months (range from 40 to 93 months). They were diagnosed with progressive familial intrahepatic cholestasis, propionic academia, ornithine transcarbamylase and biliary atresia, respectively. Four donors were all mothers with a median age of 32.5 years (31–38 years). Computer tomography angiography indicated posterior right branches branched off separately from main portal veins (type III variation). Three of these donor livers had 1 orifice of right hepatic veins (RHV). In the remaining 1 donor liver, the RHV showed 3 orifices and an outflow patch plastic was performed. Inferior right hepatic veins weren’t found in four donor grafts. The median graft weight was 397.5 g (352–461 g) and the median graft-to-recipient weight ratio was 2.38% (1.44–2.80%).Postoperative complications occurred in neither donors nor recipients. Within the median follow-up duration of 29 months (14–64 months), four children are all alive with normal liver function.In summary, for older children weighed more than 15 kg with donors’ variation of type III portal veins, the use of RPS grafts could be a feasible and favorable option. Living donor liver transplantation (LDLT) is widely performed for the treatment of end-stage liver diseases to overcome organ shortage . SimultaComparing to the left lobe graft, the RPS graft may carry a higher risk to donors by the reason of more surgical difficulties . In addiBetween January 2015 and April 2020, 1868 pediatric patients underwent LDLT at the Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University. RPS grafts were used for 4 of these recipients. We retrospectively analyzed the clinical data and postoperative outcomes of these 4 cases. This study was approved by the institutional review board of Renji Hospital. Written informed consent was obtained from the patients for publication of this research and any accompanying images. The graft selection criterion has been strictly modified in our center. In general, we used the left lateral lobe as our first choice in pediatric LDLT because the left lateral lobe usually could provide sufficient liver volume in a child with the minimized donor risk. The RPS graft would be taken into consideration if the right posterior branch of PV branched off separately from the main portal vein (Type-III PV). The Existence and the domination area of inferior right hepatic veins (IRHV) would be strictly identified during imageological examination to evaluate the demand and difficulty in reconstructions of IRHV. Three-dimensional computed tomography (CT) was applied for the preoperative anatomical measurement and visualization of the donors’ vascular anatomy. The IQQA®-3D Liver system  was applied to finish our volumetric calculation and analyses. In addition, Magnetic Resonance Cholangiopancreatography (MRCP) was conducted before the surgery to estimate the biliary tract. Intraoperative Cholangiography (IOC) was also performed during the operation to further conform the BD condition.The surgery of recipients and donors were performed simultaneously. For RPS graft procurement, hilar dissection was carefully performed to identify vessels of the RPS. We then temporarily clamped these vessels including the right posterior branch of PV and HA. A boundary line between right anterior lobe and RPS would be clearly exposed and the parenchymal dissection was next performed along the ischemic demarcation. The Cavitron ultrasonic surgical aspirator  was applied in this dissection process. During the parenchymal transection, all vascular branches on the dissection plane were cautiously isolated and ligated. The PV catheterization with University of Wisconsin solution (UW solution) perfusion was immediately performed after the graft procurement. During the implantation process of the liver, 5-0 and 6-0 PDS sutures were respectively used for continuous suturing of the PV reconstruction and outflow tract reconstruction. Anastomoses between the right hepatic artery of the recipient and the right posterior hepatic artery of the donor were completed under a surgical microscope with 8-0 Prolene sutures. End-to-end anastomosis was used for the bile duct reconstruction with 7-0 Maxson sutures.For donors, the functions of remnant livers were tested every day after grafts procurement until the parameters had returned to normal. As for recipients, initial immunosuppressive therapy consisted of a dual drug regimen of tacrolimus combined with methylprednisolone. Doppler ultrasound (US) tests estimating the vascular system were performed daily in the first week after LT, every 2 days in the second week, monthly during the first 6 months, and every 3 months thereafter .2 (19.7–21.3 kg/m2). Each pair of the recipient and donor had identical ABO group. The detailed anatomical variations of donors were displayed in Table Preoperative profiles of 4 children using RPS grafts and their donors were shown in Table Detailed information during transplant surgery was shown in Table Living donor liver transplantation (LDLT) has now become an efficient treatment to overcome end-stage liver diseases. With the development of global organ shortage, especially in Asian countries, nearly seventy percent of this operations are performed in major Asian transplant centers . HoweverIn preoperative volumetric evaluation, if the left lateral lobe can satisfy the minimum standard of a recipient’s requirement- 40% of the recipient’s standard liver volume, the left lateral lobe may serve as the first choice in LDLT graft procurement . HoweverSome obstacles stand in the way of expanded application of RPS grafts. First, it is difficult to maintain a slight difference between the actual graft volume and estimated graft volume as the parenchymal transection plane is wide. Tiny bias may cause huge deviation during the operation . Second,The RPS graft is not only used in adult living donor liver transplantation (LDLT). In pediatric LDLT, especially for some older children who weighed more than 15 kg, the most commonly used left lateral lobe grafts cannot provide sufficient liver tissues for these patients. The criteria in adult LDLT concerning procurement of the RPS graft do not apply to pediatric LDLT. There have been no reports to propose a standard for procurement of the RPS graft in pediatric LDLT up to now. Based on our single-center clinical experience, for older children ranging from 15 to 30 kg, both the right posterior lobe and the left liver can meet the requirements in most cases. Therefore, anatomical factors have become the most important consideration in choosing the right posterior lobe in pediatric LDLT.Actually, comparing to the left lobe graft, the RPS graft has irreplaceable advantages. For example, it is a contradictory to harvest the left lobe graft with or without the middle hepatic vein (MHV). On the one hand, the left lobe graft without the MHV often has difficulties in the venous return of segment IV. On the other hand, the left lobe graft with the MHV can induce the congestion of segment V and VIII in the remnant donor liver. The right posterior graft can maximize the use of donor liver tissues and reduce the donor’s surgical damage. Furthermore, the RPS graft conforms to the normal physiological structure. The right posterior graft is placed in the right side of the recipient's abdominal cavity, which is in accordance with the physiological position and is not prone to torsion of the bile duct and portal vein in the process of liver regeneration. Thirdly, the type III portal vein has a long right posterior lobe branch, which is more conducive to anastomosis. In addition, for type III portal vein, the left branch of PV belongs to the tertiary branch, and part of the IV segment is supplied by the right anterior branch. As a result, part of the IV segment of the left lobe graft with MHV will lack the PV blood supply and only have the arterial blood supply. Last but not least, the type III portal vein often combines with bile duct variation (the right posterior bile duct often branches independently). In such circumstances, the left liver procurement may easily cause bile duct damage or cut out multiple bile duct openings, which increases the complexity of the operation. In summary, based on our experience, we first proposed the selection criteria for the right posterior graft in LDLT for children weighed more than 15 kg. According to our present study, favorable outcomes after LDLT using RPS grafts could be achieved in pediatric patients through strict volumetric and anatomical assessment of the donor livers.Four pediatric patients experienced smooth recovery after the surgery. The median length of postoperative hospital stay was 18.5 days (range from 14 to 23 days). The median follow-up duration is 29 months (range from 14 to 64 months) and all recipients are alive with normal graft function. Figure


Background and Aims: Recipient demographics affect outcomes after kidney transplantation. The aim of this study was to assess, for kidneys retrieved from living donors, the effect of recipient sex, ethnicity, and body mass index (BMI) on delayed graft function (DGF) and one-year graft function, incidence of acute rejection (AR), and recipient and graft survivals. Methods: A systematic review and meta-analysis was performed. EMBASE and MEDLINE databases were searched using algorithms through Ovid. Web of Science collection, BIOSIS, CABI, Korean Journal database, Russian Science Citation Index, and SciELO were searched through Web of Science. Cochrane database was also searched. Risk of bias was assessed using the NHBLI tools. Data analysis was performed using Revman 5.4. Mean difference (MD) and risk ratio (RR) were used in analysis. Results: A total of 5129 studies were identified; 24 studies met the inclusion criteria and were analysed. Female recipients were found to have a significantly lower serum creatinine 1-year-post renal transplantation (MD: −0.24 mg/dL 95%CI: −0.18 to −0.29 p < 0.01) compared to male recipients. No significant difference in survival between male and female recipients nor between Caucasians and Africans was observed (p = 0.08). However, Caucasian recipients had a higher 1-year graft survival compared to African recipients (95% CI 0.52−0.98) with also a lower incidence of DGF (RR = 0.63 p < 0.01) and AR (RR = 0.55 p < 0.01). Recipient obesity (BMI > 30) was found to have no effect on 1-year recipient (p = 0.28) and graft survival (p = 0.93) compared to non-obese recipients although non-obese recipients had a lower rate of DGF (RR = 0.65 p < 0.01) and AR (RR = 0.81 p < 0.01) compared to obese recipients. Conclusions: Gender mismatch between male recipients and female donors has negative impact on graft survival. African ethnicity and obesity do not to influence recipient and graft survival but negatively affect DGF and AR rates. In kidney transplantation, the relative contribution of donor versus other factors on clinical outcomes is considered a main criterion to allocate an organ .Living kidney donation (LKD) represents the optimal treatment for kidney failure ,3. PreviIn the context of living donation, recipient demographics are considered equally important and are constantly evaluated as potential contraindications for an LD to come forward. For instance, there is still an ongoing debate whether or not to use a body mass index (BMI) cut-off , especiaAdditionally, growing attention is being attributed to donor-recipient gender match  and ethnThe aim of this study was to assess, for kidneys retrieved from LDs, the effect of recipient sex, ethnicity, and BMI on short- and long-term graft outcomes.The study was registered with PROSPERO (CRD42020221109) before commencement of the literature search. The review was conducted and reported according to PRISMA guidelines .Literature searches were performed in Ovid , Web of Science, and Cochrane databases, using combinations of free text and keyword terms for living kidney donation and donor demographics of interest. A full search strategy is shown in Any study relating to recipient’s demographic characteristics on graft outcomes after LKD were eligible for inclusion, including full articles and meeting abstracts. Only studies in English were included for the analysis.The primary objective was to assess the effect of recipient demographics of ethnicity, BMI, and sex on kidney function evaluated using estimated glomerular filtration rate (eGFR) adjusted for body surface area, serum creatinine, and proteinuria incidence, where reported.The secondary objectives included assessing effect of the above-mentioned recipient demographics on patient and graft survival, incidence of delayed graft function (DGF), and acute rejection (AR).Study identification and data extraction were performed in three stages: the first stage included downloading the studies identified by the search strategy from Cochrane, Ovid, and Web of Science databases into EndNote reference management software. The reference management software was then used to remove duplicate studies. The second stage included two independent researchers (M.I.B. and M.N.) screening the titles and abstracts of long-listed studies. The researchers then each produced a list of studies eligible for the review. The two lists were compared to produce a single short-list of studies selected for full text review. The third stage of data extraction included the researchers fully read of the short-listed studies to identify the studies meeting the inclusion criteria. Data extraction was performed by two independent reviewers (M.I.B. and M.N.), and disagreements were solved by discussion or consulting a third reviewer. Data were extracted into a Microsoft Excel sheet.Risk of bias assessment was performed using National Institute of Health National Heart, Lung and Blood Institute (NIH NHBLI) quality assessment tool , as showp-values. Where p-values were <0.05, and 95% CI did not include 0, a statistically significant difference between the two groups was recorded. Forest plots were created in Revman 5.4.1. Heterogeneity of the data was assessed using the I2 test, where the I2 value greater than 0.5 heterogeneity of the data was assumed to be high and where the I2 value lower than 0.5 heterogeneity of the data was assumed to be low.All data analyses were performed in Revman 5.4.1 and IBM SPSS Statistics 26. Meta-analysis of mean difference was used for continuous data. Random effect models were used for all meta-analyses due to the heterogeneous and small study samples. Mean differences with a 95% confidence interval were calculated for the summary effect. The Z test was performed to calculate A total of 5129 studies were identified; 24 studies met the inclusion criteria and were analysed.p = 0.006). In both studies, there was no significant difference in graft survival between females who received grafts from male and female donors.Jacobs et al.  comparedp < 0.00001).Four studies ,11,13,14p = 0.78), , b.p = 0.06 , as represented in No significant difference in one-year post-transplantation serum creatinine was found between female recipients who had received their transplant from a male donor and female recipients who had received their transplant from a female donor (p = 0.52) was found one-year post-transplantation between male and female renal transplant recipients . The effect size of the difference between 2 means was medium (95%CI: 0.14 to 1.22).In p < 0.00001), as represented in p = 0.13)  h.Two studies ,16 invesTwo studies ,18 compap = 0.88)  a.p < 0.00001) [Williams et al.  and Isaa0.00001) .p ≤ 0.00001), as shown in Two studies by Williams  and Redfp = 0.04   a.p = 0.93), as observed in There was no significant difference between one-year graft survival in the obese and non-obese groups (In p < 0.00001) (p < 0.00001) (It was found that non-obese donors were 19% less likely to develop acute transplant rejection compared to obese recipients (0.00001) c. Non-ob0.00001) d.The survival advantages of transplantation over long-term dialysis are known if a given patient with end-stage kidney disease is suitable for a transplant. A major challenge is to optimize modifiable variables that could improve long-term survival , and witWith regards to sex, an interesting finding of our meta-analysis was that at three years follow up, male recipients who had received a transplant from a male donor were 65% less likely to lose a graft compared to male recipients who have received grafts from female donors. This result might lead to think there is a nephron mass effect playing an increasing role in the medium and long-term graft function, as a female kidney could be in general of lower weight and therefore with less functional nephrons, demonstrated also by a lower eGFR in women in the general population . In addition to this, the graft survival advantage for male recipients of male donor kidneys was previously also reported by Kayler et al. , who anaIn the present meta-analyses, we found no significant difference in graft survival among female recipients according to the sex of their donors. To this regard, as a risk factor for inferior outcomes in women, it is worth to mention the theory related to the sex-determined minor histocompatibility antigen (H-Y antigen), firstly described in 1976 on a female recipient who rejected the bone marrow transplant from her HLA-identical brother . More rep = 0.06), the above finding was confirmed in one-year post transplant serum creatinine, with male recipients recovering better from a graft from male donors. In this view, the use of sex as a biological variable in medical research is increasingly recognized as an important modulator to better understand the complex pathophysiology of several diseases [Although almost significant (diseases  and bettp = <0.00001) as well as lower AR incidence. Reasons unpinning this discrepancy are several, from different socio-economic status to prevalence of metabolic diseases [This approach with a close eye to diversity and inclusion extends also to individuals from minority backgrounds: interventions to ameliorate the effects of demographic discrepancies, different ethnicity, and cultural backgrounds may improve access to transplantation ,43 as wediseases , althougdiseases ; in factp = 0.28); therefore, even if it is true that bridge interventions, such as bariatric surgery [Finally, the same discourse regarding discrimination could be raised with regards to high BMI recipients who are denied access to the waiting list because of their body weight only. From the present meta-analysis, the four studies investigating the effect of recipient BMI on the post-transplantation one-year recipient and graft survival ,29,30,31 surgery , are inc surgery .The retrospective nature of the studies analysed has limited the level of evidence we could achieve, based on observational registry data, small number of studies, and great deal of heterogeneity. Longer-term follow up reports should be also warranted to better analyse any potential relationship between the other contributing factors and the recipients’ demographics.In conclusion, gender mismatch between male recipients and female donors has a negative impact on graft survival, with male recipients who received a transplant from a male donor 65% less likely to lose a graft compared to male recipients who have received grafts from female donors. African ethnicity increases DGF and AR rates compared to the Caucasian, and no significant difference between one-year graft survival in the obese and non-obese groups has been observed; therefore, BMI-only cut-offs to waitlist are not considered appropriate.


Journal of New Chinese Medicine, vol. 50, no. 11, pp. 196–198, 2018.  [13] H. Hua, “Clinical observation on the treatment of external humeral epicondylitis by hysteresis acupuncture combined with acupuncture manipulation,” Hebei Journal of Traditional Chinese Medicine, vol. 33, no. 6, pp. 890–891, 2011.  [14] H. R. Yu, “Therapeutic effect of acupuncture on 147 cases of external humeral epicondylitis,” Journal of External Therapy of TCM, vol. 26, no. 6, pp. 10–11, 2017.  [19] L. S. Liao and W. J. Guo, “Ironing combined with acupuncture therapy for 30 cases of tennis elbow,” Journal of Sichuan of Traditional Chinese Medicine, vol. 33, no. 4, pp. 168–170, 2015.  [20] X. Y. Zhang, Q. Liu and M. Huang, “Effect observation of 30 cases of tennis elbow treated by fire needle,” Shandong Journal of Traditional Chinese Medicine, vol. 30, no. 9, pp. 639–640, 2011.  [21] M. Lin, “Effect observation of 36 cases of external humerus epicondylitis treated with elbow five needle,” AsiaPacific Traditional Medicine, vol. 14, no. 8, pp. 165–166, 2018.  [22] Y. L. Wang, “Clinical observation of electroacupuncture in treatment of refractory external humeral epicondylitis,” In the article titled “Effectiveness of Acupuncture for Lateral Epicondylitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials” , some of


Tendons of the hands and wrists and the median nerve were imaged using gray-scale and power Doppler ultrasound (US) and US SWE. Arthralgia symptoms were evaluated using the Breast Cancer Prevention Trial (BCPT) Symptom Checklist musculoskeletal subscale (MS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and stiffness subscales. At baseline, there were significant differences in the SW velocities of tendons between dominant and nondominant hands. Increased velocity in 2 of 6 tendons and the median nerve was associated with greater pain at baseline, whereas slower velocity of the extensor digitorum tendon (suggesting decreased stiffness) was associated with a higher WOMAC stiffness score. Increased SW velocity (suggestive of increased stiffness) at baseline in the abductor pollicis longus tendon was associated with a worsening of all three pain and stiffness measures by 6 months. Future studies should evaluate SWE scores related to AIA outcomes in a larger sample size.Aromatase inhibitor-induced arthralgia (AIA) comprises significant, activity-limiting musculoskeletal symptoms, including joint pain, myalgia, and joint stiffness. We conducted a prospective feasibility study in postmenopausal women diagnosed with early-stage (0–3) hormone receptor positive (HR+) breast cancer who were candidates for treatment with adjuvant AI therapy ( Aromatase inhibitor-induced arthralgia (AIA) comprises significant, activity-limiting musculoskeletal symptoms, including joint pain, myalgia, and joint stiffness . AIA canPrevious studies have used Doppler ultrasound (US) to evaluate pathological changes of the tendons and joints associated with AIA. Our prior study suggested that women with AIA had non-significantly higher hyperemia and increased tenosynovial fluid relative to asymptomatic, age-matched controls using a Doppler US . SimilarShear wave elastography (SWE) is a novel imaging technique used to acquire a measure of tendon stiffness via shear acoustic waves of a focused ultrasonic beam . In our Here, in the context of an ongoing prospective study to evaluate the biomarkers of AIA in postmenopausal women, we evaluated tendon features of the hands and wrists using US SWE in a subset of patients. Tendon stiffness was evaluated at initiation and after 6 months of AI treatment. To our knowledge, this is the first study to use US SWE to associate tendon stiffness with AIA symptoms in breast cancer patients taking AI and to determine whether it is feasible to associate tendon stiffness at baseline with worsening AIA symptoms by 6 months.clinicaltrials.gov (NCT03665077). All eligible patients completed their definitive treatment (surgery ± radiation) and were recruited at the time of their medical oncologist visit, prior to initiation of anastrozole as adjuvant therapy. For this sub-study, US SWE images were captured at the initiation of their AI (n = 16) and after 6 months (n = 9). The US SWE component of this study was originally planned for all participants; however, the US instrument was no longer available for continuation of SWE studies for reasons that were unrelated to the current study or the authors. Of the 16 patients with baseline SWE and questionnaire data, 14 had paired questionnaire data at 6 months.This study was embedded in an ongoing, single-arm, prospective clinical trial of patients with early-stage hormone receptor positive (HR+) breast cancer to evaluate and develop blood-based and imaging biomarkers of AIA. The trial was approved by our institutional review board and was conducted in accordance with the requirements of the provisions of the Declaration of Helsinki. All patients provided written informed consent. The trial was registered on Postmenopausal women diagnosed with early-stage (0–3) HR+ breast cancer who were candidates for treatment with adjuvant AI therapy were eligible for this trial. Exclusion criteria included prior breast cancer diagnosis, prior adjuvant or neo-adjuvant chemotherapy, prior endocrine therapy (AI or tamoxifen), history of rheumatoid arthritis or other autoimmune arthritis, daily NSAID use (other than baby aspirin), or any corticosteroids or immunosuppressive therapies.The Breast Cancer Prevention Trial (BCPT) Symptom Checklist is a 42-item questionnaire validated in breast cancer survivors . Here, wThe Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) is a 24-item instrument developed to assess pain, stiffness, and physical function in participants with osteoarthritis or AIA ,26. HereAll images were collected before and after the initiation of AI (baseline and 6 months). Real-time gray-scale and power Doppler US examination of the bilateral wrists were performed on a General Electric Logiq E9 machine using the 18–8 MHz linear hockey stick transducer as previously described . BrieflySWE examinations of the bilateral wrists and scoring of these images were performed as previously described . BrieflyTo score SWE images, regions of interest (ROIs) were examined by a fellowship-trained musculoskeletal radiologist with more than 5 years of experience in US SWE imaging. ROIs contained the entire anatomical site of interest in each image. The B-mode images were co-registered with SW velocity color maps. The average SW velocity within each ROI was calculated using color map values and tabulated by a biomedical engineer. Each image was captured and scored in triplicate. The code to generate ROI’s is available on the public repository, GitHub.Baseline characteristics were summarized using the median and interquartile range (IQR) for continuous variables and proportions for categorical variables. Changes in symptom scores across time were tested using linear mixed-effects models, with time  as a continuous variable, adjusted for the baseline symptom score, and clustered on the participant. Additional models further adjusted for age at baseline, BMI at baseline, and definitive therapy (mastectomy versus lumpectomy). For SWE data, the velocity at each image location (7 locations), axis (long or short), and side (dominant or nondominant) was measured in triplicate and reported as the mean ± SD or median (range). Changes in SW velocity across time were tested using linear mixed-effects models with time  as a continuous variable, adjusted for transducer and baseline velocity (mean of the triplicate measures), clustered on the participant. The random-effect constant could not be reasonably estimated in 8 of the 28 models (one model for each location–axis–side combination), presumably due to the complexity of the model. Thus, a sensitivity analysis used the same models without clustering on the participant, and another sensitivity analysis did not adjust for the baseline velocity (but clustered on the participant). For the association between the baseline SW velocity and baseline symptoms, symptom scores were dichotomized into asymptomatic (score = 0) or symptomatic (score > 0) participants, and median velocities (mean of triplicate measures) were compared between these two groups using Wilcoxon rank-sum tests. Similar Wilcoxon rank-sum tests were used to compare the median baseline SWE velocity (mean of the triplicate measure) across groups of participants whose symptoms worsened or did not worsen between baseline and 6 months. No adjustments were made for multiple comparisons. Statistical analyses were conducted using Stata 17.0 .2, and the majority were non-Hispanic white (87.5%). There were 15 participants classified as right-hand dominant, and one was left-handed. For their definitive treatments, 75% had lumpectomy, and 62.5% had adjuvant radiation. There were three participants with stage 0 breast cancer, 11 with stage I, and two with stage II. All patients were still adherent to their AI at 6 months.The participants in the SWE subgroup were older adults with a median (IQR) age of 64.9 (63.5–71.5) years at enrollment . PatientThere was no increased power Doppler signal to suggest active inflammation at baseline or after 6 months in any participants on the Power Doppler interrogation. Additionally, all anatomical sites appeared normal using Grayscale US.p = 0.020), with no difference in the short axis.Mean ± SD baseline SW velocities were compared between dominant versus nondominant sides in the long a and shop = 0.007), flexor digitorum profundus , and the flexor digitorum superficialis . Additionally, the median nerve had a significantly slower mean velocity on the dominant side in the long axis . Given these observed differences, all other results are stratified by side and axis.Differences between sides in the abductor pollicis longus at the baseline are illustrated for a representative patient a,b. Thern = 12; asymptomatic, n = 4), WOMAC pain , and WOMAC stiffness . Patients that were symptomatic, as reported by the BCPT-MS, had a significantly faster median (range) SW velocity, suggesting greater stiffness, in the extensor carpi ulnaris (4.6 (3.3–4.9) versus 4.0 (2.7–4.3) m/s; p = 0.008 ) and the flexor digitorum profundus ((7.9 (4.8–9.9) versus 4.5 (2.7–6.8) m/s; p = 0.020 ). Patients that were symptomatic using the BCPT-MS also had a faster median (range) SW velocity for the median nerve on the dominant side in both the long ((5.7 (4.2–9.2) versus 3.5 (2.5–5.8) m/s; p = 0.030) and short ((5.0 (4.0–7.7) versus 4.3 (3.8–4.6) m/s; p = 0.042) axes. The median SW velocity was not different in any other tendons for women with a score > 0 on the BCPT-MS at baseline on either side or in either axis. For women that were symptomatic on the WOMAC stiffness subscale, the extensor digitorum tendon had a significantly slower median (range) SW velocity ((4.8 (3.0–5.6) versus 5.4 (4.7–7.1) m/s; p = 0.009 ). No other tendons nor the median nerve were related to a score > 0 on the WOMAC stiffness subscale at baseline. No tendons nor the median nerve were related to a score > 0 on the WOMAC pain subscale at baseline.Median (IQR) SW velocities among symptomatic (score > 0) versus asymptomatic (score = 0) patients were compared for BCPT-MS  but no change on the non-dominant side or on either side in the short axis. Differences in the abductor pollicis longus from baseline to 6 months in the long axis on both sides are illustrated for a representative patient (p < 0.001) but an increase in the short axis . The flexor digitorum superficialis had a significant decrease in SW velocity in the long axis on both the dominant  and non-dominant  sides. The median nerve had a significant increase in SW velocity on the dominant side in both the long  and short  axes, but it had a significant decrease in velocity on the non-dominant side in the long axis .Changes in SW velocity from baseline to 6 months of AI treatment were calculated in the 9 participants that had paired images . The abd patient . The extn = 10 worsening, n = 4 non-worsening); WOMAC pain ; WOMAC stiffness ). The abductor pollicis longus had significantly faster median (range) SW velocities at baseline in women that had a worse BCPT-MS at 6 months relative to women with a non-worsening score ((5.1 (4.1–8.9) m/s versus 3.8 (2.8–4.5) m/s; p = 0.024) and in women with a worse WOMAC stiffness score at 6 months ((5.1 (4.0–8.9) m/s versus 4.2 (2.8–8.4) m/s; p = 0.043), both in the long axis on the dominant side. Women that had worsening WOMAC pain scores also had a non-significantly faster median (range) SW velocity in the abductor pollicis longus at baseline relative to women with a non-worsening score ((8.4 (4.3–8.8) m/s versus 4.5 (2.8–8.9) m/s; p = 0.083; long axis, dominant side). The only other anatomical site associated with questionnaire scores at 6 months was the flexor digitorum superficialis, which had a significantly faster median SW velocity in women with a worsening WOMAC stiffness score relative to women with a non-worsening score ((6.7 (4.9–9.1) m/s versus 4.7 (4.1–6.0) m/s; p = 0.008 ). There were no other significant differences in SW velocities at baseline for any anatomical sites with regard to worsening pain or stiffness scores at 6 months.We then sought to determine whether baseline SW velocity predicted a worsening of pain and stiffness scores from baseline to 6 months  could predict whether or not women taking AI as their adjuvant therapy for breast cancer would develop AIA symptoms. However, our final sample size limited our ability to perform the appropriate statistical models that would allow for prediction of AIA. Despite this setback, our results suggest that increased SW velocity (suggestive of increased stiffness) at baseline in the abductor pollicis longus was associated with a worsening of all three pain and stiffness measures by 6 months. Additionally, an increased velocity in two of six tendons and the median nerve was associated with greater pain at baseline, whereas a slower velocity of the extensor digitorum tendon (suggestive of decreased stiffness) was associated with a greater WOMAC stiffness score. Furthermore, we identified important differences in SW velocity by the image axis and between dominant and non-dominant hands that can inform standardization procedures for SWE image collection in future studies.At baseline, there were significant differences in SW velocity between dominant and non-dominant sides for four of six tendon sites as well as the median nerve. The greatest difference was observed for the abductor pollicis longus, which had a significantly faster median SW velocity, suggesting stiffer tendons, on the dominant side in the long axis (15.7% difference) than the non-dominant side. The abductor pollicis longus is responsible for facilitating movement and stabilization of the thumb, and the increased velocity in this tendon may be related to high use of the thumb, particularly on the dominant side. The extensor pollicis brevis had a faster median SW velocity on the dominant side than the non-dominant side but in the short axis only (9.1% difference). The flexor digitorum profundus and flexor digitorum superficialis both had significantly slower velocities on the dominant side than the non-dominant side in the short axis only . The importance of evaluating these differences in SW velocities by side has been suggested in other studies for different tendons. For example, in athletes with unilateral patellar tendonitis, the more painful side was significantly more stiff than the less painful side (169% difference) and was significantly more stiff than the dominant side patellar tendon of controls (159% difference). However, there was no difference by side within the healthy control group . Siu et For some tendons , it has consistently been shown that softer tendons are associated with symptomatic findings; however, the opposite has been observed in the rotator cuff and patellar tendon ,31. For Several patients had elevated pain and stiffness at baseline quantified by the WOMAC and BCPT-MS questionnaires, prior to AI treatment. Therefore, we next sought to determine whether tendon stiffness at baseline was associated with these measures. There were two of six tendon sites that were significantly stiffer among patients with a BCPT-MS score > 0, and one of six was stiffer with a WOMAC stiffness score > 0. Interestingly, the median nerve had significantly faster velocities at baseline in both axes on the dominant side in women with a BCPT-MS score > 0. This is consistent with other studies noting a relationship between symptomatic findings and a stiffer median nerve . NotablyThere were 14 patients that had both baseline SWE images and paired baseline to 6-month pain and stiffness questionnaire data. Higher SW velocity in the abductor pollicis longus at baseline was associated with a worsening of all three subscales. While the difference in baseline SW velocity only reached statistical significance for the BCPT-MS and WOMAC stiffness scores, there was a 185% higher SW velocity at baseline among women with higher WOMAC pain scores at 6 months for the abductor pollicis longus. While no other studies have demonstrated a relationship between SWE scores in the abductor pollicis longus and the development of AIA, this finding is consistent with a small study showing symptomatic findings on MRI in the abductor pollicis longus in two women that developed AIA . Similarn = 16) with an even smaller paired baseline-to-post-treatment subset for the SWE component (n = 9). However, there were 14 patients with paired baseline SWE images and 6-month questionnaire data that allowed for generating hypotheses regarding the use of SWE as a predictive imaging biomarker of AIA, particularly for the abductor pollicis longus tendon. Given the small sample size, all results should be considered hypothesis-generating; many of the observed changes were small and need to be tested in a larger sample size. Despite the small sample size, we were still able to identify important differences between dominant and non-dominant hands in both the long and short axes that could inform image acquisition for future studies. The use of two separate transducers (9–4 MHz and 12 MHz) is also a limitation [A critical weakness of our study is a small sample size  it is feasible to recruit women with breast cancer not yet experiencing AI symptoms and to collect an SWE measurement at two timepoints, (2) this method of collecting SWE data is reproducible and that capturing SW velocity measurements of each tendon in triplicate is also feasible, (3) study procedures impose a low patient burden, (4) it is important to capture both dominant and non-dominant sides, and (5) we have refined the code to quantify SWE measurements. Furthermore, our results suggest that the abductor pollicis longus tendon could be an important anatomical site to predict AIA in breast cancer patients using US SWE. Given the small sample size, all findings should be considered as hypothesis-generating. Future studies should evaluate SW velocities related to pain and stiffness outcomes in a larger sample size. Future studies should also consider hand dominance and image acquisition along both axes when reporting clinical outcomes.


Starch plays an important role in food industry. In this study, three wheat cultivars with different protein contents were used to investigate the different ratios of starch addition on starch pasting properties, starch thermal performance, dough rheology, biscuit quality, and their relationships. Results showed that with the increase in starch content, gluten, protein and glutenin macropolymer (GMP), lactic acid solvent retention capacity (SRC), sucrose SRC, and onset temperature (To) decreased, while most pasting parameters and gelatinization enthalpy (ΔH) increased. Viscosity parameters were significantly negatively correlated with dough stability time, farinograph quality number (FQN), and sucrose SRC. Biscuit quality was improved by starch addition, indicated by lower thickness and hardness, higher diameter, spread ratio, and sensory score. Viscosity parameters were positively correlated to diameter, spread ratio, and sensory score of biscuit, while negatively correlated to hardness and thickness of biscuit. Image analysis showed that the crumbs of biscuit were improved as shown by bigger pores in the bottom side. The results provide useful information for the clarification of the role of starch in determining biscuit quality and the inter-relationships of flour, dough, and biscuit. Biscuits are one of the most popular wheat products due to their ready to-eat, long shelf-time, and wide-variety . The bisIt is believed that biscuit quality is closely related to flour protein content. The hardness of biscuits are suggested to increase gradually with elevated protein and gluten levels . Good quAlthough starch is the most abundant component of wheat grain (about 70–75%), its role in biscuit baking has not been paid enough attention. Our previous studies showed that the characteristics of starch are strongly related to biscuit quality . The texWeak gluten wheat was less supplied because it is usually associated with low yield due to low N input. Starch addition is an effective way to produce flour with low protein and gluten content to meet the requirement for biscuit baking. However, the functionality of starch on the processing quality during biscuit making is far less understood than protein. In this work, recombined flour of different starch gradients were produced to probe and clarify the influence of different incorporation levels of starch addition on starch pasting properties, starch thermal performance, dough rheology, biscuit quality, and their inter-relationships. This work will be attempted to disclose how starch addition may regulate the properties of flour, dough, and biscuits and provide guidance for the improvement in biscuit quality.Triticum aestivum L.) in Jiangsu province and surrounding areas were taken in the present experiment. The three cultivars contain different grain protein content (GPC), such as Ningmai 13 , Yangmai 16 , and Zhengmai 9023 . Wheat grain was tempered to 14% moisture prior to milling for 12 h with a laboratory Miller . The flour yield was about 70%. The starch contents of NM13, YM16, and ZM9023 were 78.81, 78.30, and 77.61%, respectively.Three widely grown winter wheat cultivars (Starch from flour of each cultivar of wheat was isolated with the method of Flour N content was determined using the micro-Kjeldahl distillation method of AACC 46-11A (2000), and the protein content was calculated as N content multiplied by 5.7. Gluten content was determined according to AACC 38-12.02 procedure  with a gSolvent retention capacity tests of flour were determined according to AACC 56-11 . BrieflyPasting properties were analyzed with a Rapid Viscosity Analyzer 130  according to AACC 76-21 (2000). Thermal properties were measured by differential scanning calorimetry 8,000 (DSC)  according to the method described in our previous study . The gelDough rheology was determined using Brabender Farinograph-E  following the method of Chinese national standards GB/T 14614-2006 . Dough tThe biscuit-baking procedure was carried out according to the Commercial Industry Standard SB/T10141-93 . The forWidth, thickness, and spread ratio of biscuit were measured according to the method of L* , a* , and b* .The color of biscuit was determined using a Chroma Meter . Five replicates of each biscuit type were measured from five different points. The color parameters determined were Biscuit hardness was determined by a texture analyzer  using a sharping P/5 probe according to our previous method .Image analysis of the bottom side of the biscuit was carried out according to Sensory evaluation of biscuits was evaluated by a panel of ten trained judges from the laboratory according to the method of Commercial Industry Standard SB/T10141-93 . Biscuitp < 0.05. Correlation regression was analyzed using Sigmaplot 12.5. All the tests were performed with three technical repetitions.All data were subjected to one-way ANOVA using the SPSS Version 10.0. ANOVA mean comparisons were performed in terms of the least significant difference (LSD), at the significance level of Protein content in native flour was significantly different among the three cultivars , and tha2CO3 SRC (SODSRC) increased with the increasing addition of starch (Lactic acid SRC (LASRC) and sucrose SRC (SUCSRC) linearly decreased with the increasing starch addition in the recombined flour of the three cultivars , while Nf starch . The higf starch , and it NM13 had the highest value of most pasting parameters, with an exception of the pasting temperature, followed by YM 16 and ZM9023 . Starch NM13 had the highest value of Tp, Tc, and ΔH, followed by YM16 and ZM9023, while ZM9023 had the highest To value . Starch The addition of starch dramatically decreased dough development time, stability time, farinograph quality number (FQN), cohesiveness, and adhesiveness, while it increased softening degree in all the three cultivars . HoweverThe lowest protein content cultivar, NM 13, showed the largest biscuit diameter and spread ratio, while the highest protein content cultivar ZM9023 showed the lowest biscuit diameter and spread ratio . BiscuitThe lightness (L*) of biscuit and dough was the lowest for NM13 and the highest for ZM9023 . The addImage analysis of the biscuits indicated the effect of starch on texture and appearance . The mear = −0.775, −0.83, −0.705, −0.832, −0.823, −0.898, −0.661, −0.845, 0.911, 0.713, respectively, p ≤ 0.01). SODSRC was significantly positively related with final viscosity, setback, peak T, and ΔH, while negatively with To and pasting temperature . Consistent with SUCSRC, dough stability time, FQN, cohesiveness, and adhesiveness were significantly negatively correlated with peak viscosity, trough viscosity, breakdown, final viscosity, setback, and peak time, while positively with pasting temperature (p ≤ 0.01). The softening degree was on the contrary to stability time and FQN.Sucrose SRC was significantly negatively correlated with peak viscosity, trough viscosity, breakdown, final viscosity, setback, peak time, Tc and ΔH, while positively with To and pasting temperature . Water absorption had no relation with hardness, thickness, diameter, and spread ratio.Pasting and thermal properties were closely associated with biscuit quality. Peak viscosity, trough viscosity, breakdown, final viscosity, setback, peak time, Tp, Tc, and ΔH were significantly positively correlated to diameter, spread ratio, and sensory score of biscuit, but negatively correlated to hardness and thickness of the biscuit . As for Protein content was closely related to biscuit sensory score . There wWheat flour with low content of protein and gluten is believed to be an ideal material for biscuits, cookies, and other baking foods . Starch Protein and gluten contents are important factors affecting biscuit-baking quality. Gluten is an essential structure-building protein, which is hydrated to form gluten networks providing viscoelasticity of dough . Dough dA good quality biscuit is expected to have both a desirable appearance and a tender crumb texture . Our stuSince gluten free biscuit can be produced, starch may play a more important role in biscuit baking. Viscosity indicates the propensity of starch to gelation, and high starch content in wheat flour is responsible for high peak and final viscosity . Starch 2CO3 SRC were more important than water and lactic acid SRC in determining biscuit quality.Solvent retention capacity can provide useful information for predicting the quality of soft wheat products . LASRC iMeanwhile, the increased rate of diameter and spread and the decreased rate of hardness and thickness vs. starch addition amount showed a turning point at 10% starch addition for NM 13 and YM 16, and at 15% for ZM 9023 . At the Weak gluten wheat (with low protein and gluten) is in short supply because of low yield due to low N input. Starch addition is an effective way to produce flour with low protein and gluten content to meet the requirements of biscuit industry. Starch addition decreased the contents of protein, gluten and GMP, lactic acid SRC, sucrose SRC, and onset temperature (To), while it increased most pasting parameters and gelatinization enthalpy (ΔH). Viscosity parameters were significantly negatively correlated with dough stability time, farinograph quality number (FQN), and sucrose SRC. Biscuit quality was greatly improved by the addition of starch, as shown by higher diameter, spread ratio, and sensory score of biscuit, but lower thickness and hardness. Starch gelatinization can contribute to biscuit matrix. Viscosity parameters were negatively correlated to hardness and thickness of biscuit, but positively correlated to diameter, spread ratio, and sensory score of biscuit. Considering the effects of starch addition on the dough rheology and biscuit quality, the recombined flour with around 9% protein content after mixing with starch was more suitable for biscuit baking. The interaction between starch and protein during baking needs further investigation. This study provides guidance for the application of wheat starch in the development of high quality biscuit and discloses how starch addition may regulate the properties of flour and the inter-relationships of flour, dough, and biscuit.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.LL analyzed the dataset and prepared the first draft. TY and JY critically reviewed the manuscript. QZ and DJ conceived the project idea. MH and JC helped the isolation of starch. WC and TD reviewed the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.